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Neurology Flashcards

1
Q

Focal seizure

A

affects one side of the brain

Aware or impaired awareness
Motor or nonmotor
Focal or bilateral tonic-clonic

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2
Q

Generalized onset

A

Affects both sides of the brain

Absence (nonmotor)
Myoclonic (motor) - brief jerking movements

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3
Q

Tonic-clonic

A

5 phases:
Flexion
Extension
Tremor
Clonic
Postictal

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4
Q

Status epilepticus

A

Prolonged seizure of >5 minutes

After 30 minutes, long-term consequences possible

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5
Q

Automatisms

A

Associated with focal seizures - may occur before seizure

Lip smacking, chewing, swallong, tongue movements, scratching, thrashing arms/legs, fumbling with clothing, snapping fingers

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6
Q

Carbamazepine alleles

A

HLA-B*1502 - increased risk of SJS (Asian population)

HLA-B*3101 - increased risk of hypersensitivity (not tested routinely)

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7
Q

Phenytoin equivalents (PE)

A

1.5mg fosphenytoin = 1mg phenytoin (1 PE)

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8
Q

Dosing, administration rate fosphenytoin

A

Load: 10-20mg PE/kg IV or IM
Maintenance: 4-6 PE/kg/day in divided doses after load

Max infusion rate 150mg PE per minute (risk of severe hypotension, cardiac arrhythmias)

Less risk of phlebitis than phenytoin

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9
Q

Lamotrigine & Valproic Acid

A

Valproic acid decreases lamotrigine concentration

Lower starting and maintenance doses of lamotrigine needed to prevent ADRs

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10
Q

Estrogen effects on antiepileptics

A

Lamotrigine: estrogen OCPs increase clearance of lamotrigine so higher doses needed

Valproic acid: estrogen OCPs decrease VPA serum concentration

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11
Q

Antiepiletic drugs that are enzyme inducers

A

Carbamazepine
Cenobamate (CYP3A4)
Fosphenytoin
Oxcarbazepine
Phenobarbital
Phenytoin
Primidone
Vigabatrin (CYP2C9)

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12
Q

Phenytoin drug interactions

A

Increase phenytoin:
Anticoagulatns
Chloramphenicol
Cimetidine
Diltiazem
Disulfiram
Isoniazid
Phenybutazone
Sulfa-TMP

Decreased phenytoin:
Antineoplastics
Diazoxide
Folic acid
Rifampin

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13
Q

Carbamazepine drug interactions

A

Decrease carbamazepine:
Theophylline

Increase carbamazepine:
Cimetidine
Diltiazem, verapamil
Erythromycin
Isoniazid
Nefazodone

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14
Q

Valproic Acid drug interactions

A

Increase VPA:
Salicylates

Decreased VPA:
Estrogen OCPs
Meropenem
Rifampin

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15
Q

Carbamazepine therapeutic level

A

4-12 mcg/ml

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16
Q

Phenobarbital therapeutic level

A

15-40 mcg/ml

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17
Q

Phenytoin therapeutic level

A

10-20 mcg/ml

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18
Q

Valproic acid therapeutic level

A

40-100 (150) mcg/ml

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19
Q

Zonisamide cross reactivity

A

Avoid in patients with sulfa allergy

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20
Q

Lamotrigine starting dose

A

Typical: 25mg daily

with VPA: 25mg every other day

with inducers (carbamazepine, phenytoin, phenobarbital, primidone): 50mg daily

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21
Q

Status epilepticus Principles

A
  1. Ascertain ABCs
  2. Obtain lab (BG, BMB, BMP, Ca, Mg, serum conc)
  3. BG < 60: admin thiamine 100mg IV followed by D50%
  4. Administer emergency medication to stop seizure
  5. Administer urgent medication to prevent seizure

Administer drugs parenterally. Do not administer NMBAs.

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22
Q

Emergency Meds for Status Epilepticus

A

Lorazepam (DOC) 0.1mg/kg (max 4mg) at rate of 2mg/min

Diazepam 0.15mg/kg (max 10mg) at rate of 5mg/min

Midazolam (IM) 0.2mg/kg (max 10mg)

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23
Q

Urgent Meds for Status Epilepticus

A

FDA approved:
Phenytoin 20mg/kg
Fosphenytoin
Phenobarbital 20mg/kg

Non-FDA approved:
Valproic Acid 20-40mg/kg
Levetiracetam 40-60mg/kg
Lacosamide 200-400mg bolus

24
Q

Refractory status epilepticus meds

A

If BZD resistant: fosphenytoin, levetiracetam, or valproate

Pentobarbital (ventilator)
Midazolam drip
Propofol (ventilator)

25
Epilepsy in Pregnancy
Avoid valproate acid as much as possible in nonpregnant and pregnant women Avoid phenytoin, carbamazepine, and phenobarbital Consider monitoring serum concentrations during pregnancy
26
Antiepileptics that decrease effect of OCP, patch, ring, progesterone implant
Carbamazepine Lamotrigine Oxcarbazepine Phenobarbital Phenytoin Primirdone Topiramate (>200mg) Others: brivaracetam, cenobamate, clobazam, eslicarbazepine, felbamate, perampanel, rufinamide Recommend Medroxyprogesterone injection or levonorgesterol IUD
27
Suicide risk in antiepileptics
All anti-epileptic meds have this warning (most siG: levetiracetam, phenobarb, primidone, topiramate, vigabatrin, tiagabine, perampanel) Increased risk between week 1 thru week 24 of therapy
28
Wearing-off phenomenon
Assoc w/ Carbidopa/Levodopa Return of Parkinson's symptoms before next dose Add on therapies: DA agonist, MAO-B inhibitor, COMT inhibitor (entacapone, opicapone), increasing frequency/dose of levodopa
29
On-off phenomenon
Assoc with Carbidopa/Levodopa Unpredictable return of Parkinson disease symptoms without respect to dosing interval Add on therapies: entacapone, MAO-B inhibitors (rasagiline, selegiline), DA agonist (pramipexole, ropinirole, apomorphine)
30
Dyskinesia in PD
Assoc w/ Carbidopa/Levodopa Drug-induced involuntary movements Treatment: decrease levodopa dose, add amantadine
31
MAO-B inhibitors
Increase dopamine in brain Selegiline Rasagiline Safinamide Caution serotonin syndrome (meperidine, other serotonergic meds) Available as tabs and ODTs. Metabolized to amphetamine. Rasagiline interacts with Ciprofloxacin.
32
Carbidopa/levodopa
Carbidopa prevents peripheral conversion of levodopa to dopamine, thus increasing amount of levodopa to cross BBB and increase dopamine Long-term ADRs = wearing-off phenomenon, on-off phenomenon, dyskinesias Slow release as delay to effect so may need to combine with IR form Greatest benefit for rigidity and bradykinesia > tremor, postural instability
32
Dopamine agonists
Apomorphine Bromocriptine Pramipexole Ropinirole Rotigotine Titrate to effect Dopamine related ADRs - impulsive behavior, N/V, postural hypotension
33
Apomorphine
DA agonist that treats off-episodes by SC inj CI: 5HT3 antagonists (ondansetron, etc), sulfite allergy Trimethobenzamide helps nausea Complex dose initiation, must be done in setting w/ BP monitoring
34
Anticholinergics for PD
Trihexyphenidyl, benztropine Useful only for tremor
35
Amantadine for PD
Reduces dyskinesias
36
COMT inhibitors
Prevent breakdown of dopamine to increase amount of levodopa crossing BBB Must be used with carbidopa/levodopa Tolcapone (severe restriction) Entacapone Opicapone Diarrhea may occur after 2 weeks of initiation Orange urine
37
Pimavanserin
approved for PD psychotic disorder
38
Antipsychotic preference in PD
Quetiapine or clozapine Avoid typical antipsychotics, risperidone, olanzapine as they worsen motor features
39
Migraine highlights
Unilateral, pulsating, mod-severe intensity, aggravation by walking Nausea, vomiting, photophobia, phonophobia +/- aura
40
Tension headache highlights
Pressing or tightening (nonpulsating), mild-moderate, bilateral, no aggravation with walking
41
Cluster headache highlights
Several episodes of unilateral, orbital, supraorbital or temporal pain Conjuctival injection, lacrimation, nasal congestion, rhinorrhea, facial sweating, miosis, ptosis, eyelid edema
42
Calcitonin gene-related peptide antagonists
Refractory prophylaxis: SC: Erenumab-aooe (aimovig) Fremanezumab-vfrm (ajovy) Galcanezumab-gnlm (emgality) IV: Eptinezumab (vyepti) PO: Atogepant (qulipta) Rimegepant (Nurtec ODT) Acute: Ubrogepant Rimegepant Zavegepant (intranasal)
43
Alternate routes for triptans
SC: sumatriptan Intranasal: sumatriptan zolmitriptan ODT: zolmitriptan rizatriptan
44
Triptan & Ergot CI
CAD stroke uncontrolled HTN peripheral vascular disease ischemic bowel disease pregnancy
45
Triptan DI
MAO-I (do not use within two weeks) Propranolol & rizatriptan (propranolol 5mg max per dose)
46
Antiemetics for migraine
Prochlorperazine Metoclopramide Chlorpromazine
47
Tension HA Prophylaxis
TCAs Botox
48
Tension HA Acute Tx
APAP NSAIDs (aspirin, ibuprofen, naproxen, ketoprofen, ketorolac) w or w/o caffeine
49
Cluster HA Prophylaxis
Verapamil Melatonin Suboccipital inj of betamethasone Lithium <0.3 Warfarin Galcanezumab-gnlm Steroids (prednisone 40-60mg/day taper over 3 weeks)
50
Cluster HA Acute
Oxygen 6-12 L/min SC triptan > intranasal in efficacy
51
MS drug for pregnancy
Dimethyl fumarate (Tecfidera) Natalizumab (Tysarbi) - possibly Avoid all others in pregnancy
52
MS therapies for spasticity
1. baclofen, tizanidine 2. dantrolene, diazepam 3. intrathecal baclofen, gabapentin 4. botox
53
Dalfampirdine (Ampyra)
Treatment for walking impairment in MS -- improves walking speed 10mg BID
54
Dextromethorphan/quinidine
Treatment for pseudobulbar affect (espidoes of inappropriate laughing/crying) Quinidine blocks first pass metabolism of DM, increasing DM concentrations

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