What SERIOUS ADRs are associated with Triptans?
Coronary artery Vasospasm Transient MI MI Ventricular Tachycardia/Fibrillation HTN
What are more COMMON ADRs associated with Triptan use?
Paresthesias Fatigue Flushing Chest Tightness Swelling
What is St. Anthony’s Fire?
What class of HA treatment medications is it associated with?
Associated with Ergotamines
Sx include...... Headache Emesis Diarrhea Gangrene
Why is life-threatening ischemia associated with erogtamines?
When administered with CYP3A4 inhibitors (such as macrolides) it increases ergot levels leading to an increased risk of ischemia
What COMMON ADRs are associated with ergotamines?
Nausea Emesis Abdominal Pain Weakness Parethesias Myalgia Diarrhea Chest Tightness
Does Butorphanol have addictive properties?
Yes
What COMMON ADRs are associate with Butorphanol?
Remember: This is a partial opioid agonist
Somnolence Dizziness Nausea Emesis Nasal Congestion Insomnia Respiratory Depression
What COMMON ADRs are associated with Fiorinal/Fioricet?
Nausea
Drowsiness
Dizziness
Abdominal Pain
If Fiorinal or Fioricet are overused (more than 2x weekly) what an occur?
Rebound-Headache from withdrawal
What ADRs are seen with IV metoclorpamide use for headache treatment?
Akathisia
Drowsiness
Why should you use PA-free formulations of butterbur?
Because the PA forms are associated with Hepatoxicity
What psychiatric warnings are associated with interferon beta?
Depression
Suicidal Ideation
What organotoxicity is associated with Interferon Beta?
Hepatotoxicity
Is CHF a potential warning of interferon beta?
Yes
What COMMON ADRs are seen with interferon Beta?
Flu-like Symptoms (Fever, mayalgia)
Insomina
Injection Site Reaction
Edema
Can you see HTN with Interferon Beta?
Yes
What can be given prior to injection of Interferon Beta to prevent the flu-like reaction?
Acetaminophen/Ibuprofen
30 minutes prior
What post-injection reactions are seen in Glutiramer Acetate?
Flushing Chest Pain Palpitations Anxiety Urticaria Throat Constriction
Can a patient undergoing Glatiramer Acetate injections for MS treatment have Lipoatrophy or skin necrosis at the injection site?
Yes
What organotoxicity is associated with Mitoxantrone?
What should be done to monitor this?
Cardiotoxicity
Need Baseline LVeF
Repeat before each dose
What can be seen when Mitoxantrone is used for leukemia?
Myelosuppression
T/F: Secondary AML is seen with Mitoxantrone use
True
What are COMMON ADRs seen with Mitoxantrone?
Nausea
Alopecia
Menstrual Changes
UTI / URI
An MS patient presents complaining of a her urine now appearing a “blue-green” color…..
What medication is likely the culprit?
Mitoxantrone
Progressive Multifocal Leukoencephalopathy is associated with what MS medication?
Natalizumab
Would you expect to see leukopenia or leukocytosis with Dimethyl Fumarate?
Leukopenia
What ADRs are associated with Dimethyl Fumarate?
Flushing, Redness (Due to it’s metabolite)
Rash
N/V/D
Abdominal Pain
What organotoxicity is NEWLY associated with Dimethyl Fumarate?
Hepatotoxicity
Normalizes after stopping medication
First-dose bradycardia is associated with what MS medication?
Fingolimod
EKG prior to dosing and monitor 6 hours after dose
Varicella Zoster is associated with what MS medication?
Fingolimod
Is Fingolimod associated with increased or decreased mortality?
Increased
What COMMON ADRs are associated with Fingolimod?
Headache Influenza Diarrhea Back Pain Abnormal LFTs Cough
Is Teriflunomide teratogenic?
Yes
What organotoxicitiy is associated with teriflunomide?
Hepatotoxicity
Other than hepatotoxicity and teratogenicity, what serious ADRs are associated with Teriflunomide?
Neuropathy
Bone MArrow Supressions
Hyperkalemia
Transient Renal Failure
What ADRs are associated with Dantrolene?
Drowsiness
Dizziness
Malaise
Diarrhea
What ADRs are associated with Nudexta?
N/V/D
Cough
What lab needs to be monitored in patients on Levodopa?
LFTs
What ADR is seen commonly in patients who are on Levodopa long-term?
Dyskinesia (Choreiform Movements)
What is the “on-off” effect of Levodopa?
What medication class is used to “smooth” this out?
Off - Akinesia
On - Dyskinesia
This is due to fluctuations in Levodopa concentrations
Dopamine Receptor Agonist
What ADRs are associated with Levodopa?
Nausea
Anorexia Hypotension
Confusion
Insomnia
What psychiatric like syndrome is associated with Levodopa?
Schizophrenic-like syndrome
What ADRs are associated with Dopamine Receptor agonists?
Anoreaxia hypotension Nausea Emesis Hallucinations Sedation
Are cardiac arrhythmias a possible ADR of dopamine receptor agonists?
Yes
When Ergot DRA (Bromocriptine, Cabergoline) are used at Parkinson’s doses, what is a potiental ADR?
Cardiovulvopathy
Which Non-Ergot DRA is associated with sudden somnolence?
Rotigotine (Transdermal)
Patients on this should not drive
What may occur if metoclopramide is given with a DRA or Levodopa?
This makes it hard to distinguish what?
Tardive Dyskinesia
In Parkinson’s patients this would make it hard to distinguish if this was a side effect of metoclopramida or worsening Parkinson’s
If Selegiline or Rasagiline where given to a cocaine abuser, what may occur?
Fatal Hyperthermia
Selegiline blocks MAO-A at high doses…..
What ADR may be seen if this occurs?
HTN Crisis
What potential organtoxicity is seen in patients on Talcapone?
Hepatootoxicity
A Parkinson’s patients presents complaining of an orange discoloration to his urine…..
What class of medication is likely the culprit?
COMT Inhibitors
Talcapone
Entacapone
What COMMON ADRs are associated with COMT inhibitors?
Diarrhea
Abdominal Pain
Orthostatic Hypotension
Sleep Disturbance
What ADRs are associated with Amantadine?
CNS (Restlessness, Depression, Insomnia, Agitation, Hallucinations, Seizures)
What dose of Amantadine is potentially fatal?
1 gram
What ADRs are associated with Trihexyphenidyl and Benzotrpine?
Dry Mouth Lack of Diaphoresis Urinary Retention Constipation Drowsiness Confusion
What ADRs are associated with Pimavanserin?
Peripheral Edema Nausea Confusion Hallucinations Constipation Gait Changes
What ADRs are associated with Safinamide?
Dyskinesia
Falls
Nausea
T/F: Retinopathy is associated with Safinamide
True
Is a patient on Safinamide more likely to experience hypotension or hypertension?
HTN
What ADRs are common amongst all Cholinesterase Inhibitors?
N/V/D
Which Cholinesterase Inhibitor is associated with muscle cramps?
Donepezil
Which Cholinesterase Inhibitors are associated with weight loss?
Rivastigmine
Galantamine
T/F: Rivastigmine is associated with Hepatotoxicity
False
What ADRs are associated with Memantine?
Agitation Diarrhea Insomnia Dizziness Headache Hallucinations
Overdose of Pyridostigmine is associated with what crisis?
How is this tested?
How would this crisis be treated?
Cholinergic Crisis
Tesilon Test (Endrophonium)
If Weakness worsens = Cholinergic Crisis which is treated with atropine
If weakness improves = Myasthenia Crisis
What COMMON ADRs are seen with pyridostigmine?
Rash N/V/D Increased Salivation Increased Bronchial Secretion Miosis Diaphoresis
Riluzole can show an elevated in what lab value?
LFTs
What are pulmonary side effects of Riluzole?
Decreased lung function
PNA
T/F: Vertigo is an associated ADR with Riluzole
True
What ADRs are associated with Edaravone?
Anaphlyaxis
Bruising
Gait Disturbance
What psychiatric ADRs are seen with tetrabenazine?
Depression
SI
What is the MAXIMUM DAILY DOSE of Acetaminophen for adults?
Pediatrics (< 12 y.o.)
Adults: 4 grams daily
Peds: 5 doses of 50/75 mgs/kg
T/F: Acetaminophen is the leading cause of liver failure in the USA
True
At what dose does acetaminophen become hepatotoxic?
Fatal?
Hepatotoxic: 10 - 15 grams
Fatal: >20 g
P450 2E1 _______ (inducers/inhibitors) may result in acetaminophen toxicity.
Inducers
Consuming what in combination with acetaminophen could lead to toxicity?
Alcohol
Acetaminophen toxicity leads to metabolism of what toxic metabolite?
NAPQI
Acetaminophen has the potential to be toxic to which organs?
Liver
Renal (ATN)
Heart
Pancreas
Nausea Emesis Acidosis AMS Elevated PT/INR
….. Are all Sx of what?
Acetaminophen OD
Asymptomatic
Normal LFTs
No Liver Injury
……Is what stage of acetaminophen OD?
Stage 1
72-96 Hours Hepatic Failure Encephalopathy AST/ALT > 10,000 Potentially Fatal Stage
……Is what stage of acetaminophen OD?
Stage 3
24-36 Hours
AST > 1,000
RUQ Pain / Hepatomegaly
Increase PT, BUN, sCr
……Is what stage of acetaminophen OD?
Stage 2
What stage of acetaminophen OD is considered recovery?
Stage 4
What side effects are associated with N-acetylcysteine, especially the IV administration?
Anaphylaxis: Urticaria Flushing N/V Bronchospasms (Potetially Fatal)
Why are NSAIDs associated with renal ischemia?
In what conditions does this risk increase?
Because they inhibit prostaglandins which help to maintain renal blood flow
CHF
CKD
Cirrhosis
Why should NSAIDs be avoided in the 3rd trimester of pregnancy?
May prematurely close PDA
What ADRs are COMMONLY associated with NSAIDs?
Nausea Dyspepsia Abdominal Pain Flatulence Diarrhea
What GI risks are associated with NSAID use?
What are examples of medications that can be used to reduced this risk?
Peptic Ulcers
GI Bleeding
Naproxen/Esomeprozole
Ibuprofen/Famotidine
ASA/Omeprazole
Mistoprostol
What is the MOST COMMON ADR associated with Mistoprostol?
What are additional ADRs?
DIARRHEA
Nausea
Abdominal Pain
Why is Mistorporstol Pregnancy Category X?
Abortifacient Effect
Teratogenicity
Should NSAIDs be used for pain control following cardiac surgery?
No
What renal effects can be seen in patients using NSAIDs?
What patients at at increased risk for these?
Renal Insufficiency
Hyperkalemia
Renal Papillary Necrosis
CHF
CKD
Elderly
Medications (Diuretics, ACEi, Cyclosporine)
What class of ABx should be avoided with NSAIDs due to increase renal risks?
Aminoglycosides
How is an ASA OD treated?
Sodium Bicarbonate
Which NSAID has….
- Increased risk of cardiac events
- Increased liver toxicity
- More likely to have GI toxicity
Diclofenac
If a patient is chronically using Piroxicam, what type of exam should be preformed periodically?
What labs?
Eye Exams
CBC
Renal Function
hepatic Function
Do you need to dose adjust Celcoxib in patients with renal impairment?
Hepatic Impairment?
Renal: No
Hepatic:
Decrease by 50%
What ADRs are commonly associated with Opioids?
Sedation Lethargy Respiratory Depression Nausea Emesis Pruritis Urticaria Bronchospams
What is the TRIAD of opioid OD?
What is the antidote?
- Miosis
- LOC
- Respiratory Depression
Antidote: Naloone (Narcan)
Other than the ADRs associated commonly with all opioids……
What additional ADRs are associated with Morphine?
Orthostasis
Constipation
Can you give fentanyl to a patient with a codeine allergy?
Yes
What organotoxicity is associated with Meperidine (Demerol)?
Is this reversible with Naloxone?
Neurotoxicity (Anxiety, Tremors, Seizures)
No!
What organotoxicities are associated with Propoxyphene?
Neurotoxicity
Cardiotoxicity
What cardiac arrhythmia is associated with Methadone?
Torsades
What ADRs are associated with Naloxone (Narcan)?
Headache
Myalgia
Hypertension
Withdrawal
Tramadol has a high risk for what at the recommended and increased doses?
This risk is increased with what class of medications?
Seizures
Increased risk with.... SSRIs TCAs Opioids MAOIs
T/F: There is an increased suicide risk associated with Tramadol
True
Is Serotonin syndrome associated with Tramadol?
Yes
What has a higher risk of respiratory distress….
Morphine or Tramadol?
Morphine
Tapentadol is potentially fatal when taken with what?
Alcohol
What are THREE signs of Opioid Abuse?
- Early Refills
- Requesting higher doses
- Prescriber Hoping
Withdrawal Sx (treating with other medications Taking larger doses than prescribed and taking for longer Impairment in social and occupational settings
….are all symptoms of opioid ________
Dependence
What are Sx of opioid withdrawal?
When would these onset?
Mood Liability Chills Diaphoresis Nausea / Diarrhea Rhinoorhea Dilated Pupils Insomnia
Onset 8-16 hours after last dose peaking in 2-4 days
Is opioid withdrawal life threatening?
No
How is opioid withdrawal treated?
Detoxification either through tapering or reversing medications (Naltrexone)
Can also use clonidine, NSAIDs, anti-diarrheals, muscle relaxants
What SERIOUS ADRs are associated with Milnicipran?
Common ADRs?
Serious:
SI
Serotonin Syndrome
HTN
Tachycardia
Common:
N/V
Constipation
headache
Hyperhidrosis
What ADRs are associated with cyclobenzaprine (Flexeril)?
Remember this has anticholinergic activtiy?
Dry Mouth
Constipation
Urinary Retention
Dry Eyes
Trnasient Quadriplegia is associated with what muscle relaxant?
What are additional ADRs?
Carisoprodol (Soma)
Drowsiness, Vertigo Depression Syncope Hypotension N/V
Is there a withdrawal syndrome seen with Carisoprodol (Soma)?
What are the Sx?
how is it treated?
Yes, onsets 3 days after abrupt sesation
Sx…..
Insomnia Anxiety Muscle Twitching Incoordination N/V Anorexia
Treatment: Benzodiazapines + Anti-psychotics
Metaxalone (Skelaxin) is associated with what THREE serious ADRs?
Leukopenia
Hemolytic Anemia
Jaundice
What ADRS are associated with Baclofen?
Drowsiness Dizziness Fatigue / Wekaness Nausea Emesis Confusion
What type of ADRs are seen with Orphenadrine (Norflex)?
Anticholinergic:
Dry Mouth Urinary Retention Tachycardia Mydriasis N/V
What medication is associated with idiosyncratic hepatotoxictiy?
Chlorzoxazone
T/F: Glucosamine Sulfate may have some impact on insulin resistance
True
Ziconotide is associated with what types of ADRs?
What additional ADRs?
Neuropshychiatric
Additional:
Dizziness
Ataxia
Somnolence
Nausea
Is intrathecal Baclofen associated with hypertonia or hypotonia?
Hypotonia
What ADRs are associated with PO Menthol use?
Topical?
Oral:
Heartburn, Nausea, Emesis
Topical:
Irritation
Dermatitis
Why should camphor be avoided orally?
It can become toxic leading to seizures and respiratory failure
Capsaicin is associated with a worsening cough when taken with what class of antihypertensives?
ACEi
What ADRs are associated with Capsaicin when taken orally?
Topically?
Oral:
GI Discomfort
Diaphoresis
Flushing
Topical:
Burning, Stinging, Erythema
