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Neuro Exam 2 Flashcards

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1
Q

Tripans mechanism

A

agonist for 5HT receptor to cause
vasoconstriction of cerebral vessels
inhibition of peptide release to cause vasodilation, inflammation, pain
prevent activation of pain fibers in trigeminal n.

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2
Q

Sumatripan

A

first line tripan used to treat moderate to severe migraine

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3
Q

Absorption route of triptans

A

Oral, nasal, sc (only sumatriptan)

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4
Q

distribution Triptans

A

low lipid solubility, poor CNS penetration. newer ones are more liophilic

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5
Q

half life tripans

A

2-4 hours

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6
Q

Adverse effects - Triptans

A

Paresthesia, flushing, dizziness, drowsy.

Seriouds: coronary vasospasm, agina, MI, arrhythmia.

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7
Q

Precautions with Triptans

A

coronary, arterial disease, uncontrolled htn

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8
Q

Drug interactions - triptan

A

not with 24 hours of Ergot Alkaloid due to additive vasoconstriction
Not at same time of MAO I, SSRIs, or SNRIs - serotonin syndrome.

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9
Q

Ergot Alkaloids mechanism

A

agonist of 5Ht receptor - similar to triptan mechanism

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10
Q

Dihydroergotamine

A

ergot alkaloid

intranasal, parenteral.

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11
Q

ergotamine

A

ergot alkaloid
Oral, sublingual, rectal.
Poor oral bioavalibiliy - slow onset - long duration.

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12
Q

ergotamine+caffine

A

ergot alkaloid

added to increase absorption, still less than tripans.

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13
Q

Ergot Alkaloid uses

A

terminating moderate to severe migraines.
less effective and more toxic than triptans - 2nd line.
Used in pts with duration >48 hrs or frequent recurrence

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14
Q

Adverse effects of ergot alkaloids

A

mild: N, V, D, parasthesias, vertigo
Severe: vascular occlusion, gangrene (due to alpha1 AR receptors stimulated) - associated with overdose.

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15
Q

Drug interactions - ergot alkaloid

A

avoid use with nonselective Beta blockers - severe peripheral ischemia
not used within 24 hrs of tripan
contraindicated with CYP3A4

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16
Q

Migraine Prevention treatment

A

prophylaxis for severe frequent (>4 month), long lasting (>12 hours), or disabling.
No single med is a clear choce, and takes 3-4 weeks to take effect.

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17
Q

Migraine Prophylaxis

A 
Antihypertensives - BB, calcium channel, ACEI
Antidepressants
anticonvulsants
Botox
Metbysergide
NSAIDs
Dietary Supplements
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18
Q

Beta Blocker

A

Propanolol - migraine prevention first line.

used for continuous prophylaxis

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19
Q

Beta Blocker - side effects

A

fatigue, exercise intolerance, depression, orthostatic hypotension.
contraindicated - asthma, diabetes, CHF

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20
Q

Calcium channel blockers

A

Verapamil - Third line prophylaxis for migraines
effectivness is limited.
Should not be used with BB

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21
Q

ACE I

A

Second or third line for Migraine prophylaxis

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22
Q

Tricyclic Antidepressants

A

Amitriptyline - second line for migraine prophylaxis. and can be given to pts with insomnia or depression.
SE: sedation.

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23
Q

Anticonvulsants

A

Valproate and topiramate - first line - similar to propanolol
Gabapentin - third line for migraine prophylaxis.

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24
Q

Valproate

A

anticonvulsant used for migraine prevention

causes nasuea, tremor, eight gain, hair loss

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25
Topiramate
anticonvulsant for migraine prevention | causes parasthesias, langauage and cognitive impariment, weight loss
26
Botox
second line treatment for chronic migraine (>15 per month) | causes HA, neck pain, muscle weakness, ptosis
27
Methysergide
serotonin receptor antagonist - 5HT blocker to block vasoconstriction to iniate migraine. effective but high toxicity - N, V, D, retroperitoneal, heart valve fibrosis.
28
NSAIDs - migrain prophylaxis
short term migraine pregention
29
Dietary supplements in migraine prophylaxis
Riboflavi - Vit B2 Butterbur - antispasmatic vascular wall, anti-inflammatory Feverfew
30
Sources of Opiods
``` Plants - opium poppy Animals 1) Enkephalin 2) endorphins 3) dynorphin 4) endomorphins 5) nocicptin ```
31
Enkephalin
``` endogenous opioid modulates NT at synpase (short distance) with rapid breakdown. Found in brain and spinal cord. Met-Enkephalin Leu-Enkephalin Derived from pro-enkephalin ```
32
Endorphin
endogenous opioid that acts on NT and as a hormone derived from proopiomelatocortin Found in hypothalamus and pituitary
33
Beta - Endorphin
a 31 AA, most active endorphin that contains a Met-Enkephalin a amino terminal
34
Dynorophin
endogenous opioid unsure of role derived from pre-dynorphin
35
Dynorphin A
biologically kappa selective
36
Endomorphins
new endogenous opioids, not well characterised. variation on opioid motif Tyr-Pro-Trp/Phe-Phe Mu receptor selective
37
Nociceptins
regulate pain tranmission but act on different receptors
38
Naloxone
blocks opioids
39
Mu receptors
cause analgesia and respiratory depression. endo: beta endorphin and enkephalins Morphine
40
Delta receptor
analgesia only Endo: beta endorphin and enkephalins NO drugs
41
Kappa receptor
spinal analgesia dynorphin A drug: pentazocine
42
Mechanism of mu receptor
1) via B-gamma cose VGCC on presynaptic Neuron to decrease NT release 2) via beta-gamma activate GIRK - K channels - to hyperpolarize Pre or Post 3) via Gi/o decrase cAMP
43
Analgesic actions of opioids
1) inhibition of ascending pain pathway 2) activation of descending pain pathway 3) subjective response to pain
44
how do opioids inhibit ascending pain pathway
decrease presynaptic NT release in Dorsal horn of Substance P and glutamate Inhibit excitatory post synaptic spinothalamic neurons
45
how to opioids excite descending pain pathway
activate inhibitory neurons to medulla, PAG, locus coerulus
46
how do opioids control subjective pain?
euphoria, feel less pain, limbic system
47
Do opioids releive 2nd or 1st pain better
2nd - dull, constant
48
Behavioral consequences of opioids
Euphoria (mu receptors to active reward pathway), dysphoria (K receptors), sedation, behavioral excitation (acute toxicity)
49
Respiratory consequences of opioids
decrease RR at therapuetic doses | due to decrases CO2 sensitivity in brainstem to cause incrased CO2 in blood, cerebral vasodilation --> and increased ICP
50
GI effects of opioids
N,V - ambulatory pts. Constipation - no tolerance Urinary retention
51
Cough effects of opioids
acts on cough center in medulla | Codeine - at low does as to not cause analgesic or respiratory affect.
52
Dextromethorphan
non-analgesic opiod preffered over codeine for cough suppresion due to decrease potential for abuse, blocks NMDA recpetor - so acts like PCP or ketamine... so restricted
53
Cardiovascular risks of Opioids
minimal, but occur indirectly through histamine - vasodilaton and decrases BP. O decrease cardiac workloud and inhibit barorecpetor effect. used to treat pulmonary embolism with cardiac dysfunction
54
Contraindicaitons of opioids
``` respiratory dysfunction - severe high iCP hypotension shock - endogenous agents already active hypothyroidism impaired hepatic function ```
55
Drug interactions of opiates
CNS depressants - Barbiturates - additive to CNS depression and increase in metabolism Phenothiazine - atnipsychotic - increased risk of respiratory depression, decreased BP MAO I and tricyclic antidepressants
56
which opioid agents cross BBB
heroine and codeine
57
Metabolism of opioids
liver metabolism to form morphine-6-glucuronide
58
Morphine
mu agonist | II: used for post op and acute traumatic pain
59
Heroine
mu agonist | I - highly lipophilic, rapid onset, high abue
60
Codeine
II or III with tylenol, mu agonist 10% of caucasians are deficient in CYP2D6 - so not as effecitve antitussive, high toxicity in high doses
61
Oxycodone
II mu agonist equipotent to morphine - high abuse rate. good oral
62
Hydrocodone
Vicodin III | antitussive, weak analgesic - equivalent to codeine.
63
Tramadol
U receptor agonist | blocks monoamine uptake to potentiate descending pain pathways
64
Fentanyl
``` U receptor agonist II 100X more potent than morphine short duration of 1 hr (morphine is 4-6 hr) requires ventilatory support. has transdermal patch ```
65
Loperamide
imodium antidiarrheal low solubility so stays in GI
66
Buprenorphine
partial mu agonist precipitates mild withdrawal symptoms long acting
67
Methadone
mu receptor agonist - use to treat opioid withdrawal symptoms
68
Naloxone
Mu receptor ANTAGONIST to block effects of endogenous opioids.
69
Tolerance is due to..
frequence, dose, duration
70
Physical Dependence
usually mild, and can be uliminated by taper
71
psychological dependence
addiction - craving or desire. | due to adaptations in neuronal circuits
72
Opiate withdrawal
flu like symptoms dilated pupils, insomnia, rhinorrhea, sweat, N, D, cramps, chills. Precipitated by antagonists and mixed agonists. Tx clonidine to decreases SNS (alpha 2 agonist) not life threatening.
73
Evaluation of pain experience
``` Severity Behavior - learned Cognitive - thinking process cultural Suration Origin - nocicpetive vs neuropathic ```
74
Acute v chronic pain
acute - resolution or healing of damaged tissue Chronic - pain persisting longer than expected - beyond normal healing, chornic disease, without identifiable cause, cancer
75
neuropathic pain
disengaged from noxious or healing process. caused from nerve damage
76
Functional pain
abnormal operation of nervous system - fibromyalgia, IBS, tension type HA - hyperalgesia and allodynia
77
spinobulbar tract
carries pain info to limbic system - emotional and motivational pain experience
78
mu opioid receptors in PAG....
block GABA release and remove inhibition to activate PAG outfluw
79
PAG activates
spinal enkephalin and spinal monoamine release (5HT and NE)
80
mu opioid receptrs in spinal cord..
are activated by enkephalins to decrease glutamate and substance P release and hyperpolarize post synatpic neuron to cause analgesia
81
alpha 2 ARs...
are located presynpatically. Activation by NE attenuates excitation of 2nd order neuron and cause analgesia.
82
Drugs involved in Pain Transduction
NSAIDS
83
Drugs involved in Pain Transmission
Local Anesthetics | NMDA receptor antagonists
84
NMDA receptor antagonists
Ketamine | block glutamate receptor deplolarization - decrease transmission of nociceptive stimuli
85
Modulation of transmission drugs
mu opioid agonsts | alpha2 AR agonists - block substance P release from primary neuron
86
NSAID - action
inhibit COX2 and PG synthesis | transduction of pain
87
LA - action
block VSSC | tranmission
88
NMDA antagonists - action
block glutamate depolarization at 2nd order neurons. | Transmission to pain blocker
89
Mu opioid receptor agonists - action
block glutamate and substance P from primary neuron Hyperpolarize 2nd order neuron Modulation of transmission and perception
90
Alpha2 adrenergic agonist - action
block glutamate and substance P from primary neuorn | Modulation of tranmission
91
Management of mild pain
non opioid +/- adjuvant analgesic
92
Moderate acute pain
immediate release short-acting opioids with slow titration + non-opioid +/- adjuvant analgesics
93
Severe acute pain
immediate release short acting opioids with RAPID titration + non opioid +/- adjuvant analgesics
94
Multimodal analgesic
benefits by synergistic actions to allow lower doses and limit dose related side effects
95
`Formulations of Opioids
Immediate release - parenteral and oral opioids Sustained release - for morphine extended duration Transdermal patch
96
NSAIDs
COX2 inhibitors to interefere with inflammatory cascade at peripheral and central sites.
97
Side effects of NSAIDs
GI ulceration, increased bleeding risk, renal dysfunction
98
Acetaminophen
COX2 inhibitor to block central sensitization
99
Alpha 2 AR agonists
Clonidine acts on dorsal horn and cells and locus ceruleus to modulate tranmission can cause hypotension, bradycardia, sedations
100
Ketamine
NMDA antagonist in ascending pain modulatory pathway. | reduces development to tolerance in long term opioid use .
101
Peripheral sensitization
type of neuropathic pain damaged peripheral nerves synthesize proinflammaotry mediators to activate terminal and produce pain or render hypersensitive.
102
Central sensitization
neuropathic pain | amplification of synaptic transfer from terminal to dorsal horn neurons by BDNF and substance
103
Chronic Pain Management
mechanistic approach rather than therapuetic class stratification. Enhance descending inhibitory Decrease central sensitization and peripheral sensitization
104
What drugs enhance desending inhbitiory pain pathway
Opioids, antidepressants (block NE, serotonin reuptake)
105
What decreaeses central sensitization
anticonfulstants, ketamine
106
what decreases peripheral sensitization
anticonvulsants, LA

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