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Flashcards in Neurology Deck (28):
1

AUTONOMIC NERVOUS SYSTEM


Myasthenia gravis drugs

Cholinergic, cholinergic blocking, adrenergic, adrenergic blocking drugs
(Myasthenia gravis, alzheimers- anticholintererace inhibitors


Reversible cholintesterase inhibitors
Neostigmine
Pyridostigmine

2

ANS DRUGS
Alzheimers drugs

Donezepil (aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon)
Memantine (Namenda)- not cholinesterace indhibitor

3

ANS DRUGS
Donepizil (aricept)

rivastigmine (exelon)

Memantine

given less frequently
GI- self resolving, titrate up slowly

available as liquid, patch- esp if difficulty swallowing

NMDA antagonist

4

CNS

Which disease?
Drugs used?


ADRS

dopaminergics- balance dopamine and acetylcholine

Parkinson
Amantadine, Bromocriptine (older)
Mainstay- carbidopa-Levodopa
Newer drugs- pramipexole, ropinirole better SE profiles
rotigotine- not really used

n/v, hallucinations/confusion (bc targeting nervous system)

5

CNS DRUGS
Dopaminergics CONTINUED

How long does it take to work?

Interactions?

D/c?

Testing??

Phenomenon?

carbidopa-levodopa, amantadine, bromocriptine, pramipexole, ropinorole, rotigotine

can take up to 6 months for maximum effect

MANY INTERACTIONS

Titrate down- withdrawal effects

hepatic/renal function

On/off- unpredictable, not dose dependent

6

CNS DRUGS
Which drugs are primarily used for parkinsons disease?

Pramiprexole, ropinirole more commonly used bc of better SE profiles

Symptoms worsen go to levodopa-carbidopa

control smooth muscle tremor- cholinergic blockers

7

ANTICONVULSANTS

Hydantoins

First line for

Metabolized

Interactions

Ethotoin- not really used
Fosphenytoin- urgent care
Phenytoin (dilantin)***
-oral and injection, many forms (dosing different for each)

first line for tonic clonic and partial complex seizures

liver, CYP

many- ALCOHOL, increased levels Valproic acid allopurinol barbiturates, antacids, calcium
acute alcohol- increase chronic alcohol- decrease effects

8

ANTICONVULSANTS
phenytoin

ADRS

Careful with?

Use for

Patient education

LONG LIST- confusion, CV, GI, gingival hyperplasia, GU: urinary retention

Careful with hepatic and renal

Grandmal psychomotor seizures

OTC drug interactions- ibuprofen, antacids, good oral hygiene, avoid driving if not seizure free for > 1 year

9

ANTICONVULSANTS
Iminostilbenes
-
-
-

Important:

tegretol
trileptal
depakote

Black box- blood dyscrasias
Drug interactions
Induce own metabolism
Metabolized by liver

10

Iminostilbenes continued

patient education

Interactions

ADR

tegretol, trileptal, depakote

Grapefruit juice

Drug levels increase (cimetidine- available otc) erythromycin clarithromycin, verapamil, hydantoins
decrease levels- beta blockers, warfarin, doxycycline, haloperidol

Dry mouth, headache, depression bone marrow* liver, thyroid damage

11

Succinimides
-
-

what kind of seizures

Metabolized

ADR

Zarontin (more common) Celontin

absence seizures

liver

somnolence, fatigue, GI most common, blood dyscrasias

12

ANTICONVULSANTS
GABA
-
-
-

Topamax pregnancy

Neurontin, Gabitril, Topamax




D

13

GABA continued

ADRS

if d/c

Neurontin, Gabitril, Topamax

somnolence- bigger dose at night

mood- depression, anxiety

slowly

14

ANTICONVULSANTS
levetiracetam (keppra)

ADR- caution

adjunct- partial onset seizures

neuropsychiatric- suicidality

15

ANTICONVULSANTS
Lamotrigine (lamictal)

used for

Interactions

Metabolized

ADRS

primary generalized tonic-clonic seizures and partial seizures in adults and children <2


Decrease- barbiturates, estrogen, phenytoin
increase- alcohol, carbabazepine, CNS depressants, valproic acid

may be used concurrently with valproic acid and phenytoin

liver and kidneys

GI, somnolence/fatigue (all generally)- BB warning stevens johnson

16

Sedative Hypnotics
Nonbenzodiazepine
-
-
-
Benzodiapeine
-
-
-

Ramelteon

Ambien- lower dosing recommendations esp. elderly and female patients (is controlled release formulation)
Sonata
Lunesta- shorter duration of action

Flurazepam
Temazepam
Triazolam
- fast onset short duration (could use ativan)

Romelteon- removed rems, melatonin, potent agent, have to be on it for time, if addict this is option

17

Stimulants
-
-
-
-

start with?

Nonamphetamine

amphetamine
dextroamphetamine
methylphenidate
adderall- amphetamine/dextroamphetamine

always start IR then ER, all schedule II

Strattera- norepinephrine reuptake inhibitor

18

HEADACHE TREATMENT
Midrange analgesics

High range- recommendations

Butalbital/ASA (fiorinal)- controlled, came to market first
Butalbital/APAP (fioricet)- not controlled

Isometheptene/acetaminophen/dichloralphenazone (Midrin)- schedule IV

Opiods- Not recommended except in pregnancy, consider in pregnancy, vasoconstrictors contraindicated, nonresponsive to ergotamine or serotonin agonists

-IM meperidine- not good option, intransal (stadol)

19

MIGRAINES
Ergots

Pregnancy

vasoconstrictors
Ergotamine
tablets not available but are suppositories
category X
DHE
safer than ergotamine, IM or intranasal

not widely used

20

MIGRAINES
Serotonin 5-HT antagonists

which is the typical one?

How many times a month?

Contraindications

Interactions

TRIPTANS

Sumatriptan- typically start with
no recommendation one or other really depends on insurance

if more than 4 tablets a month- explore whats going on

CAD, uncontrolled HTN, pregnancy*

Ergotamines, MAOIS, SSRIS

orally, injection, nasal

21

MIGRAINES
Antiemetics

Preventive therapy for Migraine Considerations

Drugs:

reglan, compazine

more than 2 a month - consider these txs
goal 50% reduction
minimum 4 weeks for them to work

Beta blockers- propanolol, timolol (these have FDA use) used for migraine prophylaxis also metoprolol, atenolol
TCAS
Antiepileptics

try for at least 3 months
fatigue, lethargy, depression
failure to respond- try another bb
metoprolol/atenolol if asthma (selective)

22

MIGRAINES
TCAS

amitriptyline- lower doses, or nortiptyline
ADRs- drowsiness, weight gain, constipation

probably consulting at this point

23

MIGRAINE PROPHYLAXIS ANTIEPILEPTICS
-
-
-

Depakote- pregnancy D, liver function and CBC
Gabapentin-
Topamax- kidney stones
titrate up

no indication one over other
these are complicated patients

24

MIGRAINE MISC

naproxen- menstural

CCB- verapamil- patients with HTN who cannot tolerate BB

25

TENSION HEADACHES


Do not respond to

if more than one or two ha a week
beta blockers
tcas

pscyhological association

triptans or ergots
use mild analgesics or combo meds like fiorinal or midrin

26

TRANSFORMED MIGRAINE (overuse analgesics)

Drugs used

hospitalization
DHE + antinausea
Preventetive required- propanolol amitriptyline fluoxetine

Hemicrania continua- responds to indomethacin

27

CLUSTER HEADACHES

Drugs

Monitor

men more often

Ergotamine derivatives- suppository intranasal
or IM DHE

Intranasal lidocaine

Sumatriptan

Monitor suicidal thougts

Preventetive- verapamil, depakote, lithium

28

Medication overuse

HA present >15 days a month
Overuse for acute HA over 3 months
HA gotten worse during therapy
Reverts after discontinuation of medication

Start preventetive at any point