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230 Cards in this Set
- Front
- Back
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Dx Dementia requirements
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loss of mental fx in at least 3 of
language understanding of speech memory/reasoning emotion |
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dementia includes what seperate disease states?
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alzheimers
mild cognitive impairement lewy body dementia vascular dementia |
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what OTC is good for memory improvement
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Geritol is recc.-complete multimvitamin
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Alzheimers Disease
risk factors |
age
male sex genetics-APOE4 Brain Size |
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Parho of Alzheimers
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APP->Bamyloid->amyloid plaque
Bet a protein makes NFT=loss of neuronal activity abnormal tau protein binding also causes collapse |
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AD diagnosis
DSMIV Criteria |
confirmed upon DEATH
oneof more of: apraxia, aphasia, agnosia, executive functioning disturbance impairment of social/ocupational fxn |
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stages of AD
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MILD-16-18MMSE, repeats self, diff. word finding
MOD-17-10, unable to recall, unable to drive SEVERE-9-0, no or very little recall, irritable incontinent |
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MMSE
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mini-mental status exam
max score-30 Aids in DX usually dec in 2/3 pts/yr in AD pts |
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ADAS
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AD assesment
specific for AD vs other dementias 0-70(70 worse) longer test than MMSE |
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Mini-COG
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memory test
remember 0-demented 1 or 2-clock test-abnormal-demented -normal clock-ok 3=ok |
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Therapeutic goals
of AD for pt |
cognitive improvement-decision making
daily living improv.-washing, cleaning slow progession delay nursing home |
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no mater what exam used for AD.......Ad is a disease of _______
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exclusion
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AD drugs
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AChE-I's
NMDAs Antipsychotics/Antidepressants |
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AChE-I's for AD
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tacrine(cognex)
Donexpezil(aricept) rivastigmine(exelon) galantamine(razadyne) |
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AChE-Is
MOA indication |
inhib centerally active acetylcholinestrase= more ACH
indic-moderate AD |
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tacrine
brand? C/I |
cognex
used QID causes hepatox. CI-drug induced jaundice, bilrubin >3 |
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donepezil
brand? FOR what stages of AD? ADE |
aricept
for all 3 stages of AD titrate up in 4 weeks to 10mgQHS to help with nausea |
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Rivastigmine
brand? approved for? S/E, counselling pts |
exelon
irrevers. psuedo AChEi-butycholinesterase inhib for mild-mod AD + PD SE-N/severe vomitting TAKE WITH FOOD!!! |
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Rivastigmine patch
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replace daily
saved drug cause less NAUSEA 4 weeks between titration!!! |
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Galantamine
brand approved for? |
Razadyne/Reminyl
Revers. AChEI's for mild to mod AD TITRATE! |
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donepezil t1/2
exelons t1/2 once patch is removed? |
70H!!!
rivastigmine is 3 H past patch removal |
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AChEis CI
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bradycardia
Heart Block asthma/COPD active PUD |
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AChEIs comparison
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clinically there is no diff
if MMSE dec. 2.4 pts/yr then switch to another ACHEI, but if doesn't-keep pt on drug for life of disease |
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Memantine
brand? MOA? aprroved for? S/E |
Namenda
inhibits glutamate binding to NMDA-dec. abnormal activation approved for ONLY mod-severe AD titrate weekly, not q 4 to 6 wks like ACHEIs |
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Memantine
ADE/rare se pharmacokinetics |
flu-like sx, arthralgia, urtinary retention
100%bioavail. not affected by food if CrCL <30ml/min do NOT exceed 5mg BID CLEARANCE dependent on urine pH |
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Memantine counseling for caregivers
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oral soln-do not mix with water or other liquids
may cause constipation-use laxative at HS Namenda XR-qd with food if dysphagia-sprinkle on food |
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Vit E for AD
MAOIs for AD NSAIDS? |
mixed efficacy
selegiline-mixed results NSAIDS-dec inflam state of AD, but limited studies |
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statins for AD
estrogens for AD |
relationship of cholestrol and AD not understood
should dec amyloid no long term studies for advantages estrogen-studies show poss benefit but not RCT |
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depression with AD
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diff. to determine which came first
tx-SSRIs-prozac,celexa,zoloft avoid-TCAs and paxil-anticholinergic properties |
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agitation and psychosis in AD
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most get in 3 yrs of diagnosis
tx reversible agitation-pain, withdrawl, environmental problems use antipsychotics, antidepressants, mood stabilizers |
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what is sundowning
hot to tx |
time of day when agitation increases(evening hours)
exposure to sunlight helps-maybe melatonin antipsychotics for severe cases |
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antipsychotics in AD
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BLACK BOX WARNING-avoid if possible...increased risk of mortality....yet we still do it???
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antipsychotics commonly studied in AD
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atypicals mainly
risperdal, seroquel, geodon, haloperidol start low-go slow, and sometimes say NO! mood stabalizers-if failed other tx |
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future tx od AD
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vaccine!!!!
beta -gamma secretase inhib |
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Parkinsons Disease
what is it and where |
progessive, neurodegenerative
loss of dopaminergivc cells in basal ganglia -NO CURE! |
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PD
ach vs Dopamine |
Ach(excitatory) LOTTTSSSSS
dopamine(inhib)-LITTTTLLEEEEE |
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Hyperkinesia-da vs ach
choreatic disorders-da vs ach |
hyperkinesia-dopamine high, ach normal
choreatic-ach low, dopamine normal |
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PD
common in m or f? which race? |
men 2x>F
mostly dx after 50 equal in blacks,whites,jews, all colors of the rainbow, yay!! |
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etiology of PD
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patho unknown
maybe from-living in boonies-well water(temps is fucked) programed cell death chronic infxn |
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possible protective factors for PD
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SMOKING(WTF??) + CAFFINE
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diff btwn PD and other dementia
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unilateral-like in arm, others usually bilateral like progessive supranuclear palsy, corticobasalganglionic degen.
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drug induced parkinsonism
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20% of parkinsons cases
-antipsychotics -antiemetics -antiepileptics -CV agents-methyldopa |
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diagnosis of PD
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2 of following:
limb mucle rigidity resting tremor bradykinesia postural instab.-last stage + drugs don't tx this |
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secondary symptoms of PD
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less swinging of arms
shuffling gait-small steps hypophonia-speak softly decreased dexterity |
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how to monitor disease progession of PD
and define stages |
hoehn and Yahr scale
stage1-unilateral-just tremor 2-bilater-no postural abnormalities 3-bilater, mild post.-still independent 4-bilateral, post instabl + need help 5-bilater, bed ridden (most debilitating DTD) |
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NON Pharm agents to tx PD
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educate pt + caregiver
nutrition physical/speech therapy exercise |
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surgical options for PD
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pallidotomy + thalatomy-for refractory pts, not used much
deep brain stim(DBS)-MOST USED |
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Pharm therapy options for PD
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L-dopa/decarb inhib
D2 direct agonists anticholinergic NMDA MAO-B COMT inhib DOES NOT STOP DISEASE PROGESSION! |
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Sinemet
gen name? MOA max dose per day what dose should always be? t1/2? |
carbidopa/levodopa
increases amt of levodopa in BBB, carb-prevents conversion of ldopa outside brain-prevents hypertensive/ NV SE max 200/800/day should be at least 75mg of carb per day or get BAD NV t1/2-1.5 h, with carb is 2.5 |
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summary of controversial levodopa data?
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all doses>placebo, dose related dyskinesias
2011 study-doesnt hasten disease like thought it might |
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sinemet Pros/cons?
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pro-gold standard, good pt response
con-dyskinesias, dystonia, increased risk of dementia, lost efficacy |
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counseling pts for sinemet
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tk 30 mins before or 60 mins after meal-to prevent competition with other AA
SR form can be WITH FOOD! Do NOT give to pts with malignant melanoma/ closed angle glaucoma** taper med! |
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what happens if you abruptly DC sinemet
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Neuroleptic malignant syndrome(NMS)
fever muscle rigidity altered mentality autonomic instability |
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direct dopamine agonists for PD
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bromocriptine
apomorphine pramipexole ropinirole |
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ergot derived SE
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retroperitoneal fibrosis-fiber round kidney
pleuropulmonary fibrosis-tissue growing around lung |
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bromocriptine
brand name? receptor affected? t1/2 |
parlodel-ergot derivative
d1 antag, d2 t1/2-3H |
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ropinirole
brand? DI? |
requip-nonergot
dose should be increased by .25mg TID q wk Intxn-fluvoxamine, cipro, cigarretts(induces metab-so give more drug) |
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Pramipexole
brand? t/12 excreted? Intxn? |
mirapex-nonergot
t1/2-8H, 12-14 in elderly 90%renally excreted Intxn-cimetidine prolongs t1/2 by 40% |
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apomorphine
brand? FDA indicated for? given how? pre treat with? |
apokyn
FDA-for acute,given SC ONLY, off episodes,-hypomobility!!! pretreat with tigan(antiemetic), but not 5HT3 antag(ondanstron) |
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Dopamine agonist S/E
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at high doses at initiaion:
N/V, orthostatis confusion, hallucination BBW-for nonergot-SLEEP ATTACKS |
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Dopamine agonists
other S/E |
gambling
-mostly with mirapex -pts had no priot hx -stopped when D/Ced |
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Dopamine agonists
pros vs cons |
pros-levodopa sparing effect(less dyskinesias)
apomorphine-for off episodes cons-pedal edema(untxable) hallucination, postural hypotension |
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Dopamine agonist
Counseling |
reduce levodopa by 20-30% when given with Dopamine agonist
PTs with uncontrolled BP can NOT be given bromocriptine -don't drive on meds |
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Anticholinergic agents
drugs and MOA |
dec. cholinergic activity
benztropine .5-6mg/day trihexyphenidyl- 1-15mg/day |
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anticholinergic agents
pros vs cons |
pros-good for tremor
-useful for mild disabilities in first years of onset cons-NO benefit for others-bradykinesia, gait disturb. SE |
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NMDA for PD
drug MOA dose renal dosing |
amantadine(symmetrel)
increases dopamine release dose-100mg BID-TID CrCl 30-50: 100mgDaily 15-29: 100mg QOD <15: 200mg weekly |
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Amantadine
pros vs cons |
pros-suppres l-dopa dyskinesias
effective against tremor transient SE's cons-renally dosed, livedo reticularis(purple spots on legs) |
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NMDA counseling pts
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monitor renal fxn:Scr/Bun
watch alcohol-will increase CNS effects |
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MAOI-Bs for PD
drugs? MOA? DOSES |
selectively inhib MAO-b-icnrease DA
rasigline-for younger pts- 1mg/day mon or .5mg/day combo oral selegeline(eldepryl)- 10mg/day zelapra(ODT selegiline)-1.25-2.5mg/day |
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Selegiline
PK stuff Interactions? |
90% protein binding
metab into amphetamine derivatives=insomnia, give in AM intxn-SSRIs(prozac), meperidine, PSE |
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eldepryl or zelapar?
better choice? |
zelapar is better-higher conc-buccal absorp
less metabolities-amphetamines |
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Rasagiline for PD
pk? metab? Intxn? |
azilect
88-94% protein binding non-amphetamine derivative-no insomnia **MORE NEUROPROTECTIVE** Intxn-same as selegiline + st johns wort, cipro, cyclobenzaprine |
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MAOI-B
pros vs cons |
pros-extend effects of levodopa-reduces dose
reduces "off time" neuroprotective cons-jitteriness + insomnia serotonin syndrome |
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MAOiB Counseling
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avoid food + drink for 5 mins before and after buccal selegiline
-restrict tyramine -eldepryl in AM -don't use MAOIs and SSRIS=serotonin syndrome |
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MAO-B inhib
tyramine crisis causes |
hypertensive crisis
risk is less with MAOb vs A |
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COMT-Inhib for PD
drugs? MOA? |
allows levodopa to cross BBB, extends t1/2 of levo
entacapone(comtan)-200mg with each sinemet dose(max 8/day) stalevo(sinemet + entacopone)-max 8/day tolcapone(tasmar)-100mg TID |
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COMT inhib
pros vs cons |
pros-no titration needed
extends levo effects adjunct for motor problems cons-ineffective without levodopa canNOT be with MAOb tolcapone-fatal hepatotox |
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Counseling Pts with COMTinhib
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tolcapone with food, before or after
DO NOT USE with liver disease hx causes URINE DISCOLORATION decrease levodopa dose by 10-20% with COMT |
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treatment guidelines for PD
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1st line-levodopa, dopamine agonist, rasagline
-amandtadine, anticholin. may modestly improve mild symptoms |
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treatment guidelines PD
for younger pts <65 |
dopamine agonists or MAO-B(rasagline)
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tx guidelines for PD
>65 years old |
levodopa
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PD complications
motor fluctuations "on-off" |
mf-cuz short t1/2 of l-dopa
-freezing, transient inability to start movement on-off - good movement/then bad tx- with low protein meals, change dosage form of l-dopa, then add dopamine agonist or COMT(best option) |
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how to tx "wearing off" effect
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1-add dopamine agonist
2-then try COMT(entacopone) or MAOB(rasagline) 3-give ldopa more freq. or give CR form |
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PD complications
tx freezing with? |
usually due to environmental, physical cues
tx by walking devices, changing tx is NOT helpful |
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PD pts with dyskinesias
how to tx |
smaller more frequent ldopa
add dopamine agonist add amantadine or COMT |
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L-dopa induced dystonias, akathasia
how to tx? |
dystonia-usually in distal extremity
tx with Sustained release at night dopamine agonist Akathasia-tx with benzo, propanolol, gabapentin |
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PD non motor complication
tx with? |
depression most common
-50% tx with-SSRI, Amitriptyline(but TCA, may be bad) |
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Tx psychosis in PD
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D/C offending med
1.anti-cholin 2.amantadine 3.selegiline 4.Ldopa/COMT/dopa agonist if doesnt work tx with these: clozapine 6.25-50mg quetapine 12.5-100mg |
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how to tx dementia in PD
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decrease anticholinergic meds
cholinesterase inhib-donepezil, rivastigmine these DO NOT reverse dementia |
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migraine HA
who gets em more? whats it linked to |
<12 yo...more in boys
>or =12 girls 2,3x more linked to menstruation, usually gone by age 50, but can go one after |
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current thought for patho of migraines
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primary neuronal dysfxn
-intra + extracranial changes accounts for-1)premonitory symptoms, 2)aura, 3)HA |
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whats older theory for migraines
whats neurovascular theory |
vascluar HA caused by vasodilation, auro from vasoconstriction
neurovascular-is combo of old(vascular) + new(neuro)-confirmed by MRIs |
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trigeminal nerve stim releases wht chemicals?
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substance P, Neurokinin A, Calcitonin gene-related peptide(CGRP)
these are vasoactive-promote vasodilation |
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potential triggers for migraines
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stress
foods-alcohol estrogen barometric pressur changes flickering lights |
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how do migraines present
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usually unilateral
pain onset-gradual, 4-72H if untreated |
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Aura
what is it? what are postive features? negative features? |
fully reversibile visual, sensory or speech symptoms
pos sx-flickering lights, spot, lines neg sx-los of vision, numbess can be any combo |
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what is common migraine?
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migraine without aura
more frequently then migraine with aura |
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migraine without aura
diagnosis |
at least 5 attacks
lasts 4-72H HA with 2 or more of: -unilateral location -pulsating -mod/severe pain -aggravated by exertion during HA >1 or =: N+/-V photophobia and phonophobia |
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migraine with aura
known as? what is aura? |
AKA classic migraine
aura-neurlogic symptoms before onset of HA hours to days before HA sx are yawning, blurred vision, N |
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migraine with aura
diagnosis |
at least 2 attacks
aura has : 1 >or= 1 fully reversible aura symptom 2. >or=1 aura sx over 5mins or 2 sxns together 3. no aura sx lasts>60mins HA after aura within 60mins, or can be during |
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treatment goals for acute Migraines
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tx attacks rapidly
minimize backup/rescue meds CAN BE CONTROLLED, BUT NOT CURED |
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nonpharm therapy for migraines
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avoid triggers
-limit caffine wellness program changes in estrogen levels quiet,dark, and ice HA diary |
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point of HA diary
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track HA
detect ineffective therapy or factors that may improve HA tx |
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tx of migraines
mild to moder- mod to severe- stratified care- |
mild to mod-pts not disabled/can fxn during attack
mod/severe-pts have disability/unable to fxn normally during stratified care-pick tx on symptom severity/disability |
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general principles for migraine tx
-meds not effective against? limit use to? |
admin meds at onset of HA or aura, if migraine during aura
meds not effective for neuro symptoms of migraines(aura) dont use more than 2 days/wk |
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Mild/Moderate
use what meds to tx |
APAP/NSAID/combo OTC
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tylenol
MOA |
bloacks PG synthesis in CNS
-not an antiinfam drug -no risk with asthma |
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NSAID
MOA |
non selective COX1,2 inhib
anti-inflam action-prevents in trigeminovascular area not ideal for ppl with ulcers nor asthma |
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Excedrine migraine
whats in it MOA |
apap-250mg
asa-250mg caff-65mg inhib prostaglandin/and adenosine antag |
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Mild to Mod therpy after trying OTC drugs
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midrin
fioricet fiorinal |
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midrin
-whats in it max? comparable to what? what class? |
3 part combo drug
-isometheptene (constricts) -dichloralphenazone(Sedative) -APAP max 5 caps in 12 hr(<20caps/month) can be used for longer than other meds equally eff with ergots CIV drug |
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Fioricet
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APAP/butalbital/caffeine
must taper if long term use-or get bad HA, tremors come in codiene formulations |
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fiorinal
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asa, butalbital, caffeine
CIII has codeine forms-no alcohol |
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severe treatments
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triptans
1st gen-sumatriptan 2nd gen-all others-fuck tons |
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triptans
MOA |
analogues of 5HT
selective for 5HT1B/1D agonist 1B-constriction of vessels 1D-inhib. neuropeptide release, stops pain signal transm. |
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triptans
CI in? SE |
if CAD, or UNCONTROLLED HTN(ok if controlled HTN), CVD
SE-somnolense, tingling(parathesias) chest pain not to be within 24H of ergots or within 2 wks of MAOIs |
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Triptans
DOC for? taken when? |
moderate to severe attacks
take at onset of HA |
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whats gold standard in txing migraines
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sumatriptan
79%relief in 1-2hrs for subq form HA reccurence 40%-biggest prob w drug onsets SQ>INS>PO |
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whats point of 2nd gen triptans
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decrease HA recurrence
increase bioavai(shorten onset) decrease SE(chest sxn)- 50% for 1st gen, 15%2nd gen |
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triptans
clinical eff related to what? HA recurrence related to what? |
clinical eff-related to Tmax
HA recurrence-related to t1/2 1st gen 40% 2nd gen 30% if one fails, try another |
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which triptain has fastest onset?
longest halflife? must be repeated in 4h? |
rizatriptan is fastest-1 to 1.5H
Frovatriptin(forever) lasts 25H t1/2 Naratriptan-repeat in 4H(normally 2H for other meds) |
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which triptans come in ODT form?
which are intranasal? |
Riza + Zolmi
IN-suma + zolmi |
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STUDY
which has highest likelihood for success? |
riza, ele, and almo
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choosing a triptan
which was well tolerated? most effective? |
nara and almo
ele-but save for after trying suma |
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treximet
whats in it |
suma + naproxen
statistically better than suma alone |
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ergotamines
how often used? BBW? example of one |
less commonly used
DO NOT USE w strong CYP3A4 inhibitors-risk of cerebreal ischemia Migranal |
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Migranal
what form? |
intranasal
long half life-aka recurrence IN-good for N/V pts, gastric statis IV form must be given with IV antiemetics |
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Opioids
used for what? when? examples of meds |
used for severe migraine
last line-in ERs meperidine oxy's hydromorphone BUTORPHANOL |
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Butorphanol
MOA |
last line agent
mixed Mu agonist/antag + Kappa agonist INH, 15 min onset often overused/abused |
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Medication overuse Headache
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from frequent or excessive use of acute migraine meds-all agents possible
chronic daily headache (>15 days per month)-rebound headache must slowly taper-combos have greater risks |
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Med Overuse HA
requires what? limit use of acute tx to what? |
requires washout period-may tk several weeks
limit: 2 and NO MORE than 3 days/wk |
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preventative therapy for migraines
whos candidate |
recurring/frequent migraines interfere with daily stuff
CI/failure of acute therapies/ overuse >2days/wk |
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gen principles for preventive therapy
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start low and go slow
sustained for 4-8 wks before benefit maintained >5 to 6 months once a >50% dec in HA happens |
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success rate for preventative therapy
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50-75% success
-considered success if dec. freq of attacks by >50% rarely resut in complete eradication of HA(Not gonna be cured) |
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preventative therapy
tx strategies Episodic- Short term- Chronic |
Episodic-HA trigger known
short term-exposure to trigger is limited chronic-longer term needs |
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Preventative meds
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BB
Anti-depressants anticonvulsants CCB NSAIDs |
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preventative therapy
1st line? |
Propanolol
Timolol Amitriptyline Depakote Topiramate |
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Preventative therapy
2nd gen |
other BB
ACEI antidepress OC's Botox |
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CCBs can tx what in migraines?
serotonin receptor antag drug? |
aura symptoms
methysergide |
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BB
which ones MOA theorized |
propanolol
timool dec pressure, decrease HA |
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Antidepressants
which drugs |
amitriptyline-limited cuz weight gain,
nortriptyline-more activating |
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Anticonvulsants
SE |
Depakote
Topiramate other MAY BE effective SE-hepatotix-monitor LFT teratogenic-bad for preggers Paresthesia |
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Define remission for epilepsy
% of ppl successfully taken off meds |
5 yrs serizure free on meds
70% will 35% of retards will 75% will be successfully withdrawn form meds |
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define
seizure epilepsy epileptic syndrome |
seizure-sudden change in electrical activity=change in consciousness, motor
epilepsy- >or =2 seizures without clear reason epileptic syndrome-cluster of signs/sxs occurring same time -age of onset, type, duration, rsp to tx |
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drug induced seizures
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antidepressants-bupropion, maprolline
alcohol theophylline/caffiene amphetamine, ritalin, cocaine, Meperidine |
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patho of seizures
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abnormal discharge of neurons in cerebral cortex
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spread of excess sitability
local= 2 more subdivision of this widely= |
local=FOCAL or partial seizure(1 sided)
a) simple-conscous b) compex-UNcon. widely=generalized seizures (2 sides) |
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Neurotransmitters
Excitatory- Inhibitory- Other Factors- |
Excit-Glutamate, ACH, H1, NE
Inhib-GABA, Dopamine OF-pH, Ion Channel, O2 supply, energy supply |
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Glutatmate
describe |
IONTROPIC-NMDA, AMPA, Kainate(Na/Ca)
Metabotropioc-2d mess. cAMP |
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GABA
describe |
IONOTROPIC
-chlories movement inhibitoary action **REMEMBER BENZO'S |
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phases of seizure activity
prodrome- aura icta- postictal |
prodrome-behavior change before seizure by D or H
Aura-senses warning of seizure(smell, sound, sight) ictal-seizure happening posticta-HA, confused, lethargy |
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secondary generalized falls under which classification
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under partial, starts in 1 side then spreads
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types of generalized seizures
absense myoclonic tonic-clonic |
ab-nonconvulsive, 10-30sec loss of conscousness, stare, distant
myoclonic-quick jerky movements of upper body tonic-clonic- convulsive motor w loss of cons. 5 phases |
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what are 5 phases of tonic-clonic
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flexion, extension, tremor, clonic, postical
tonic-rigidty clonic-rhytmic jerk atonic-loss of muscle tone |
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epilepsy syndromes
symptomatic idiopathic cryptogenic |
sympto.-known cause/brain damage known
idio-unknown reason, usually primary generalized cryptogenic-suspected cause but cant document -no reason for partial seizure ex-LGS, Juvi Myoclonic Epilepsy |
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partial seizure drug tx
1st line |
carbamazepine/Oxcarb
Topiramate phenytoin Valproic Acid |
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absence seizure
1st line |
ethosuxamide
Valproic Aicd if other types also like tonic-clonic |
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myoclonic seizures
1st line 2nd line |
1st-VPA
2nd-Clonazepam Lamictal will make worse |
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Gen Tonic Clonic Tx
preferred |
Carbam
Phenytoin Phenobarb |
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Atonic seizure Tx
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NO APPROVED TX
1st line-VPA, Zonisamide others ok-topiramate, lamictal, flbamate- theses used for LGS also |
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Infantile Spasms Tx
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ACTH, Vigabatrin-FDA approved meds
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describe LGS
Lennox-Gastuate Syndrome |
onset before age 4
mental retardation multiple seizure types |
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describe Juvi Mycolonic Epilepsy
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onset in adolenscence
early AM jerking Hx of Absence** |
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LGS drug Tx
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no consistent effect tx
caused by CNS infxn/ brain malform/injury Clonazepam |
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Status Epilepticus Tx
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when u have continuous seizures >30mins-recover conscioun inbetween seizures
emergency situation use Benzo(Loraz + Diaz) phenyo/fospheny phenobarb |
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Antiepileptic drugs work how
3thigns |
1-affect Na + Ca ion channel
2-increase GABA(inhib) 3-decrease excitatory (glutamate + aspartate( transmission |
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goals of therapy
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stop seizure, lessen freq
lower drug S/E/DDI Address QOL-no prg, running |
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whats better than PB or Primidone for efficacy and has has lowest SE?
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CBZ, PHY
CBZ had fewer SE |
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Oxcarb is similar in efficacy with ?
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CBZ, PHY, PB
with fewer SE |
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which drugs have high cognitive impairment
low impairment? |
high-PHB, Primidone, Topiramate(without insight)
low-VOA, Gabapentin, Lamictal |
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DDI
which are 3A4 Inducers? |
(wide)3A4 inducer-CBZ, PHY, PB, Primidone
lesser-felbamate, OCBZ, Topirmate |
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2C19 inhibitors
UGT1A4 |
VPA, Topirmate, OCBZ, Felbamate
UGT-Valproic Acid |
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Medication Management steps
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1establish syndrome
2-select right med for specific pt and syndrome 3-start and titrate med for tolerability 4-increase med-regardless of conc-till seizure control |
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medication step continued
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if cant control-change med
goal-monotherapy next- add 2nd drug if necc. document all steps |
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T or F
diff seizures respond to different serum concentrations |
true
CBZ-27% higher level needed for partial vs general PHY-67% higher needed |
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when to draw a dose for drug levels
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4-5 half lives after giving or dosage change
morning prior to giving dose |
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drug D/C
criteria for doing it |
2-5 yrs seizure free, single seizure type
process- slow 6wks to 3months per drug 1 agent at time if seizure-does NOT mean failure |
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risk factors for seizure recurrence when D/Cing
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seizures after age 12
family hx partial seizures withdrawls from Valproate or PHY |
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Tegretol
gen name? FDA indications? MOA? Tx range |
Carbamazepine
for-partial seizures, 2nd generalized seizures, GTC, neuralgia MOA-Na channel blocker Conc- 6-12mcg/ml |
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Carbamazepine
DDI? |
autoinducer/inducer
can be therapuetic level now, then 2 wks its lower cuz autoinduction |
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CBZ
SE BBW Monitor? |
SE-double vision
SIADH Lupus like sx BBW-SJS, Aplastic anemia + agranulocy. monitor-WBC <2500 or ANC <1000 D/C LFT baseline-q2wks PREG CAT D |
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Dilantin
gen name? FDA indications? MOA TX range |
phenytoin
GTC, complex partial seizure, prevention head surgery MOA-Na channel blocker conc- 10-20mcg/ml |
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Phenytoin
PK |
90%protein bounc
if hypoalbum <3.5 do equation PHTCORR=PHTmea/(adjX ALB) + .1 small dose increase can have disporpotional effex-MM absorption |
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Phenytoin
SE toxicity |
ocular-nystagus, blurred vision
toxicity: 20mcg-nystagmus, slurring 30-drowsiness, diplopia >40 coma, seizure, status epilepticus |
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Phenytoin
other SE IV:PO |
purple glove-IV
gingical hyperplasia Vit D, Folate def-osteoporosis 1:1 |
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Phenytoin
if <7mcg/ml do what? 7-12 >!2 |
<7- increase by 100mg/day
7-12 increase 50mg >12 increase by 30 or less |
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Phenytoin DDI
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Preg D
inducer decrease FA, but if u give FA it will decrease PHY-FUCK! PHY lvl decrease by chronic alcohol, but increased by acute alcohol OC decreased by PHY |
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Phenytoin
given how? limited to what rate? mixed with? |
given IV, if IM-get crystals
50mg/MIN mixed ONLY w/ NS |
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Fosphenytoin
conc range FDA indication given how iv:PO |
10-20mcg/ml
status epilecpticus, neurosuregry IV or IM 1:1 IV:PO water soluble-mix with NS or D5W |
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PHY may worsen what?
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absence seizures
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Fosphenytoin
FPHY TO PE ratio? rate? monitor what? |
1.5FPHY:1PHY
150mg Phenytoin EQ/min 1.5Fosphy=1PE monitor-drug level 2H after IV, 4H after IM |
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Depakote
gen name? indication? MOA conc? |
valproic Acid
1st line-primary generalized, complex partial, mixed seizures MOA-increases GABA activity |
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Valproic Acid
S/E monitor give when IV rate? |
GI irriatation-take with food
monitor-PLT, INR give at bedtime rate:admin over 60 mins <20mg/min |
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when switching from depakote to DR,to ER do what?
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increase ER 8TO 20%, not equivalent
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Valproic Acid
BBW |
hepatic failure-monitor LFTS 1st 6 months
teratogenic-SPINA BIFIDA pancreatitis |
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VPA DDI
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increase PHY, PB, CBZ, Lamictal
aspriin increases VPA DOES NOT INTERFERE WITH OC!!!! |
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Zarontin
gen nname? DOC for? MOA DDI |
ethosuximide
DOC-absence siezures inhibits T-type Ca channel DDI-srum levels increase when with VPA |
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Phenobarb
DOC? MOA Indications IV mix with what |
DOC-neonatal seizures
enhances GABA+ increases seizure threshold Conc- 20-40mcg/ml adults 15-30 kids IV-mix with propylene glycol and alcohol |
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Primidone(mysoline)
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prodrug of phenobarb
metab to phenobarb and PEMA-PEMA will potentiate phenobarbital metab |
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Felbamate
FDA INDICATION MOA used for.... |
>14 yo-partial seizures
>2yo LGS moa-blocks MDA used for refractory pts |
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Felbamate
watch for? decrease what? |
watch for infxn, brusining, hepatitis-may cause aplastic anemia
decreased PHY, CBZ, VPA by 30% |
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Gabapentin
FDA indications MOA- |
for partial seizures(adjunct)
inhibits Ca Channel, increases GABA in brain |
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Gabapentin
eliminated how? Pt counseling |
renal-adjust in renal pts
do not take with antacids, take with FOOD |
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Lyrica
gen name? FDA MOA |
pregabalin
FDA-partial seizure, neuraliga MOA-binds Ca channel-dec in excitation decrease dose if Crrcl<60 no interactions, Weight gain |
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Lamictal
FDA indications MOA DDI |
partial seizure(adjunct + mono)
LGS Tonic-Clonic, primary generalize inhibits Na channel + Ca channel clearance inhib by BPA induced by PHY, CBZ, PB, primidone |
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Lamictal
BBW |
titrate to reduce these
SJS aseptic meningitis OCs decrease ? |
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Gabitril
gen name> MOA conc increase with... |
Tiagabine
inhibits GABA uptake increase with hepatic impairment serum lvls lower in PM than evening |
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Gabatril
DDI |
pretty safe
clearence inc by CBZ, PB, PHY, PRIM displaced by naproxen |
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Topiramate
Indications? MOA |
partial seizure, GTC (adjunct + mono)
blocks Na, Ca channel and affects GABA (all 3) |
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Topamax SE
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oligohydrosis/hypertermia
hydrate/keep outta sun weight loss from Nausea |
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Trileptal
gen name? conc? for? MOA CBZ:OCBZ ration |
oxcarbazepine
conc- 12-30 for-partial seizure(mono+adjunct) block Na channel via 10-MHD effective in ppl no responding to CBZ CBZ:OCBZ 1:1.5 |
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Oxcarbazepine
SE |
better tol then CBZ
more hyponatremia-bad in old ppl DECREASES OC effect. monitor Na |
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Keppra
MOA |
Levetriacetam
unkown: binds to SV2A to prevent nerve conduction |
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Zonisamide
for? MOA SE |
partial seizure adjunct
MOA-blocks NA, Ca increase every 2 weeks SE-nephrolithaias skin eruptions sulf allergy |
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Vimpat
gen name? for? MOA? |
Lacosamide
partial adjunct enhance slow inactivation of Na binds collapsin response mediator protein CV med POdose=IV dose |
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Lacosamide
SE |
prolongs PR interval-get ECG first
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Sabril
gen name? for? MOA |
vigabatrin
infantile spasms(mono) inhib GABA transminase, incr GABA only thru SHARE program |
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Vigabatrin BBW
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permanent vision loss-vision test at baseline and Q 3month
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non pharm epilepsy tx
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surgery-focal epilepsy 8--90% success
ketogenic diet vagal nerve stimulator |
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which drugs increase metab of OC
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PB, PHY, CBZ, OXCARB, Felbamate
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which have no interaction with OC
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VPA, Lamictal, gabapentin, tiagabine, keppra
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to prevent teratogenicity do what
preg complication of PK |
give folic acid suppl 4mg QD
albumin binding decreases hepatic/renal metab increase |
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breast feeding
neglible conc in infants |
CBZ, PHY, VPA
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neoname+ infants require-
newborns up to 2-3 requier 2-3 require |
neonames-lower doses, more water less ablumin
newborns-lower doses, bad renal systems 2-3yo- higher dose, hepatic lvl > adults |
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Ethosuximide conc levels
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therapuetic conc is 40-1100mcg/ml
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status epilepticus
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>or = 2 seizures, with incomplete consciousness or seizure >30mins
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status epil
etiology |
no structual lesion-infxn, low AED lvls, alcohol
structural lesion-tumor, hypoxia, trauma, stroke |
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evaluate what labs for status epilep
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electrolytes
urine drug screen CBC w differential arterial blood gas EEG MRI, spinal tap |
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benzos for status
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lorazepam-long DOA
diazepam-30 min onset dilute in equal volume of dilutent give IV not IM |
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TX ALOGRITHM
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1 supportive care
2 benzo 3 pheny, fospheny 4. pehnobarb 5. valproate |
