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130 Cards in this Set
- Front
- Back
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agents used for inflammation (3)
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glucocorticoids - chronic use limited by toxicity
SAARDs - slow acting antirheumatic drugs DMARDs - disease modifying antirheumatic drugs |
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NSAIDs are excreted by the _________
must decrease dose in ________ disease |
kidney
renal |
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NSAIDs Indications (4)
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Rheumatoid arthritis
osteoarthritis local MS sydromes (sprains) gout - execept tolmentin |
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Aspirin inhibits __________ synthesis and inhibits _________ aggregation
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prostaglandin
platelet |
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Aspirin indications (5)
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TIA
MI Unstable angina coronary artery thrombosis to decrease incidence of colon cancer |
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Aspirin adverse effects:
GI ___________ __________________ ____________ renal toxicity ______ asthma |
bleeding
gastric & duodenal ulcers hepatotoxicity rashes |
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High doses of aspirin causes salicylism - _________,________,_________,_________
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vomititng, vertigo, tinnitus, decreased hearing
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Aspirin toxicity tx:
__________ within 4 hrs NaHCO3 infusions to alkaline urine __________ assistance as needed |
gastric lavage
ventilatory assistance |
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NSAIDs - Non Acetylated Salicylates
Mg choline salicylate and Na salicylate _____________ agent less effective analgesic less effective cycloogenase inhibitor used for _________ and _________ |
anti-inflammatory
asthma and blood dyscrasias |
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NSAIDs - Cox 2 selective inhibitors
MOA: inhibits _________ synthesis Effects: analgesic, antipyretic, anti-inflammatory do not offer ______________ effects of traditional NSAIDs |
prostacyclin
cardioprotective |
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NSAIDs - Cox 2 selective inhibitor indications (6)
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OA
RA gouty arthritis famililial adenomatous polyposis acute MS syndromes ankylosing spondylitis |
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NSAIDs - Cox 2 selective inhibitors: Celecoxib (________)
effective against ___ and ___ fewer _______ than most NSAIDs it's a __________ - may cause rash dose - ____/____ mg PO bid |
Celebrex
RA and OA ulcers sulfonamide 100/200 |
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NSAIDs - Cox 2 selective inhibitors: Valdecoxib (_________)
indications - primary dysmenorrhea, OA, RA dosages dysmenorrhea - ____ mg PO qd prn OA/RA - _____ mg PO qd serious rxns reported in _____________ sensitive pts |
Bextra
20 10-20 sulfonamide |
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NSAIDs - Cox 2 selective inhibitors: Rofecoxib (_______)
indications - RA, OA, dysmenorrhea dosages dysmenorrhea - ____ mg PO qd x5 days OA/RA - _____ PO qd withdrawn b/c of strokes |
Vioxx
50 12.5-25 |
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NSAIDs - Cox 2 selective inhibitors: Etoricoxib (Arcoxia)
newest cox 2 inhibitor dosages OA/MS pain - _____ mg PO bid prn RA - _____ mg PO qd Gouty arthritis - ______ mg qd |
60
90 120 |
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NSAIDs - Cox 2 selective inhibitors: Meloxicam (_________)
popular in Europe, approved in the US for _____ fewer ___ symptoms & complications not as selective as other Cox 2 inhibitors |
Mobitz
OA GI |
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NSAIDs - Nonselective Cox 2 inhibitors: Diclofenac
(________, _________) diclofenac + _________ or _________ = < GI effects dose - _____ mg qd 0.1% opthalmic soluntion - prevent post op ___________ 3% topical gel - ____________ |
Cataflam, Voltaren
misoprostol or omeprazole 150 inflammation solar keratosis |
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NSAIDs - Nonselective Cox 2 inhibitors: Etodolac (________)
indicated for post op pain after ________ causes less ___ toxicity dose - ______ mg q6-8hrs XL formulation - _______ mg PO qd |
Lodine
CABG GI 200-400 400-1000 |
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NSAIDs - Nonselective Cox 2 inhibitors: Fenoprofen (________)
most associated with ____________ adverse effects: _______, dyspepsia, perpheral edema, _____, puritis, ________ |
Nalfon
interstitial nephritis nausea rash tinnitus |
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NSAIDs - Nonselective Cox 2 inhibitors: Flurbiprofen (_________)
dose - _______ mg qd rarely can cause: _________,__________,________ |
Anasaid
200-400 cogwheel rigidity, ataxia, tremor |
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NSAIDs - Nonselective Cox 2 inhibitors: Ibuprofen (________)
also effective in closing a _____________ - ______ mg IV at 12-24hr intervals dose - max of _____ mg/day |
Motrin
patent ductus arteriosus 0.1-0.25 2400 |
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NSAIDs - Nonselective Cox 2 inhibitors: Ibuprofen
adverse effects: GI irriation & bleeding (< than with aspirin) _______,__________ acute renal failure ________ retention interstitial nephritis ________ syndrome hepatitis aseptic meningitis in pts with SLE rarely, agranulocytosis & aplastic anemia |
Rash, Pruritis
fluid nephrotic meningitis |
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Ibuprofen contraindications (3)
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bronchospams rxn w/ aspirin
nasal polyps angioedema |
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NSAIDs - Nonselective Cox 2 inhibitors: Indomethacin (________)
indications: rheumatic conditions including JRA gout ____________ PDA - given IV ________ nephrotic syndrome __________ inflammation |
Indocin
ankylosing spondylitis pleurisy conjunctiva |
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NSAIDs - Nonselective Cox 2 inhibitors: Indomethacin
Adverse effects: GI - __________, ______, ________ CNS - _________, ________ Hematologic - ____________, __________ Renal failure Contraindications (2) |
hemorrhage, pain, diarrhea
headache, dizziness thrombocytopenia, aplastic anemia nasal polyps & angioedema |
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NSAIDs - Nonselective Cox 2 inhibitors: Ketorolac (________)
not an __________ like other NSAIDs has replaced _________ in some situations dosages PO - ____ mg PO q6hrs (max 40mg/day) IM - ____ mg x1, then 30mg q6hrs (max 120mg/day) IV - ____ mg x1, then 30mg q6hrs x5days (max 120mg/day) reduce dose in renal dz |
Toradol
anti-inflammatory morphine 10 60 30 |
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NSAIDs - Nonselective Cox 2 inhibitors: Naproxen (__________)
available OTC as ________ ADR - ___________ incidence is low but twice that of ibuprofen dose - ____ mg PO bid or tid (max 1500mg/day) |
Naprosyn
Aleve GI hemorrhage 500 |
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NSAIDs - Nonselective Cox 2 inhibitors: Nabumentone (________)
half life doubles in _______ impairment may cause ___________ is some pts dose - ______ mg qd |
Relafen
renal photosensitivity 1500-2000 |
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drugs used in gout (4)
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cochicine
NSAIDs Uricosuric agents Allopurinol |
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Gout Therapy: Colchicine
Dosages Prophylatic: ___ mg PO bid or tid Tx of attack: ___ or ___ mg followed by 0.6mg PO q2hrs ___ mg in 24hrs could be fatal |
treatment and prevention
0.6 0.6 or 1.2 8 |
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Colchicine adverse effects:
_______ - most common SE _____ & abdominal pain peripheral _________ myopathy may cause _________ and __________ |
diarrhea
N/V neuritis hair loss and bone marrow depression |
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Colchicine intoxication:
bloody ________ burning ______ pain _________ oliguria fatal _________ TX - _________ |
diarrhea
throat hematuria CNS depression supportive |
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Gout Therapy: NSAIDs
_________ is used in place of colchicine dose - ____ mg PO q6hrs x3 doses or until response occurs, then 25mg PO q6hrs x5days treats acute attack but not for prevention b/c of ___________ |
indomethacin
50 renal toxicity |
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Gout Therapy: Uricosuric Agents - Probenecid (________)
not used as 1st line tx, only used when attacks are not controlled by other agents dose - ____ mg PO bid (max 2-3 g/day) Also Sulfinpyrazone don't start therapy till ____ wks after an attack |
Benemid
250 2-3 |
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Uricosuric agents adverse effects:
_____ irritation Allergic _________ __________ w/ probencid use aplastic anemia - rare |
GI
dermatitis nephrotic syndrome |
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Gout Therapy: Allopurinol (________)
dose - ____ mg qd but depends on serum uric acid level use in acute attack in combo w/ something else |
Zyloprim
100-300 |
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Allpurinol Indications:
chronic _____________ when 24 urine exceeds ____ mg when there are ADRs to other uricosuric agents recurrent __________ serum urate levels grossly elevated goal < ___ mg/dL |
tophaceous gout
600-700 renal stones 6.5 |
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Allopurinol adverse effects:
GI effects - _______, _______, _______ peripheral neuritis allergic skin rxns - ___________ rarely - exfoliate dermatitis, necrotizing vasculitis, bone marrow depression |
nausea, vomiting, diarrhea
maculopapular rash |
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Allopurinol drug interactions:
inhibits metabolism of ___________ and oral ___________ may increase effects of _______________ reduce dose by 75% if also taking _____________ |
Probenecid
anticoagulants cyclophosphamide mercaptopurine |
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Rheumatoid Arthritis Agents
________ - Offer symptomatic relief & decrease inflammation Have little effect on progression of bone & cartilage destruction ________ - Arrest or slow progression of bone & cartilage destruction Effects may take 6wks to 6 months to be evident |
NSAIDs
DMARDs |
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Methotrexate
Azathioprine Penicillamine Hydroxychloroquinolone Chloroquine Organic gold compounds Sulfasalazine Leflunomide Tumor Necrosis Factor blocking agents Immunoadsorption apheresis |
DMARDs
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DMARDs: Methotrexate
1st DMARD of choice in treatment of ____ dose - _______ mg weekly PO Increased effects seen with doses up to 30 or 35mg weekly |
RA
7.5 - 15 |
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DMARDs: Methotrexate Adverse Effects
Nausea & ___________ Progressive dose related __________ - enzyme elevation Liver cirrhosis (<1%) rare Myelosuppression ______________ reaction- rare hypersensitivity lung reaction with SOB |
mucosal ulcers
hepatotoxicity Pseudolymphomatous |
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DMARDs : Methotrexate Adverse Effects
Prevention - GI & liver function test abnormalities decreased with use of _________ 24hrs post each dose Contraindicated - __________ |
leucovorin
Pregnancy |
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DMARDs: Chlorambucil (________)
Indications: _____ and ________ disease Adverse Effects: _________ suppression _________ Amenorrhea Risk of ________ increased 10 fold after 3yrs |
Leukeran
SLE and Behcet’s disease Marrow Infertility leukemia |
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DMARDs: Cyclophosphamide(__________)
______ suppression correlates with clinical response Indications: RA Vasculitis SLE Wegener’s granulomatosis Other Rheumatic conditions |
Cytoxan
T cell |
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DMARDs: Cyclophosphamide
Adverse Effects ________ in both men & women __________ suppression Alopecia Hemorrhagic ________ _________ Ca (rare) |
Infertility
Bone marrow cystitis Bladder |
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DMARDs: Cyclosporine (_________, _________)
Indications: _____ Maybe used in SLE, Dermatomycosis, Wegener’s gramulomatosis etc Dose: ___ mg/kg/day divided into 2 doses Available in 25mg, 100mg caps Solution ___ mg/ml (Neoral) |
Neoral, Sandimmune
RA 3-5 100 |
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DMARDs: Azathioprine (_______)
Indications: _____ Studies show efficacy in _________ arthritis, polymyositis, SLE Dose: __ mg/kg/day Available in 50mg,75mg, 100mg |
Imuran
RA psoriatic 2 |
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DMARDs: Azathioprine
Adverse Effects: ___ disturbances Bone marrow suppression Increase in _________ risk Increased risk for _________ Rarely, rash Rarely hepatotoxicity |
GI
infection lymphoma |
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DMARDs: Myophenolate (________, _________)
Indications: Tx of _______ disease due to SLE ___________________ RA (few controlled studies exist) Dose: __ gm/day in 2 divided doses Tabs, caps- 250mg, 500mg Adverse Effects: ____ Effects _________ effects _________ toxicity |
Cellcept, Myorfortic
Wegener’s granulomatosis renal 2 GI Hematologic Hepatic |
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DMARDs: Chloroquine & Hydroxychloroquine
mainly for _______ Indications ____ - not considered efficacious DMARD _________ Joint Pain of _____ |
malaria
RA Serositis SLE |
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DMARDs: Choroquine & Hydroxychloroquine
Dose: ___ mg/day for chloroquine ___ mg/kg/day for hydroxychloroquine Adverse Effects: _______ toxicity for doses >250 mg/day of chloroquine or doses >6.4 mg/kg/day of hydroxychloroquine GI- __________ _________ ________ |
200
6.4 Ocular Abdominal pain Nightmares Rashes |
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DMARDs: Gold Compounds (_________)
Adverse Effects: Hematologic abnormalities - __________, leukopenia, even pancytopenia & aplastic anemia __________ Neuropathy Rash _________ Syndrome Dose: __ mg PO bid or __ mg PO qd |
Auranofin
thrombocytopenia Jaundice Nephrotic 3 6 |
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DMARDs: Penicillamine
A metabolite of __________ & analogue of amino acid ________ Rarely used today because of toxicity |
penicillin
cysteine |
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DMARDs: Sulfasalazine
Metabolized to sulfapyridine Indications: ___ - reduces rate of appearance of new bone damage _______ _______________ Dose: ___ gm/day |
RA
JRA Ankylosing spondylitis 2-3 |
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DMARDs: Sulfasalazine
Adverse Effects: ____________ __________ Rash _________ anemia Neutropenia Methyglobinemia Drug induced jaundice (rare) Reversible infertility in _____ |
Nausea/vomiting
Headache Hemolytic men |
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DMARDs: TNF α Blocking Agents
TNF α blocking agents combine with TNF to inhibit effect of endogenous __________ 3 TNF agents approved by the FDA: Adalimumab Infliximab Etanercept |
cytokines
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DMARDs: TNF α Blocking Agents - Adalimumab (________)
Indications: RA – Can use as monotherapy or in combination with ___________ _________,__________ Dose: __ mg SQ once weekly |
Humira
methotrexate Juvenile RA , Psoriasis 40 |
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DMARDs: TNF α Blocking Agents - Adalimumab
Adverse Effects: Risk of macrophage dependent infection - usually ___ & other opportunistic infections Screen for latent or active TB prior to adm. Rarely __________ |
TB
leukopenia |
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DMARDs: TNF α Blocking Agents - Infliximab (_________)
Dose: ____ mg/kg IV infusion typical 3-5mg/kg Q 8weeks Indications: RA _____________ ___________ Giant cell arteritis __________ arthritis Juvenile chronic arthritis - Should be used with _____ Can be used with other DMARDS – cyclosporine, Azathioprine |
Remicade
3-10 Ulcerative Colitis Sarcodosis Psoriatic MTX |
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DMARDs: TNF α Blocking Agents - Infliximab
Adverse Effects: GI- _____ HA/___________ Rash _______ Could be associated with latent ____- screen Other opportunistic infections |
N/V
sinusitis Cough TB |
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DMARDs: TNF α Blocking Agents - Etanercept (_______)
Dose: ___ mg SQ 2x/weekly (50mg/wkly) Indications: RA Juvenile chronic arthritis Psoriatic arthritis Ankylosing spondylitis - Use as monotherapy or w/ ____ |
Enbrel
25 MTX |
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DMARDs: Leflunomide (______)
Indications: ____ Adverse Effects: ______ - 25% Increase liver enzymes Alopecia Wt gain Dose: LD ___ mg PO qd x3 days, then ______ mg PO qd Tab 10mg, 20mg,100mg |
Arava
RA Diarrhea 100 10-20 |
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Immunoabsorption Apheresis
Apheresis of _____ ml of plasma wkly x3 months Recommended for patients who have failed numerous other therapies Indications: _____ Adverse Effects: _______ Pain & Swelling ____________ Nausea, rash, Pruritis (1-6%) |
1200
RA Joint Hypotension |
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Skeletal Muscle Relaxants:
Drugs that affect skeletal muscle - 2 categories Used during surgical procedures (adjunct to general anesthesia) or in ICU setting to cause paralysis - ________________ Used to reduce spasticity in a variety of neurological conditions Referred to as central muscle relaxants (except dantrolene) - _______________ |
Neuromuscular Blockers
Spasmolytics |
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Skeletal Muscle Relaxants: Neuromuscular Blockers
All have structural resemblance to ____________ Two categories exist: ________________ and ________________ |
acetylcholine
Non Depolarizing Agents and Depolarizing Agents |
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________________ agents:
Includes all NMBAs in US except Succinylcholine _____________ - considered the prototype Rate of elimination correlates with duration of action: ________ elimination – long t1/2, longer duration ________ elimination- shorter t1/2, shorter duration |
Non Depolarizing
Tubocurarine Renal Hepatic |
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__________ Derivatives
Atracurium (Tracrium) Cistracurium (Nimbex) Doxacurium (Nuromax) Metocurine Mivacurium (Mivacron) Tubocurarine |
Isoquinolone
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_____________ derivatives:
Pancuronium (Pavulon) Pipecuroniun (Arduan) Rapacuronium Rocuronium (Zemuron) Vercuronium (Norcuron) Depolarizing agent - Succinylcholine |
Steroid
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Skeletal Muscle Relaxants: NMBAs: Non Depolarizing Agents - Rapacurium
Fastest onset of action than any non depolarizing agent Shortest duration of action Expected to be alternative to ___________ for rapid intubation High incidence of ___________ - withdrawal from market |
Succinylcholine
bronchospasm |
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Skeletal Muscle Relaxants: NMBAs: Non Depolarizing Agents - Atracurium (_________)
Inactivated spontaneously- _________ elimination/less hepatic metabolism By product - _________ crosses Blood brain barrier to cause ____________ |
Tracrium
hoffman landanosine seizures |
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Skeletal Muscle Relaxants: NMBAs: Non Depolarizing Agents - Cisatracurium (________)
Forms less landanosine & releases less ___________ Has all the advantages of atracurium with less side effects Has largely replace atracurium in clinical practice |
Nimbex
histamine |
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Skeletal Muscle Relaxants: NMBAs: Non Depolarizing Agents - Mivacurium (__________)
Short duration of action; similar to Rapacurium Large doses- signifcant release of _________, causing ________, __________, __________ Clearance - by plasma cholinesterase Duration of action longer with impaired ________ function |
Mivacron
histamine hypotensionm, flushing, bronchospasm renal |
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Skeletal Muscle Relaxants: NMBAs: Non Depolarizing Agents - Tubocurarine
cause motor weakness followed by skeletal muscle becoming placid & inexcitable Large muscle (abdomen, diaphragm) resistant to blockade, but recover quickly Dose - _______ mg/kg IV Duration: ______ mins |
0.1-0.5
45-60 |
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NON Depolarizing Agents:
Longer duration of action Longer onset of action ___________ - fastest onset followed by Rocuronium Depolarizing Agents: Short duration of action Shorter onset of action ____________ only |
Rapacurium
Succinylcholine |
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Skeletal Muscle Relaxants: NMBA: Depolarizing Agent - Succinylcholine
Charaterized by 2 phases: Phase 1 - depolarization Phase 2 - desentization Short onset - < ____ secs Short Duration - _____ mins Dose - _____ mg/kg IV |
60
5-10 0.75-1.5 |
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Skeletal Muscle Relaxants: NMBA Adverse Effeects
_________ CV effect: Vercuronium Doxacurium Cistracurium Rocuronium __________ CV effect: Pancuronium –tachycardia by release of norepinephrine Mivacurium produces hypotension (less) Atracurium -produces hypotension (less) |
Minimal
Moderate |
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Skeletal Muscle Relaxants: NMBA Cardiovascular Adverse Effects
Tubocurarine - produces ___________ Succinylcholine - __________ if given with halothane anesthesia __________ if 2nd dose given <5 min later (transient) ___________ causing cardiac arrest in burn, trauma & closed head injury pts |
hypotension
Arryhthmias Bradycardia hyperkalemia |
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Skeletal Muscle Relaxants: NMBA Other Adverse Effects
Succinylcholine - increased __________ & __________ pressure __________ pain in large doses _________,_________,_________ all cause bronchospasm |
Intra-occular & Intragastric
Muscle Tubocurarine, Mivacurium, Rapacurium |
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Skeletal Muscle Relaxants: NMBA: Effects on Disease
Myasthenia gravis - strongly _________ NMB effect Advanced Age - Prolonged duration for ___________ agents due to poor renal & hepatic clearance Severe Burns - __________ dose requirements for non depolarizing NMBA to block sufficient receptors |
enhances
non depolarizing Increased |
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Reversal of Non Depolarizing Agents
Neostigmine, Pyridostigmine - Antagonize Non depolarizing NMBA by increasing the availability of __________ at the motor end plate Eduphronium - antagonizes neuromuscular blockade by inhibition of acetylcholinesterase. May be _____ effective than neostigmine in more pronounced blockade |
acetycholine
less |
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Muscle relaxants maybe divided into two groups - _________ and __________ agents
_________ - only agent with direct action at the level of the nerve-muscle connection |
Centrally acting agents and Peripherally acting agents
Dantrolene |
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Skeletal Muscle Relaxants Indications
To relieve the _________ of neuromuscular disease such as: Multiple sclerosis Spinal Cord Injury Stroke Pain relief of minor strain injuries Control of muscle symptoms of tetanus Prevent or treat ____________ in surgery (Dantrolene) |
spasticity
malignant hyperthermia |
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Carisoprodol (Soma®)
Chlorphenesin (Maolate®) Chlorzoxazone (Paraflex®) Metaxalone (Skelaxin®) Methocarbamol (Robaxin®) Cyclobenzaprine (Flexeril®) Dantrolene (Dantrium®) Diazepam (Valium®) Ophenadrine (Norflex®) Baclofen (Lioresal®) |
Skeletal Muscle Relaxants
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Skeletal Muscle Relaxants - Diazepam (_________)
Spasmolytic Agent Adverse Effects- ________, _______ Dose: ____ mg/day given in 2-4 doses may increase to 60 mg/day Available- 2mg, 5mg, 10mg tabs |
Valium
sedation, apnea 2-10 |
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Skeletal Muscle Relaxants - Baclofen (_________)
As effective as diazepam in reducing spasticity, but produces less _________ Dosages: Spasticity - ____ mg PO tid (Max 100 mg/day) Hiccups - ____ mg 2-3x/day Dosage Form: tabs 10mg, 20mg Intrathecal dose: ______ mcg/24hrs Injection: For intrathecal use 50mcg/ml,500mcg/ml 5ml, 2000mcg/ml 5ml |
Lioresal
sedation 5-10 10-20 50-100 |
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Skeletal Muscle Relaxants - Baclofen Adverse Effects
PO admin: __________ - tolerance develops Intrathecal admin: can control severe spasticity & muscle pain in pts, unresponsive to meds given by other routes Tolerance may develop after months Excessive _________ _________ depression _______ Challenges - maintenance of delivery catheter in __________ space Advantages - improved quality of life in pts with spastic disorders |
Drowsiness
somnolence Respiratory Coma subarachnoid |
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Skeletal Muscle Relaxants - Tizanidine (________)
Reduces spasticity at doses that cause < ___ effects than clonidine Adverse effects: _________ (48%) hypotension Bradycardia Dry mouth Asthenia Dose: ___ mg tid Capsules: 2mg, 4mg, 6mg Tablets: 2mg, 4mg Hepatic/renal insufficiency- may need to dose adjust |
Zanaflex
CVS Somnolence 2-4 |
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Skeletal Muscle Relaxants - Dantrolene (_________)
Treats spasticity & _____________ Dosages: Spasticity - ___ mg PO qd, increased to 2-4x/day up to max of 100mg PO qid Adverse Effect: ___________________ ________,__________ Occasional hepatitis |
Dantrium
malignant hyperthermia 25 generalized muscle weakness Sedation, Dizziness |
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Skeletal Muscle Relaxants - Dantrolene (Dantrium)
Malignant hyperthermia - rare heritable disorder triggered by stimuli like ____________ and _________ MOA: Sudden & prolonged release of ________, with massive muscle contraction & lactic acid production increased body temperature Dose - __ mg/kg IV Repeat PRN to a maximum of 10 mg/kg Prophylaxis - ____ mg/kg IV 1.5hrs prior to anesthesia Dosage Forms - Caps: 25mg, 50mg, 100mg Inj: 20mg vials |
general anesthetics and NMBA
calcium 1 2.5 |
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Skeletal Muscle Relaxants - Botulinum Toxin
Has become popular for the TX of generalized spastic disorders e.g. ___________ |
cerebral palsy
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Skeletal Muscle Relaxants - Agents for Acute Local Spasms (spasmolytics)
Relief acute muscle spasm caused by local tissue trauma or muscle strain ___________ (Flexeril)- regarded as prototype for group |
Cyclobenzaprine
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Cyclobenzaprine (Flexeril)
Structurally related to TCAs Not effective for Tx of muscle spasm due to ___________ or ____________ Dose: _____ mg/day in 3 divided doses Adverse Effects: ________ ________ Transient Visual ___________ |
cerebral palsy or spinal cord injury
20-40 Sedation Confusion Hallucination |
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Relaxants - Agents for Acute Local Spasms (spasmolytics)-for relaxing stiff, sore muscles
Carisoprodol (Soma®) Dose - ____ mg PO qid Children (6-12yr) - 6.25 mg/kg PO qid Tabs 350mg Chlorphenesin (Maolate®) Dose: ____ mg PO tid Tabs 400mg Chlorzoxazone (Paraflex®) Dose: ____ mg PO 3-4x/day Tabs 250,500mg Metaxalone (Skelaxin®) Dose: ____ mg PO 3-4x/day Tabs 400mg |
350
800 500 800 |
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Relaxants-Agents for Acute Local Spasms (spasmolytics)-for relaxing stiff, sore muscles
Methocarbamol (Robaxin®) Dose: ____ mg PO qid IV __ gm q8hrs Max duration of therapy for IV=3days Children (tetanus only) 15 mg/kg/dose q6hrs (Max 1.8 gm/mg x 3days) Orphenadrine (Norflex®) Dose: ____ mg PO bid IM/IV 60 mg q12h Inj. 30 mg/ml 2ml Tabs- 100mg |
1500
1 100 |
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Discrete time limited alterations in brain function
including changes in motor activity, autonomic function, consciousness or sensation that result from an abnormal & excessive electrical discharge of a group of neurons within the brain |
Seizures
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__________ - Specific type of seizures where the attack is primarily manifested by involuntary muscular contractions
____________ - A condition characterized by recurrent (2 or more) seizures unprovoked by any immediately identifiable cause |
Convulsions
Epilepsy |
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Seizure Etiology:
60-70% of patients- no specific cause of seizures can be identified ___________ - congenital malformations, perinatal injuries, neurologic disorders, metabolic, infections ___________ - head trauma, brain tumors, infections- common causes __________ - cerebrovascular diseases, brain tumor ________ - 2-3times increased risk in persons with first degree relatives with epilepsy |
Infants/Children
Young adults Elderly Genetic |
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Sleep deprivation
Fever emotional stress Lack of food, alcohol withdrawal Pregnancy, Menses Sensory stimuli-television, reading Pseudo seizures - psychogenic basis |
Predisposing factors to seizures
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Classification of Seizure Type
Generalized Seizures: Generalized __________ (grand mal seizures) _________ (Petit mal seizures) Tonic/Atonic Seizures Clonic & Myoclonic seizures __________ spasms |
tonic clonic
Absence Infantile |
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Classification of Seizure Type
Partial Seizures: ________ partial seizures ________ partial seizures Partial seizures ________________ |
Simple
Complex secondarily generalized |
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localized onset of attack ascertained by clinical observation or electroencephalogram (EEG)
3 types exist- determined by the degree of brain involvement by the abnormal discharge Simple Complex Secondarily Generalized |
Partial seizures
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Least complicated, characterized by minimal spread of the abnormal discharge.
normal consciousness and awareness present e.g. patient may have sudden onset of clonic jerking of an extremity lasting 60-90secs Residual weakness may last 15-30mins after attack |
Simple partial Seizure
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Has a localized onset but discharge becomes more widespread (usually bilateral and almost always involving the limbic system
Arise from temporal lobe -hypoxia, infection Presentation-pt may have brief warning, followed by alteration of consciousness during which pt may stare or stagger or fall Automatism may be present-swallowing, fumbling, walking Lasts 30-120sec, after which pt recovers, but may feel tired or ill after attack |
Complex Partial seizure
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Partial seizure immediately precedes generalized tonic clonic (grand mal seizure)
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Secondarily generalized partial seizure
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No evidence of localized onset of seizure
5 Types: Generalized tonic clonic (grand mal seizures) Absence (Petit mal seizures) Tonic/Atonic Seizures Clonic & Myoclonic seizures Infantile spasms |
Generalized seizures
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Most dramatic of epileptic seizures
Characterized by tonic rigidity of all extremities followed in 15-30sec by a tremor then excessive jerking of the body lasting 60-120sec (clonic phase) Pt usually left in a stuporous phase; tongue or cheek maybe bitten; urinary incontinence common |
Generalized tonic–clonic (grand mal seizures)
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Characterized by sudden onset & abrupt cessation
Duration- < 10sec; rarely>45sec Consciousness is altered; mild clonic jerking of eyelids or extremities may occur Attacks begin in childhood or adolescence; may occur up to 100x/day |
Absence (Petit mal) seizure
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Seen in a wide variety of seizures-generalized tonic clonic seizures, partial seizures, partial seizures, absence seizures & infantile spasm
Tx should be directed at the primary seizure type, rather than at the myoclonus |
Myoclonic Seizure
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Pt has sudden loss of postural tone
If standing, falls suddenly to the floor If sitting head & torso fall forward Seizure type found in children |
Atonic Seizures
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An epileptic syndrome, not a seizure type
Characterized by brief myoclonic jerks of the body with sudden flexion or extension the body & limbs 90% of pts have first attack before age of 1 yr Most are mentally retarded Cause unknown - infection, kernicterus, tuberous sclerosis, hypoglycemia |
Infantile Spasms
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MANAGEMENT OF EPILEPSY: PARTIAL SEIZURES & GENERALIZED TONIC-CLONIC SEIZURES
Till recently choice of drug limited to Phenytoin, carbamazepine, barbiturates Tendency in recent decades to limit sedative antiseizure drugs like barbiturates & benzodiazepine to pts unable to tolerate other meds Choice now between ___________ & ___________ |
carbamazepine & phenytoin
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MANAGEMENT OF EPILEPSY: GENERALIZED SEIZURES
Drugs used for generalized tonic clonic seizures are same as for partial seizures; plus ___________ |
valproic acid
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Drugs effective against absence seizures: Two are non sedative, therefore preferred
____________ ____________ ___________ - sedative effective but has dose related adverse effects, plus tolerance |
Ethosuximide (Zarontin)
Valproic Acid (Depakene, Depakote) Clonazepam |
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TX of Myoclonic Syndromes:
Use _________ - can use IV in acute phase non sedating & effective Alternatives: _________, or other Benzodiazepines ______________ & _____________could be useful |
Valproate
Clonazepam Zonisamide (Zonegran) & Levetiracetam |
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Tx of Juvenile myoclonic epilepsy:
__________ is drug of choice, followed by __________,___________ aggravated by __________, ___________ |
Valproate
lamotrigine, topiramate phenytoin, carbamezapine |
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Rx of Atonic Seizures:
Often refractory to all available medications __________& ___________ maybe beneficial ____________ - may improve control in some & worsen attacks in others ___________ - effective in some; limited by toxicity |
Valproate & lamotrigine
Benzodiazepines Felbamate |
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Rx of Infantile Spasms:
Meant to control seizures - no effect on mental retardation Most pts get one course of IM ____________ ____________ maybe equally effective _______________ also used |
Corticotropin
Prednisone Benzodiazepines (clonazepam) |
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Rx of Status Epilepticus:
___________ - most effective Adult Dose: ______ mg IV q10-20 mins up to 30mg in 8hrs may cause ____________; effect not lasting |
Diazepam
5-10 resp. depression |
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Rx of Status Epilepticus:
____________ - alternative to diazepam Dosages: Infants - ____ mg/kg IV slow over 2-5 mins (max 4 mg/dose) may repeat 2nd dose of 0.05 mg/kg in 10-15 mins PRN Adults: __ mg/dose slow IV over 2-5mins. May repeat in 10-15 mins (Max dose 8mg) Start long acting agent like ____________ |
Lorazepam (Adovan)
0.1 4 phenytoin |
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Tx of Status Epilepticus (SE):
IV _________ - was mainstay for continuing therapy for SE Effective & non sedating LD = ____ mg/kg IV at a maximum rate of 50mg/min Monitor cardiac rhythm & BP especially in elderly _________ toxicity from propylene glycol |
Phenytoin
13-18 Cardiac |
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Tx of Status Epilepticus (SE):
IV ____________ - better parenteral agent Prodrug of phenytoin Dose: LD ______ mg PE/kg IV given at 150 mg PE/min Maint.D = 4-6 mg PE/kg/day |
Fosphenytoin
15-20 |
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Rx of Status Epilepticus (SE):
For pts not responding to Phenytoin, __________ given in large doses of _______ mg IV to a total dose of 400-800mg ________________ - common complication General anesthesia may be necessary in highly resistant cases For pts in absence status, _________________ still drug of choice |
Phenobarbital
100-200 Respiratory depression benzodiazepines |
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ANTSEIZURE MEDICATIONS - PHENYTOIN (DILANTIN)
Indications: __________ or __________ partial seizures primary or secondarily generalized seizures convulsive status epileticus Adverse Effects: (concentration dependent) ________ _________ or ________ vision __________ Idiosyncratic: hepatoxicity rash, exfoliative dermatitis _____________ syndrome Lupus like reaction |
Simple or complex
Nystagmus double or blurred drowsiness Steven-Johnson |
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ANTSEIZURE MEDICATIONS - DILANTIN
Adverse Effects: (Chronic) ______ hypertrophy ____________ neuropathy Chronic ____________ __________ _____________ anemia Osteoporosis Acne Dose (maintenance): Adults - ____ mg/kg/day (300-500 mg/day) Children ____ mg/kg/day Steady state achieved in 1-3 wks if initiated at maintenance dose Dosage Forms: 30mg, 100mg caps 30 mg/5ml, 125 mg/5ml(susp) 50 mg/ml phenytoin Na inj |
Gum
Peripheral cerebral damage Hirsutism Megalobasltic 4-6 4-10 |
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ANTSEIZURE MEDICATIONS - DILANTIN
___ mg phenytoin Na equivalents/ml fosphenytoin sodium inject able solution for IV and IM use Advantages: first line agent for _________ seizures inexpensive IV form available Disadvantages: Dose dependent kinetics drug interactions chronic neurologic & connective tissue effect |
50
partial |
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ANTSEIZURE MEDICATIONS - Levetiracetam (KEPPRA)
IV/PO Indication: Adjunctive therapy in the treatment of ________ seizures in children & adults 4yrs of age & older Time peak = 20-120 mins Excreted 91% ________ |
Partial
renally |
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ANTSEIZURE MEDICATIONS - KEPPRA
Adverse Effect: CVS - _________ CNS - _____________, _____________, ___________ Skin – ________, __________ GI - N/V, ____________, ____________, ____________, __________ MS – _____________, ____________ |
chest pain
Somnolence, asthenia, coordination difficulties rash, ecchymosis abdominal pain, constipation, diarrhea, gingivitis arthralgia, back pain |
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ANTSEIZURE MEDICATIONS - KEPPRA
Dosages: Adults - ____ mg IV/PO bid Increase by 1000 mg q2wks to 3000 mg/day in 2 divided doses Pediatric (4-<16yrs) - ___ mg/kg IV/PO bid or ___ mg/kg qd May increase 20 mg/kg/day q2wks to a maximum of 60 mg/kg/day in 2 divided doses Levetiracetam injection (500 mg/5mL) must be diluted in 100 mL of a compatible diluent and administered IV as a __-minute IV infusion |
500
10 20 15 |
