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230 Cards in this Set

  • Front
  • Back
Dx Dementia requirements
loss of mental fx in at least 3 of
language
understanding of speech
memory/reasoning
emotion
dementia includes what seperate disease states?
alzheimers
mild cognitive impairement
lewy body dementia
vascular dementia
what OTC is good for memory improvement
Geritol is recc.-complete multimvitamin
Alzheimers Disease

risk factors
age
male sex
genetics-APOE4
Brain Size
Parho of Alzheimers
APP->Bamyloid->amyloid plaque

Bet a protein makes NFT=loss of neuronal activity

abnormal tau protein binding also causes collapse
AD diagnosis

DSMIV Criteria
confirmed upon DEATH

oneof more of:
apraxia, aphasia, agnosia, executive functioning disturbance

impairment of social/ocupational fxn
stages of AD
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
MMSE
mini-mental status exam
max score-30
Aids in DX

usually dec in 2/3 pts/yr in AD pts
ADAS
AD assesment
specific for AD vs other dementias
0-70(70 worse)
longer test than MMSE
Mini-COG
memory test

remember 0-demented
1 or 2-clock test-abnormal-demented
-normal clock-ok

3=ok
Therapeutic goals
of AD for pt
cognitive improvement-decision making
daily living improv.-washing, cleaning
slow progession
delay nursing home
no mater what exam used for AD.......Ad is a disease of _______
exclusion
AD drugs
AChE-I's

NMDAs

Antipsychotics/Antidepressants
AChE-I's for AD
tacrine(cognex)
Donexpezil(aricept)
rivastigmine(exelon)
galantamine(razadyne)
AChE-Is
MOA
indication
inhib centerally active acetylcholinestrase= more ACH

indic-moderate AD
tacrine

brand?
C/I
cognex

used QID
causes hepatox.
CI-drug induced jaundice, bilrubin >3
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
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!!!
Rivastigmine patch
replace daily
saved drug cause less NAUSEA
4 weeks between titration!!!
Galantamine
brand
approved for?
Razadyne/Reminyl
Revers. AChEI's
for mild to mod AD
TITRATE!
donepezil t1/2


exelons t1/2 once patch is removed?
70H!!!

rivastigmine is 3 H past patch removal
AChEis CI
bradycardia
Heart Block
asthma/COPD
active PUD
AChEIs comparison
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
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
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
Memantine counseling for caregivers
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
Vit E for AD
MAOIs for AD
NSAIDS?
mixed efficacy

selegiline-mixed results

NSAIDS-dec inflam state of AD, but limited studies
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
depression with AD
diff. to determine which came first

tx-SSRIs-prozac,celexa,zoloft

avoid-TCAs and paxil-anticholinergic properties
agitation and psychosis in AD
most get in 3 yrs of diagnosis
tx reversible agitation-pain, withdrawl, environmental problems

use antipsychotics, antidepressants, mood stabilizers
what is sundowning
hot to tx
time of day when agitation increases(evening hours)

exposure to sunlight helps-maybe melatonin
antipsychotics for severe cases
antipsychotics in AD
BLACK BOX WARNING-avoid if possible...increased risk of mortality....yet we still do it???
antipsychotics commonly studied in AD
atypicals mainly
risperdal, seroquel, geodon, haloperidol

start low-go slow, and sometimes say NO!
mood stabalizers-if failed other tx
future tx od AD
vaccine!!!!
beta -gamma secretase inhib
Parkinsons Disease
what is it and where
progessive, neurodegenerative
loss of dopaminergivc cells in basal ganglia
-NO CURE!
PD
ach vs Dopamine
Ach(excitatory) LOTTTSSSSS
dopamine(inhib)-LITTTTLLEEEEE
Hyperkinesia-da vs ach

choreatic disorders-da vs ach
hyperkinesia-dopamine high, ach normal

choreatic-ach low, dopamine normal
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!!
etiology of PD
patho unknown
maybe from-living in boonies-well water(temps is fucked)
programed cell death
chronic infxn
possible protective factors for PD
SMOKING(WTF??) + CAFFINE
diff btwn PD and other dementia
unilateral-like in arm, others usually bilateral like progessive supranuclear palsy, corticobasalganglionic degen.
drug induced parkinsonism
20% of parkinsons cases
-antipsychotics
-antiemetics
-antiepileptics
-CV agents-methyldopa
diagnosis of PD
2 of following:
limb mucle rigidity
resting tremor
bradykinesia
postural instab.-last stage + drugs don't tx this
secondary symptoms of PD
less swinging of arms
shuffling gait-small steps
hypophonia-speak softly
decreased dexterity
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)
NON Pharm agents to tx PD
educate pt + caregiver

nutrition
physical/speech therapy
exercise
surgical options for PD
pallidotomy + thalatomy-for refractory pts, not used much

deep brain stim(DBS)-MOST USED
Pharm therapy options for PD
L-dopa/decarb inhib
D2 direct agonists
anticholinergic
NMDA
MAO-B
COMT inhib

DOES NOT STOP DISEASE PROGESSION!
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
summary of controversial levodopa data?
all doses>placebo, dose related dyskinesias
2011 study-doesnt hasten disease like thought it might
sinemet Pros/cons?
pro-gold standard, good pt response

con-dyskinesias, dystonia, increased risk of dementia, lost efficacy
counseling pts for sinemet
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!
what happens if you abruptly DC sinemet
Neuroleptic malignant syndrome(NMS)
fever
muscle rigidity
altered mentality
autonomic instability
direct dopamine agonists for PD
bromocriptine
apomorphine
pramipexole
ropinirole
ergot derived SE
retroperitoneal fibrosis-fiber round kidney

pleuropulmonary fibrosis-tissue growing around lung
bromocriptine
brand name?
receptor affected?
t1/2
parlodel-ergot derivative
d1 antag, d2
t1/2-3H
ropinirole
brand?
DI?
requip-nonergot
dose should be increased by .25mg TID q wk

Intxn-fluvoxamine, cipro, cigarretts(induces metab-so give more drug)
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%
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)
Dopamine agonist S/E
at high doses at initiaion:
N/V, orthostatis
confusion, hallucination
BBW-for nonergot-SLEEP ATTACKS
Dopamine agonists
other S/E
gambling
-mostly with mirapex
-pts had no priot hx
-stopped when D/Ced
Dopamine agonists
pros vs cons
pros-levodopa sparing effect(less dyskinesias)
apomorphine-for off episodes

cons-pedal edema(untxable) hallucination, postural hypotension
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
Anticholinergic agents
drugs and MOA
dec. cholinergic activity
benztropine .5-6mg/day

trihexyphenidyl- 1-15mg/day
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
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
Amantadine
pros vs cons
pros-suppres l-dopa dyskinesias
effective against tremor
transient SE's

cons-renally dosed, livedo reticularis(purple spots on legs)
NMDA counseling pts
monitor renal fxn:Scr/Bun

watch alcohol-will increase CNS effects
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
Selegiline
PK stuff
Interactions?
90% protein binding
metab into amphetamine derivatives=insomnia, give in AM
intxn-SSRIs(prozac), meperidine, PSE
eldepryl or zelapar?
better choice?
zelapar is better-higher conc-buccal absorp
less metabolities-amphetamines
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
MAOI-B
pros vs cons
pros-extend effects of levodopa-reduces dose
reduces "off time"
neuroprotective

cons-jitteriness + insomnia
serotonin syndrome
MAOiB Counseling
avoid food + drink for 5 mins before and after buccal selegiline
-restrict tyramine
-eldepryl in AM
-don't use MAOIs and SSRIS=serotonin syndrome
MAO-B inhib
tyramine crisis causes
hypertensive crisis

risk is less with MAOb vs A
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
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
Counseling Pts with COMTinhib
tolcapone with food, before or after

DO NOT USE with liver disease hx

causes URINE DISCOLORATION
decrease levodopa dose by 10-20% with COMT
treatment guidelines for PD
1st line-levodopa, dopamine agonist, rasagline

-amandtadine, anticholin. may modestly improve mild symptoms
treatment guidelines PD
for younger pts <65
dopamine agonists or MAO-B(rasagline)
tx guidelines for PD
>65 years old
levodopa
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)
how to tx "wearing off" effect
1-add dopamine agonist

2-then try COMT(entacopone) or MAOB(rasagline)

3-give ldopa more freq. or give CR form
PD complications
tx freezing with?
usually due to environmental, physical cues

tx by walking devices, changing tx is NOT helpful
PD pts with dyskinesias
how to tx
smaller more frequent ldopa
add dopamine agonist
add amantadine or COMT
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
PD non motor complication
tx with?
depression most common
-50%

tx with-SSRI, Amitriptyline(but TCA, may be bad)
Tx psychosis in PD
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
how to tx dementia in PD
decrease anticholinergic meds
cholinesterase inhib-donepezil, rivastigmine

these DO NOT reverse dementia
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
current thought for patho of migraines
primary neuronal dysfxn
-intra + extracranial changes
accounts for-1)premonitory symptoms, 2)aura, 3)HA
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
trigeminal nerve stim releases wht chemicals?
substance P, Neurokinin A, Calcitonin gene-related peptide(CGRP)

these are vasoactive-promote vasodilation
potential triggers for migraines
stress
foods-alcohol
estrogen
barometric pressur changes
flickering lights
how do migraines present
usually unilateral
pain onset-gradual, 4-72H if untreated
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
what is common migraine?
migraine without aura

more frequently then migraine with aura
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
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
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
treatment goals for acute Migraines
tx attacks rapidly
minimize backup/rescue meds

CAN BE CONTROLLED, BUT NOT CURED
nonpharm therapy for migraines
avoid triggers
-limit caffine
wellness program
changes in estrogen levels
quiet,dark, and ice
HA diary
point of HA diary
track HA
detect ineffective therapy or factors that may improve HA tx
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
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
Mild/Moderate
use what meds to tx
APAP/NSAID/combo OTC
tylenol
MOA
bloacks PG synthesis in CNS
-not an antiinfam drug
-no risk with asthma
NSAID
MOA
non selective COX1,2 inhib
anti-inflam action-prevents in trigeminovascular area

not ideal for ppl with ulcers
nor asthma
Excedrine migraine
whats in it
MOA
apap-250mg
asa-250mg
caff-65mg

inhib prostaglandin/and adenosine antag
Mild to Mod therpy after trying OTC drugs
midrin
fioricet
fiorinal
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
Fioricet
APAP/butalbital/caffeine
must taper if long term use-or get bad HA, tremors

come in codiene formulations
fiorinal
asa, butalbital, caffeine
CIII
has codeine forms-no alcohol
severe treatments
triptans
1st gen-sumatriptan
2nd gen-all others-fuck tons
triptans
MOA
analogues of 5HT
selective for 5HT1B/1D agonist

1B-constriction of vessels
1D-inhib. neuropeptide release, stops pain signal transm.
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
Triptans
DOC for?
taken when?
moderate to severe attacks

take at onset of HA
whats gold standard in txing migraines
sumatriptan
79%relief in 1-2hrs for subq form
HA reccurence 40%-biggest prob w drug

onsets SQ>INS>PO
whats point of 2nd gen triptans
decrease HA recurrence

increase bioavai(shorten onset)

decrease SE(chest sxn)- 50% for 1st gen, 15%2nd gen
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
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)
which triptans come in ODT form?

which are intranasal?
Riza + Zolmi

IN-suma + zolmi
STUDY
which has highest likelihood for success?
riza, ele, and almo
choosing a triptan
which was well tolerated?

most effective?
nara and almo

ele-but save for after trying suma
treximet
whats in it
suma + naproxen
statistically better than suma alone
ergotamines

how often used?
BBW?
example of one
less commonly used

DO NOT USE w strong CYP3A4 inhibitors-risk of cerebreal ischemia

Migranal
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
Opioids
used for what?
when?
examples of meds
used for severe migraine

last line-in ERs

meperidine
oxy's
hydromorphone
BUTORPHANOL
Butorphanol
MOA
last line agent
mixed Mu agonist/antag + Kappa agonist

INH, 15 min onset
often overused/abused
Medication overuse Headache
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
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
preventative therapy for migraines
whos candidate
recurring/frequent migraines interfere with daily stuff

CI/failure of acute therapies/ overuse >2days/wk
gen principles for preventive therapy
start low and go slow
sustained for 4-8 wks before benefit

maintained >5 to 6 months once a >50% dec in HA happens
success rate for preventative therapy
50-75% success
-considered success if dec. freq of attacks by >50%

rarely resut in complete eradication of HA(Not gonna be cured)
preventative therapy

tx strategies
Episodic-
Short term-
Chronic
Episodic-HA trigger known

short term-exposure to trigger is limited

chronic-longer term needs
Preventative meds
BB
Anti-depressants
anticonvulsants
CCB
NSAIDs
preventative therapy
1st line?
Propanolol
Timolol
Amitriptyline
Depakote
Topiramate
Preventative therapy
2nd gen
other BB
ACEI
antidepress
OC's
Botox
CCBs can tx what in migraines?

serotonin receptor antag drug?
aura symptoms

methysergide
BB
which ones
MOA theorized
propanolol
timool
dec pressure, decrease HA
Antidepressants
which drugs
amitriptyline-limited cuz weight gain,
nortriptyline-more activating
Anticonvulsants

SE
Depakote
Topiramate

other MAY BE effective

SE-hepatotix-monitor LFT
teratogenic-bad for preggers
Paresthesia
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
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
drug induced seizures
antidepressants-bupropion, maprolline

alcohol

theophylline/caffiene

amphetamine, ritalin, cocaine, Meperidine
patho of seizures
abnormal discharge of neurons in cerebral cortex
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)
Neurotransmitters
Excitatory-

Inhibitory-

Other Factors-
Excit-Glutamate, ACH, H1, NE

Inhib-GABA, Dopamine

OF-pH, Ion Channel, O2 supply, energy supply
Glutatmate

describe
IONTROPIC-NMDA, AMPA, Kainate(Na/Ca)

Metabotropioc-2d mess. cAMP
GABA

describe
IONOTROPIC
-chlories movement
inhibitoary action

**REMEMBER BENZO'S
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
secondary generalized falls under which classification
under partial, starts in 1 side then spreads
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
what are 5 phases of tonic-clonic
flexion, extension, tremor, clonic, postical

tonic-rigidty
clonic-rhytmic jerk
atonic-loss of muscle tone
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
partial seizure drug tx
1st line
carbamazepine/Oxcarb
Topiramate
phenytoin
Valproic Acid
absence seizure
1st line
ethosuxamide

Valproic Aicd if other types also like tonic-clonic
myoclonic seizures
1st line
2nd line
1st-VPA
2nd-Clonazepam

Lamictal will make worse
Gen Tonic Clonic Tx
preferred
Carbam
Phenytoin
Phenobarb
Atonic seizure Tx
NO APPROVED TX

1st line-VPA, Zonisamide

others ok-topiramate, lamictal, flbamate- theses used for LGS also
Infantile Spasms Tx
ACTH, Vigabatrin-FDA approved meds
describe LGS
Lennox-Gastuate Syndrome
onset before age 4
mental retardation
multiple seizure types
describe Juvi Mycolonic Epilepsy
onset in adolenscence
early AM jerking
Hx of Absence**
LGS drug Tx
no consistent effect tx

caused by CNS infxn/ brain malform/injury

Clonazepam
Status Epilepticus Tx
when u have continuous seizures >30mins-recover conscioun inbetween seizures

emergency situation

use Benzo(Loraz + Diaz)
phenyo/fospheny
phenobarb
Antiepileptic drugs work how
3thigns
1-affect Na + Ca ion channel

2-increase GABA(inhib)

3-decrease excitatory (glutamate + aspartate( transmission
goals of therapy
stop seizure, lessen freq

lower drug S/E/DDI

Address QOL-no prg, running
whats better than PB or Primidone for efficacy and has has lowest SE?
CBZ, PHY

CBZ had fewer SE
Oxcarb is similar in efficacy with ?
CBZ, PHY, PB

with fewer SE
which drugs have high cognitive impairment


low impairment?
high-PHB, Primidone, Topiramate(without insight)

low-VOA, Gabapentin, Lamictal
DDI

which are 3A4 Inducers?
(wide)3A4 inducer-CBZ, PHY, PB, Primidone

lesser-felbamate, OCBZ, Topirmate
2C19 inhibitors

UGT1A4
VPA, Topirmate, OCBZ, Felbamate

UGT-Valproic Acid
Medication Management steps
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
medication step continued
if cant control-change med
goal-monotherapy

next- add 2nd drug if necc.

document all steps
T or F
diff seizures respond to different serum concentrations
true
CBZ-27% higher level needed for partial vs general
PHY-67% higher needed
when to draw a dose for drug levels
4-5 half lives after giving or dosage change

morning prior to giving dose
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
risk factors for seizure recurrence when D/Cing
seizures after age 12
family hx
partial seizures
withdrawls from Valproate or PHY
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
Carbamazepine
DDI?
autoinducer/inducer
can be therapuetic level now, then 2 wks its lower cuz autoinduction
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
Dilantin
gen name?
FDA indications?
MOA
TX range
phenytoin

GTC, complex partial seizure, prevention head surgery

MOA-Na channel blocker
conc- 10-20mcg/ml
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
Phenytoin
SE

toxicity
ocular-nystagus, blurred vision

toxicity: 20mcg-nystagmus, slurring

30-drowsiness, diplopia

>40 coma, seizure, status epilepticus
Phenytoin
other SE

IV:PO
purple glove-IV
gingical hyperplasia
Vit D, Folate def-osteoporosis

1:1
Phenytoin
if <7mcg/ml do what?

7-12

>!2
<7- increase by 100mg/day

7-12 increase 50mg

>12 increase by 30 or less
Phenytoin DDI
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
Phenytoin
given how?
limited to what rate?
mixed with?
given IV, if IM-get crystals

50mg/MIN
mixed ONLY w/ NS
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
PHY may worsen what?
absence seizures
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
Depakote
gen name?
indication?
MOA
conc?
valproic Acid
1st line-primary generalized, complex partial, mixed seizures

MOA-increases GABA activity
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
when switching from depakote to DR,to ER do what?
increase ER 8TO 20%, not equivalent
Valproic Acid
BBW
hepatic failure-monitor LFTS 1st 6 months

teratogenic-SPINA BIFIDA

pancreatitis
VPA DDI
increase PHY, PB, CBZ, Lamictal

aspriin increases VPA

DOES NOT INTERFERE WITH OC!!!!
Zarontin
gen nname?
DOC for?
MOA
DDI
ethosuximide
DOC-absence siezures
inhibits T-type Ca channel

DDI-srum levels increase when with VPA
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
Primidone(mysoline)
prodrug of phenobarb

metab to phenobarb and PEMA-PEMA will potentiate phenobarbital metab
Felbamate
FDA INDICATION
MOA
used for....
>14 yo-partial seizures
>2yo LGS

moa-blocks MDA

used for refractory pts
Felbamate
watch for?
decrease what?
watch for infxn, brusining, hepatitis-may cause aplastic anemia

decreased PHY, CBZ, VPA by 30%
Gabapentin
FDA indications
MOA-
for partial seizures(adjunct)
inhibits Ca Channel, increases GABA in brain
Gabapentin
eliminated how?
Pt counseling
renal-adjust in renal pts

do not take with antacids,
take with FOOD
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
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
Lamictal
BBW
titrate to reduce these

SJS
aseptic meningitis
OCs decrease ?
Gabitril
gen name>
MOA
conc increase with...
Tiagabine
inhibits GABA uptake

increase with hepatic impairment
serum lvls lower in PM than evening
Gabatril
DDI
pretty safe

clearence inc by CBZ, PB, PHY, PRIM
displaced by naproxen
Topiramate
Indications?
MOA
partial seizure, GTC (adjunct + mono)

blocks Na, Ca channel and affects GABA (all 3)
Topamax SE
oligohydrosis/hypertermia

hydrate/keep outta sun

weight loss from Nausea
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
Oxcarbazepine
SE
better tol then CBZ
more hyponatremia-bad in old ppl

DECREASES OC effect.
monitor Na
Keppra
MOA
Levetriacetam
unkown: binds to SV2A to prevent nerve conduction
Zonisamide
for?
MOA
SE
partial seizure adjunct
MOA-blocks NA, Ca

increase every 2 weeks

SE-nephrolithaias
skin eruptions
sulf allergy
Vimpat
gen name?
for?
MOA?
Lacosamide
partial adjunct

enhance slow inactivation of Na
binds collapsin response mediator protein

CV med
POdose=IV dose
Lacosamide
SE
prolongs PR interval-get ECG first
Sabril
gen name?
for?
MOA
vigabatrin
infantile spasms(mono)

inhib GABA transminase, incr GABA
only thru SHARE program
Vigabatrin BBW
permanent vision loss-vision test at baseline and Q 3month
non pharm epilepsy tx
surgery-focal epilepsy 8--90% success
ketogenic diet

vagal nerve stimulator
which drugs increase metab of OC
PB, PHY, CBZ, OXCARB, Felbamate
which have no interaction with OC
VPA, Lamictal, gabapentin, tiagabine, keppra
to prevent teratogenicity do what

preg complication of PK
give folic acid suppl 4mg QD

albumin binding decreases
hepatic/renal metab increase
breast feeding
neglible conc in infants
CBZ, PHY, VPA
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
Ethosuximide conc levels
therapuetic conc is 40-1100mcg/ml
status epilepticus
>or = 2 seizures, with incomplete consciousness or seizure >30mins
status epil
etiology
no structual lesion-infxn, low AED lvls, alcohol

structural lesion-tumor, hypoxia, trauma, stroke
evaluate what labs for status epilep
electrolytes
urine drug screen
CBC w differential
arterial blood gas
EEG
MRI, spinal tap
benzos for status
lorazepam-long DOA
diazepam-30 min onset
dilute in equal volume of dilutent

give IV not IM
TX ALOGRITHM
1 supportive care
2 benzo
3 pheny, fospheny
4. pehnobarb
5. valproate