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99 Cards in this Set
- Front
- Back
Acute agitation: nonpharm?
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- safety (pt + others)
- control behaviour - reassure - physical restraint if verbal fails |
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What do do for DELIRIUM
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- remove MEDICAL CAUSE
- HALOPERIDOL (PO/IM/IV) regular not PRN - 2nd gen (R/O/Q) also used - BDZ *only* when ETOH withdrawal |
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Why are medium/long-term antipsychotics reserved only when benefits >>> risks in acute agitation?
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Increased risk of STROKE and DEATH in elderly
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What to Rx for DEMENTIA? Why? Why not haloperidol?
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- Atypical antipsychotics
- b/c favourable SFX profile - Risperidone .5, 1, 2mg QD beneficial in Alz - Halo only good for AGGRESSION |
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What else has been studied for DEMENTIA-related AGITATION?
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- trazodone (limited, but good b/c SFX and sedating)
- cholinesterase inhibitors (donepezil + for behav disturbances) - BDZ + for acute anxiety and agitation |
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Which BDZ to use for acute anxiety/agitation? Why?
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LORAZEPAM, OXAZEPAM, b/c no active metabolites and metabolism minimally affected by age.
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What to do for agitation from BRAIN INJURY?
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- BBlockers (propranolol)
- Antiepileptics (CBZ, VPA) - !BDZ b/c paradoxical disinhibition |
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Why !-IM olanzapine + BDZ?
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Cardiac and respiratory complications
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What serves as an alternative to intramuscular atypical antipsychotics?
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Rapidly dissolving OLANZAPINE and/or RISPERIDONE (also liq)
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What to give for substance intoxication vs. withdrawal (ETOH)?
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Haloperidol + lorazepam vs. diazepam
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First-gen antipsychotics: DIs?
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- Antagonisim of dopamine agonists
- Additive CNS depression |
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Atypical antipsychotics: DIs?
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- Antagonizes dopamine agonists
- CNS depression - Potentiates antihypertensive drug effects |
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First-gen antipsychotics: SFX?
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Sedation, parkinsonism, akathisia, acute dystonia, NMS
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Risperidone: SFX?
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Akathisia, dizziness, NMS
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Olanzapine: SFX?
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Risperidone + anticholinergic
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Quetiapine: SFX?
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Sedation, dizziness, NMS
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NMS: Risk factors?
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- Up to 1%, within 30 days, younger males, high-potency depots, 10% mortality
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NMS: S/Sx?
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>39oC, MM rigidity, delirium, labile BP, tachycard, high CPK, arrhythmia, tremor, sz, coma
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NMS: Tx?
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- NonRx: d/c neuroleptic, cooling blanket, hydrate
- Rx: dantrolene, bromocriptine, BDZ |
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TD: Risk factors?
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Months-years of neuroleptics, elderly
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TD: S/Sx?
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Fly catching/protruding tongue, facial tics, chewing, excessive blinking
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TD: Tx
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d/c or change or lower dose of neuroleptic, anticholinergic
- Tetrabenazine, donepezil, VitE (400-1600 IU QD) |
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Antipsychotics in pregnancy?
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- Risk v. benefits
- LOW dose of HIGH potency (eg Haloperidol - cat C) - d/c b4 delivery if possible - avoid during 1st trimester if possible |
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BDZ: SFX?
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Sedation, dizziness, cognitive impairment, respiratory depression (rare)
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BDZ: DIs?
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Additive sedation, cardiorespiratory depression.
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Anxiety: nonpharm
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!caffeine, !etoh, PRN BDZ !>4 days, > stress, CBT
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Panic disorder: Tx (with/without agoraphobia)?
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- SSRIs, venlafaxine (+ BDZ for <=8 weeks to maximize adherence and response)
- Start low to avoid agitation - Tx months/years |
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Panic disorder: 2nd line?
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TCA (imip, desip, clomip), mirtazapine, MAOI (phenelzine, tranylcypromine)
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ACUTE panic disorder tx?
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Alprazolam 0.25 T-QID, clonazepam 0.25 BID. Also loraz/diaz
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Role of BDZ?
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adjunct or failure w/ BDZ, acute
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Tx for SOCIAL PHOBIA?
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SSRI/SNRI, or propranolol 10mg 30 min before event
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Why is dose of MOCLOBEMIDE significant?
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Loses MAO-A selectivity > 600mg QD thus need to watch consumption of aged cheese, red wine, beer, smoked meat
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Tx for SPECIFIC PHOBIA
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No meds. CBT
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1st- and 2nd-line for OCD? Augment with?
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1) CBT
2) SSRI (F/X/P/S) @ usual doses. Augment with RISPERIDONE |
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SSRIs used for:
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PD (FPS), PDA (PS), PTSD (PS), OCD (FXPS), SAD/GAD (PSE)
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SNRIs used for:
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GAD/SAD, PD/PDA, ?PTSD, !OCD
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SSRI SFX?
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NAUSEA, tremor, anxiety, insomnia, somnolence, sweating, dry mouth, headache, dizz, diarrh, constipation, sexualdysfx
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SNRI SFX?
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^BP, agitation, tremor, sweating, nausea, sleep alter, headache, `sexual dysfx than SSRI
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SSRI: intra-class
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C, Es - `drug interactions
F - ^anorexia, ^t1/2, ^stimulation X - ^nausea, ^sedation, ^constipation, ^DIs P - ^anticholinergic (^weight gain, D/C rxn) S - ^sexual, ^diarrhea, `DIs, ^for <3 pts |
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PTSD: 1st- and 2nd-line?
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1) SSRI/SNRI
2) Mirtaz, moclob, phenel, risp, olanz |
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GAD: 1st- and 2nd-line?
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1) CBT (20 sessions!)
2) SSRI, SNRI 3) Imipramine, bupropion, pregabalin |
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BUSPIRONE: pros and cons?
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+ | `abuse potential, `sedating than BDZ
- | slow onset of fx; must taper BDZ slowly if switching to busp b/c no cross-tolerance. CAN PRECIPITATE BDZ WITHDRAWAL |
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Anxiety: if one antidepressant fails, what to do?
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- Confirm dose and time, switch agent (can be same class). If 2nd fails, switch class.
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BDZ: max length of use for SS/SNRI-related agitation?
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6-8 weeks
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BDZ: uses
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PD, PDA, GAD, SAD
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BDZ: side effects
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Drowz,dizz, ^traffic accidents, dependence, `concentration, anterograde amnesia
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Which BDZ affected by CYP?
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Alprazolam. Level ^by fluvox, nefaz, GFJ, ketoconazole. Level `by theophylline
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Which preg cat are most BDZ? Which are X?
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1) D
2) Temazepam, triazolam, flurazepam |
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Short-acting BDZ? Role?
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- Alpraz, bromazepam, lorazepam, oxazepam, triazolam
- To sedate, elderly, liver dz |
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Long-acting BDZ? Role?
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- Diazepam, flurazepam, clonazepam, nitrazepam, chlordiazepoxide
- Tapering off, `rebound |
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BDZ: length of therapy in
1) Anxiety 2) Hypnotic |
1) Adjunct only - reeval in 4-6wk
2) 4 wk |
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Effects of BDZs in pregnancy?
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Floppy infant sx, ?teratogen (oral cleft), newborn withdrawal if 3rd trimester
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BDZs precautioned:
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Hx of substance abuse, sleep apnea, cog/renal/hepatic dz, elderly, porphyria, CND depression, myasthenia, prego
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BDZ withdrawal depends on what 4 factors?
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1) Duration of tx
2) Dose 3) Rate of tapering 4) BDZ t1/2 |
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BDZ withdrawal s/sx?
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Insomnia, NV, twitching, ^anxiety, paresthesia, tinnitus, delirium, sz
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How to withdraw BDZ?
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IF > 12 wks, 10-25%/week, esp slow last week. Consider changing to equivalent dose of clonaz/diaz (X/C alprazolam!)
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Why ~!-BDZ + clozapine?
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^sedation, salivation, respiratory arrest
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Which BDZs for ETOH withdrawal?
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Oxazepam, chlordiazepoxine,
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Diazepam: why IV q> IM?
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IM is painful.
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Which BDZ:
1) severe withdrawal 2) behav disturbs in elderly 3) accumulates |
1) alprazolam
2) triazolam 3) flurazepam (despite quick onset) |
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ADHD: nonpharm q> or q< than Rx?
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q< solo. combo better than either alone.
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ADHD: efficacy of stimulants?
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70% some benefit. First-line. Switch after 2-3 weeks if none
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Daily dosing of:
1) Immediate release (Ritalin) vs. 2) Sustained release (Ritalin SR, Dexedrine) vs. 3) Concerta, Biphentin, Adderal XR |
1) OD-TID
2) BID 3) OD |
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Which formulation first-line? Why?
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Long-acting. `rebound hyperactivity, adherence, !- @ school, `abuse
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Stimulants and atomoxetine: what risks highlighted by Health Canada?
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SCD (if underlying cardiac dz), hallucinations, irritability
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Modafinil: class? used in ADHD? Other uses?
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CNS stimulant. Used in narcolepsy. `effective than other agents, !approved. q>placebo.
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Atomoxetine: class? indicated for? efficacy?
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NE reuptake inhibitor. !stimulant, !controlled. >= 6yo->adults [esp if comorbid SUBSTANCE ABUSE/DEPRESSION]. >60-70% patients get 20-30% `sx
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Role of antidepressants in ADHD?
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1) 2nd/3rd line (!as effective)
2) Comorbid depression, enuresis, anxiety, tics |
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Which antidepressants used, !used in ADHD?
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Bupropion. TCAs q< stim
!venlafaxine |
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Clonidine: effective/ineffective for?
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^aggression, impulsivity, overarousal, hyperactivity, `inattention, poor concentration. ADJUNCT with stim
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Antipsychotics used for?
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BEHAVIOURAL sx. Low-dose risperidone. !-inattention; `cogfx.
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What can be sprankled on applesauce?
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Adderall XR, Dexedrine spansules, biphentin capsules.
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Drug holidays: Y/N?
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N in mod-sev who are doing well on stimulant. Use if weight loss >= 10%
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CIs for ADDERALL
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Advanced arteriosclerosis, symptomatic CVD,HYPERthy, HTN, glaucoma, agitation, drug abuse hx, MAOI
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CIs for DEXEDRINE
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As in ADDERALL + motor tix/Tourettes
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CIs for METHYLPHENIDATE. Cautions?
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!- As in ADDERALL + DEXEDRINE +anxiety, pheochromocytoma
~!- SZ/EEG changes: reduces sz thresh; severe depression, normal fatigue, may worsen PSYCHOSIS |
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Methylphenidate SFX? (dex, adderall essentially the same)
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Insmnia, anorexia, NV, `weight, tic, emotional lability, nasal congestion, headache, RARE-blood dyscrasia, angioedema, sudden death. (Adderall also sexual dysfx)
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Concerta vs. Biphentin?
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Concerta 8-12hr, biphentin 10-12hr. Concerta non-deformable shell (in stool!) to `abuse. Biphentin spranklable on foods. NEVER CRUSH EITHER
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Methylphenidate: DI?
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Clonidine (ECG/sudden death), linezolid & MAOI (^BP), phenobarbital and phenytoin (^ level), TCAs (^TCA level), warfarin (^INR), CBZ (`MPH level)
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Stimulants: monitor
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Sx, academics, behaviour, phys exam, cardiac Hx, ECG, BP/HR @ day 0, 1, 3 mo then q6-12 mo. Peds: weight growth, development
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Modafanil sfx?
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Rhinitis, SJS/TEN, anxiety/psych
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When !-use antipsychotics for DEMENTIA?
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If hallucinations/delusions are early/presenting signs - may be DLB; ^risk of precipitating antipsychotic sensitivity sx
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When is a dementia tx considered effective?
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Provides IMPROVEMENT or N/C in sx
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DONEPEZIL - dose, when to ^dose?
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5mg QD, take qAM if sleep disturbances. ^after 28 days to 10mg QD
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RIVASTIGMINE - dosing? Additional indications?
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1.5mg BID, after 30 days 3mg BID max 6mg BID. Also DLB and PARKINSON'S DEMENTIA
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GALANTAMINE - dosisng? Add'l indications?
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8mg OD, up to 16mg OD after 30D. Max 24mg QD. Vascular dementia
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Memantine - MOA? Indication?
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Blocks glutamate-induced neuronal excitotoxicity. Mod-severe AD.
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Which ONE of the following has proven efficacy and safety benefits for `incidence of dementia?
a) Dyslipidemia tx b) Estrogen tx c) Chronic NSAID d) Hypertension tx |
d)
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Why SSRI > TCA for dementia-depression
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`anticholinergic sfx, `orthostatic HTN (note: elderly need longer trial- 2-3mo)
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If TCA, which TCA for dementia-depression?
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Desipramine/nortriptyline
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For dementia-psychosis, what tx? why? dose?
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2nd gen. Risperidone `0.25 *1.0 ^2mg QD. Olanzapine `2.5, *5, ^10. Elderly demented brain ^sensitive to antipsychotics!
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What to give for dementia-psychosis if preexisting mvmt dx or pt develops EPS?
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QUETIAPINE
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Trazodone - class/use in dementia?
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Serotonin agonist. Sundowning (worse behaviour as darkness falls)
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Buspirone - class/use in dementia?
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Serotonin agonist; used for anxiety
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Donepezil & galantamine DIs
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Metab by CYP 2D6 & 3A4
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CheIs: onset? when to ^dose?
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3-6 months, ^qmonth
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~! for use of CheIs?
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bradycardia, sick sinus sx, active PUD, asthma/COPD, anethesia, anticholinergic meds, parkinsons (^eps), epilepsy (?`sz thresh), beta-blockers (?^brady)
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First-line in mild-mod RLS?
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Levodopa PRN <=400/100
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First-line in mod-sev RLS?
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Dopamine agaonists (ropinrole 2mg QD/pramipexole <=0.5mg QD)
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