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Pharm Exam 3 Spring > misc > Flashcards

misc Flashcards

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1
Q

Parkinson’s mechanism

A

Loss of pigmented cells in substantia nigra - make and store dopamine

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2
Q

L-Dopa

A

1st line
Most effective for symptomatic relief
Usually for >65

DO NOT stop abruptly
Wearing off phenomenon: 50% of pts

Incr risk of hip fractures d/t homocysteine

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3
Q

Dopamine Agonists

A

No response to L-Dopa: Dopamine agonists ineffective

Bromocriptine (ergot derivative)

Pramipexole
Ropirinole
Apomoprhine
Rotigotine (patch)

Decrease milk production

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4
Q

Bromocriptine

A

Dopamine Agonist, ergot derivative

SEs: stroke, szs, AVH, hypotension, HTN, MI, GI bleed, pulmonary fibrosis, LFTs elevation

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5
Q

Pramipexole

A

Dopamine Agonist

Take to d/c: NMS

Renally adjusted, EPS, hypotension, rhabdo, AVH
CNS depression, hypotensive effects

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6
Q

Apomorphine

A

Intermittent or continuous infusion/injection

NO ZOFRAN! severe hypotension and loss of consciousness
Premed w/ trimethobenzamide

Test dose; monitor BP and Scr

SEs: AVH, sudden sleep, ortho hypotension/syncope/dizziness, MI, headache, rhinorrhea, edema

QT prolongation

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7
Q

MAO B Inhibitors

A

Early PD
Only modest symptomatic relief

Selegiline (more SEs?), Rasagiline (adjunct), Safinamide (adjunct)

Serotonin syndrome!

Caution: HTN, high tyramine foods, cardiovascular dz, etoh

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8
Q

COMT Inhibitors

A

Entacapone (prolong L dopa)

Tolcapone (prolong central L-Dopa breakdown. Red: hepatotoxicity, orthostatic hypotension)

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9
Q

Anticholinergics in Parkinsons

A

Artane (trihexyphenidyl) - most widely used

Cogentin (Benzotropine), may also inhibit dopamine reuptake

Propantheline (peripheral): drooling, urinary freq

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10
Q

Amantadine

A

Antiviral? with mild antiparkinson activity
MOA uncertain
More effective than anticholinergics

best as short term monotherapy

SE: livedo reticularis

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11
Q

Pimavanserin

A

Tx of hallucinations/delusions with parkisonian psychosis

Atypical antipsychotic, inverse agonist/antagonist activity at 5-HT2A/C

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12
Q

Alzheimers pathophys

A

Shortage of Ach
Neurofibrillary tangles - tau protein intracellular
neuritic plaques: extracellular amyloid beta

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13
Q

Alzheimers Dx

A

No bio marker

Thorough testing: Hx, MMSE, exclude other possible causes

Start Tx ASAP!

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14
Q

Donepezil

A

Reversible/non comp inhibition; ACHe inhibitor
Mild-mod AD

Titration Q 4-6 weeks

Amiodarone will increase level
B block: risk of AV block
NSAIDs: risk of GI bleed

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15
Q

Rivastigmine

A

Mild-mod AD
Inhibits AchE and butrylrylcholinesterase (sp) - broader efficacy

PO or Patch

DDI: bradycardia (b blcok), cholinergic effects (pyridostigmine), lowers sz threshhold

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16
Q

Galantamine

A

Mild-mod AD
Inhibits AchE and modulates nicotinic receptors: increase ACH release
Increased release of glutamate and serotonin

Bradycardia, cholinergic, lowers sz threshold

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17
Q

NMDA receptor antagonist

A

Memantine

Noncompetitive inhibitor, blocks glutamate from overstimulating NMDA receptors.

Moderate/severe AD

Acetazolamide, amiloride: reduce memantine excretion
Dextromethorphan: increase SEs

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18
Q

Red flags in HA

A

SNOOP

Systemic
Neurologic
Onset - new/sudden
Other associated conditions
Previous HA Hx - serverity
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19
Q

Migraine Abortive

A 
NSAIDs
APAP or w/ caffeine 
Triptans
Ergots
Gepants
Ditans
Antiemetics
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20
Q

Migraine preventative - established efficacy

probably effective

A 
Candesartan (lisinopril)
VPA
Frovatriptan
Metop,propan,timolol (atenolol, nadolol)
Topamax
(memantine, venlafaxine, amitriptyline)

others:
gabapentin, lamictal, verapamil/amlodipine, ami/nortriptyline

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21
Q

Hemicrania continua/paroxysmal hemicrania

A

Indomethacin

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22
Q

Cluster abortive

A

Triptans + O2

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23
Q

Cluster prevention

A

Verapamil!
Topamax
Glucocorticoids, lithium

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24
Q

Triptans

A

Inhibit release of vasoactive peptides –> vasoconstriction –> block pain pathways

Stimulate serotonin 1b/1d: inhibit dural nociception

Contraindications:
Cardiac: ischemic, vasospasm/angina, WPW, arrhythmias, peripheral vascular dz, uncontrolled HTN

Stroke: migraine/basilar/hemiplegic; ischemic bowel, cerebrovascular dz

SEs: vasospasm, MI, VT/VF, stroke, somnolence, N/V, CP/pressure/tightness, neck/jaw pain

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25
Triptans general
Inhibit release of vasoactive peptides --> vasoconstriction --> block pain pathways Stimulate serotonin 1b/1d: inhibit dural nociception Contraindications: Cardiac: ischemic, vasospasm/angina, WPW, arrhythmias, peripheral vascular dz, uncontrolled HTN Stroke: migraine/basilar/hemiplegic; ischemic bowel, cerebrovascular dz SEs: vasospasm, MI, VT/VF, stroke, somnolence, N/V, CP/pressure/tightness, neck/jaw pain General caution w/: ergot deriviatives, MAO-AIs
26
Triptans specific
Sumatriptan: PO x1, may repeat in 2hours (half life 2.5 hours) SC: 1-6mg x1, may repeat in 2 hours. more efficacious than PO, fastest onset Nasal: less SEs, unpleasant taste Zolmitriptan: PO, Nasal spray, ODT serotonergic effects Naratriptan: slower onset, lower efficacy Rizatriptan (Maxalt) Caustion w/ propanolol! increases riza level by 70% Almotriptan: contraindicated w/ ergots/triptans w/in 24 hours, strong serotonergic. Eletriptan: most likely to produce short term and sustained benefit. 3A4 substrate, avoid within 72 hours after 3a4 inhibitors Frovatriptan: slower onset, lower efficacy
27
Ergots
5HT 1b/d receptor agonists (like triptans) Ergotamine: poor PO bioavailability (2%) Avoid: CAD, PVD, HTN, hepatic/renal DDI: avoid with 3a4 inhibitors: life threatening peripheral ischemia nad vasospasm Dihydroergotamine Alpha blocking: weaker arterial vasoconstrictor More potent venoconstrictor and fewer SEs than ergotamine No physical dependence or rebound headache IV, IM, SC, NS
28
CGRP
Calcitonin gene related peptide Most prevalent neuropeptide in trigeminovascular system Alpha: cerebral Beta: gut very potent vasodilator in cerebral
29
Gepants
CGRP ANTAgonists. Prevent vasodilation. Rimegepant: acute/proph Atogepant: prophylaxis only Urbogepant: acute only
30
CGRP
Calcitonin gene related peptide Most prevalent neuropeptide in trigeminovascular system Alpha: cerebral Beta: gut very potent vasodilator in cerebral
31
5HT1F Agonists
"Ditans" - lasmiditan Inhibits trigeminal nerve firing. Acute HA only. 1 dose in 24 hours. 50-200mg PO x2 No driving w/in 8 hours Caution with CNS depressants/ETOH/older
32
Migraine MABs
IV q3mo: eptinezumab, IgG1 SubQ Q mo: galcanezumab, IgG4 SubQ q month OR q3 months: Fremanezumab IgG2 ^ acts as anti cgrp antibodies IgG targets CGRP receptors: SubQ qmonth, Erenumab
33
Absence seizures tx
Ethosuximide - 1st line w/ other seizure types: VPA, lamictal, topamax DO NOT: tegretol, gabapentin, tiagabine, pregabalin
34
Tonc/atonic/myoclonic/tonic-clonic sz
Lamictal, VPA, topamax, tegretol, trileptal
35
General/unclassified seizure treatment
VPA, lamictal, topamax
36
Focal onset
``` Carbamazepine Cenobamate/lacosamide? Lamotrigine Oxcarbazpeine Topiramate ``` Adjunct: Keppra, Tiagabine, Gabapentin Cenobamate/lacosamide?
37
Keppra
Selectively prevents hypersynchronization SEs: Leukopenia, pancytopenia, hyponatremia. Withdrawal seizures if abrupt DC Binds to resins/polymers T1/2: 6-8hrs
38
Zonisamide
Blocks Na/Ca channels, suppress hypersyncrhonization, inhibits carbonic anhydrase T1/2: 63h SEs: SJS, TEN, agranylocytosis, angle closure glaucoma, psychosis, rhabdo
39
Vigabatrin
REMS program d/t vision loss inhibits GABA degradation - partial seizures or refractory complex Progressive permanent bilateral concentric visual field constriction Baseline, then 4week, then q3 months until 3-6 months after D/c
40
Vestibular suppressants
Metoclopramide (D2 blocker) Prochlorperazine (D2 blocker) Dimenhydrinate - dramamine Meclizine (central anticholinergic) Promethazine (antihistamine, antimuscarinic, etc) Diazepam Valium
41
Myasthenia Gravis Immune Tx
Acute immunomodulation: IVIG, plasma exchange Short term immunosuppression: Prednisone ``` Long term immunosuppression: Azathioprine (first line) MTX (second line) Mycophenolate mofetil (third line) Tacrolimus (third/fourth line) ``` Last: Ciclosporin, Cyclophosphamide LAST last: rituximab
42
Diagnostic tests for Myasthenia Gravis
Ab against Ach receptor (Achr-ab) - first test Ab against MuSK - nonresponsive to Mestinon 6-12% sero negative: most likely pure ocular dz Other: electrophysiologic test; RNS, SFEMG CT, MRI Ice pack test if ptosis
43
Pyridostigmine (Mestinon)
PO q8 for MG SE: cholinergic crisis/bradycardia arrhythmias/hypotension GI
44
Fingolimide
2nd line MOA: sequester lymphocytes; sphingosine 1 phosphate receptor modulator Check EKG prior to dosing, end of observation. Watch for brady for at least 6 hours (possibly overnight) Contraindicated: 1a or III antiarrhythmics (amiodarone) Siponimod - 1st line (no need for 6hr monitoring)
45
Novantrone / Motoxantonre
Cumulative lifetime dose | last line? for MS
46
REMS for JCV
Natalizumab
47
CD20? CD52?
20: Rituximab (mouse; less favorable) Ocrelizumab Ofatumumab 52: Alemtuzumab
48
MS in pregnancy - know
Cat B: Glatiramer,!! oxybutynin, SSRI D: Azathioprine, clabridibe, cyclophosphamide, mitoxanthrone X: MTX, teriflunomide
49
Prophylaxis for Alemtuzumab
Herpes - Acyclovir | PJP - Septra
50
Ampyra / dalfamipride
Block K+ Improves walking in MS DDI: NO CIMETIDINE / h2 blockers --> seizures
51
Drugs to avoid in MG
Abx: aminoglycoside, fluoroquinolones, macrolides, "quins" B-blocks, Botox, Statins Contrast Sorta steroids ("paradoxical exacerbation") - first 2 weeks
52
DMF
Dimethyl Fumarate for MS (similar: MMF ) Neuroprotective and immunomodulatory, antioxidant Check CBC baseline and annually - lymphocytopenia - d/c
53
Teriflunomide
Preg Cat X Inhibits pyrimidine synthesis: disrupts T cells interacting with antigen presenting cells Hepatotoxicity (main problem), diarrhea DDI: phenytoin (incr level of phenytoin, decrease level of teriflunomide) live vaccines, dexamethasone, immunosuppressants
54
Lines of tx for MS
Moderate DMT first line: Siponimod, DMF 2nd line: fingolimod, clabridine (2/3rd) ozanimod??
55
Injectable modestly (low) effective for MS (interferons)
Interferons: 1a ("animal", mammalian: avonex (weekly IM), rebif (SC TIW), plegridy (SC q2 weeks) 1b ("bacteria", e. coli: betaseron (SC every other day), extavia DDI: drugs lowering sz threshold (buprion, clozapine, abx, propofol, theophylline), drugs causing depression (phenobarb, topamax, steroids, tamoxifen) pancytopenia, depression, lft elevation injection site rxn, flu like sx, abd pain other modestly effective MS --> GLATIRAMER (not interferon)
56
GLATIRAMER
Random polymer - modest (low) Decoy for immune system relatively mild SEs: tachy, lipoatrophy, flue like, flsuhing, sob, anxiety
57
Highly effective MS tx
Alemtuzumab - 1st Ocrelizumab - 1st Ofatumumab - 1st Natalizumab - 2nd Mitoxantrone - obsolete - 2nd/3rd
58
Cladribine
DMT for MS, prodrug DNA breakdown 2nd/3rd line 2 cycles/year for 2 years Lymphocytes must be wnl for 1st cycle, >800/ml 2nd cycle (ALC) BBW: malignancy, teratogencicity
59
Anti inflammatory T cell
T helper 2
60
IM Interferon for MS
Avonex
61
Verapamil
Non dihydropyrdine | depresses cardiac conduction + contractility
62
Atropine
Inhibits acetylcholine Improves cholinergic crisis if given
63
Sz meds affecting voltage dependent Na+ channels
Lamictal Topamax Oxcabazepine, eslicarbazepine Zonisamide, lacosamide, rufinamide
64
Binds to alpha 2 delta subunit of Ca+ channels
Pregabalin | Gabapentin
65
Inhibits gaba reuptake? Irreversibly inhibits GABA metabolism
Tiagabine Vigabatrin
66
AMPA receptor blocker
Permpanel
67
Triptan w/ longest half life
Frovatriptan
68
Exacerbates absence seizures
Carbamazepine, + (gabas) gabapentin, tiagabine, pregabalin
69
Tegretol / Carbamazepine
MOA unknown epilepsy, trigeminal neuralgia, mood Screen for genetics: risk of SJS or TEN risk aplastic anemia, agranulocytosis CYP 3a4 inducer and substrate
70
Antiseizure which increases GABA effects and inhibits glutamade/NMDA receptor
Depakote - hepatotoxicity, SIADH, wt gain, rash, photosensitivity
71
Topamax
inhibits CAH enzyme --> metabolic acidosis SJS, Kidney stones
72
Cholinergic receptor w/ faster response time
nicotinic
73
Postganglionic fibers ANS
sympathetic: long parasympathetic: short
74
Botox mechanism
Irreversibly block Ach vesicle release --> muscle paralysis
75
Azathioprine
purine antagonist, inhibits DNA synthesis/cell proliferation
76
Supportive care in MS
``` Dalframpridine Muscle relaxants (antispastic - baclofen) Amantadine (reduce fatigue) Antidepressants Analgesics PT, Exercise ```
77
Acute attacks in MS
prednisone: HIGH dose: 500-2000mg/day x 3-5 adys methylprednisolone IV: 500-1000mg/day x 3-5 days Acthar gel: adrenocorticotropic analogue if cannot tolerate high dose steroids 80-120 units IM/SQ Qday x 2-3 weeks Plasmapharesis
78
Other NMDA ANTagonists
Dextrometorphan, ketamine, methadone
79
Do not use zofran with
Apomorphine | use trimethyl benzamide (Tigan)
80
Gepant prophylaxis AND acute
Rimegepant (all gepants PO)
81
tension HA tx
abortive: NSAIDS, APAP, caffeine, triptans prophylaxis: TCA
82
MOA Natalizumab
IgG targets alpha4 subunit of integrins on leukocytes --> INHIBITS cell adhesion 300mg IV over 1 hour q4 weeks

Pharm Exam 3 Spring (1 decks)

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