Oncology & Psych/Neurological Flashcards
(203 cards)
1
Q
what is carcinoma?
A
cancer that starts in skin or in the tissues that line or cover internal organs
2
Q
What is Luekemia?
A
cancer of the leukocytes (WBCs): leukemia is referred to as blood cancer
3
Q
What is Lymphoma?
A
cancer of the lymphatic system
4
Q
What is Multiple myeloma?
A
a type of bone marrow cancer
5
Q
What is sarcoma?
A
cancer in connective tissue (tissue that connects, supports, binds or separates other tissues), including fat, muscle, blood vessels and bone. Osteosarcoma is a type of bone cancer
6
Q
Skin cancers: Basel cell/squamous cell & melanoma
A
BC/SC: common, unlinkey to metastasize, simple to remove surgically or with topical tx
M: skin cancer that forms in the melanocytes (the skin cells that produce the pigment (melanin) that colors skin] the least prevalent type of skin cancer (2%) but the most deadly
7
Q
Staging of cancer: 0-4, TNM staging
A
-used to describes the cancer, how large the tumor is and if it has metastasized
TNM:
–T = tumor size and extent
– N=spread of the cancer to lymph nodes
–M = whether the cancer has metastasized
8
Q
7 Signs of cancer: CAUTION
A
C: change in bowel or bladder
A: a sore that does not heal
U: unusual bleeding or discharge
T: thickening or lump in breast/elsewhere
I: indigestion or difficulty swallowing
O: obvious change in wart or mole
N: nagging cough or hoarseness
9
Q
How can low dose aspirin help in cancer prevention/protection?
A
-rec for prevention of coloractal cancer in those who are 50-59 y/o, have ACSVD risk > 10%, have > 10 yr life expectancy and are at low risk of bleeding
10
Q
Consideration for highly toxic drugs: Bleomycin
A
-lifetime cumulative dose of 400 units
–> causes pulmonary toxicity
11
Q
Consideration for highly toxic drugs: Doxorubicin
A
-lifetime cumulative dose: 450-550 mg/m2
–> causes cardiotoxicity
-anthracycline durg GIVE DEXRAZOXANE PROPH
12
Q
Consideration for highly toxic drugs: Cisplatin
A
-dose per cycle not to exceed 100 mg/m2
–> nephrotoxicity
*give Amifostine (Ethyol) for prohp to reduce risk
-ensure hydration
13
Q
Consideration for highly toxic drugs: Vincristine
A
-single dose “capped” at 2 mg
–> neuropathy
14
Q
Cancer tx drugs that commonly cause hepatotoxicity
A
-antiandrogens [ bicalutamide, flutamide, nilutamide –> used mainly for prostate cancer]
-metothrexate
15
Q
What 2 cancer tx drugs cause hemorrhagic cystitis?
A
-ifosafamide (all doses)
-Cyclophosphamide (higher doses > 1 gram/m2)
** give mesna (mesnex) w/ Ifosafamide (and sometimes cyclo) to reduce risk & ensure hydration–> push fluids with mannitol to cause osmotic diuresis
16
Q
What cancer medications cause neuropathy?
A
-vinca alkaloids (vincristine, vinblastine, vinorelbine)
–> limite dose of vincristine to 2 mg /dose
-platinums (cisplatin, oxaplatin)
–> oxa: avoid cold temps and cold drinks
17
Q
What cancer meds cause thromboembolic risk?
A
-aromatase inhibitors ( anastrozole, letrozole)
-SERMs (tamoxifen, raloxifene) – breast cancer drugs
18
Q
Chemo man toxicity: Methotrexate
A
-mouth sores (mucrositis), 5 FU can also cause
–> give leucivorin to help reduce toxicity
19
Q
Chemo man toxicity: CNS toxicity
A
-caused by nitrosureas: carmustine and lomuestine
20
Q
Chemo man toxicity: nephrotoxicity and ototoxicity
A
-Cisplatin (dose < 100 mg/m2 per cycle!!)
-Carboplatin
–> give fluids and mannitol!
–> MUST DISPENSE AMIFOSTINE with both meds for protection
21
Q
Chemo man toxicity: pulmonary fibrosis
A
-bleomycin (life time cap of 400 units!)
-busulfan
22
Q
Chemo man toxicity: cardiotoxicity
A
-Doxorubicin: lifetime dose capped at 450-550 mg/m2
-Daunorubicin
–> MUST GIVE DEXRAZOXAME!
23
Q
Chemo man toxicity: hemorrhagic cystitis (“I Pee”)
A
Ifosfamide: more toxic
Cyclophosphamide
–> give fluids (NS and mannitol) and MESNA TO PROTECT THE BLADDER!
24
Q
Chemo man toxicity: Peripheral neuropathy
A
-both hands and feet (VT)
-Vinca alkaloids: vincistine (max single dose 2 mg), vinloblastine, vinorelbine)
-Taxanes: pacitaxel, docetaxel
25
Chemo man toxicity: Bone marrow suppression
ALL EXCEPT:**
-vincristine (bad nausea, neuropathy, capped at 2 mg/dose)
-bleomycin (pulm fibrosis, capped at lifetime 400 un
-monoclonal abs
-TKIs
**give colonoy stimulating growth factors (filgrastim)*
26
Chemo man toxicity: acute diarrhea
-irinotecan --> " I ran to the can"
--> stop this with adding atropine to IV bag (stops acute cholinergic crisis)
-sent pts home with loperamide
27
chemo adjunctant medications: Doxxorubicin
-dexrazoxane (Zinecard)
-dexrazone (totect) --> antidote
28
chemo adjunctant medications: Fluorouracil
-leucovorin or levoleucovorin --> give with to enhance efficacy
29
chemo adjunctant medications: Fluorouracil or capecitabine
-give uridine triacetate as an antidote
30
chemo adjunctant medications: Methotrexate
-leucovorin or levoleucovorin: give proph to protect cells from toxicity
-glucarpidase: used as an antidote it acute renal failure to increase med clearance
31
difference stages of neutropenia
--> the lower the WBC count, the higher risk of infection
-neutropenia: < 1000
-severe neutropenia: < 500
-profound neutropenia: < 100
ANC= [WBC * (% neutrophils + % bands) / 100] *
32
CSF: Filgrastim (Neupogen), Pegfilgrastin (Neulasta)
-F: given daily
-P: given weekly with chemo (should give at least 14 days before next doc chemo cycle)
SE: fever, bone pain, arthalgias, myalgias, rash
--> store in fridge
33
Febrile neutropenia temp requirements
-oral temp > 38.3 (101) x 1 reading
-oral temp > 30.0 (100.4) sustained for > 1 hr
--> ANC < 500 or ANC < 1000 and is expected to dec to < 500 during the next 48 hrs
34
Febrile neutropenia tx: low risk
-expected ANC < 100 for < 7 days, no comorbidities
--> oral anti-pseudomonal abx: cipro, levofloxacin PLUS amox/clauv (for gram + coverage) or clindamycin (if allergic to penicillin)
35
Febrile neutropenia: high risk
-expected ANC < 100 for > 7 days, presence of comoborbities, evidence of renal or hepatic impairement
--> IV anti-pseudomonal beta-lactams: cefepime, ceftazidime, meropenem, imipenem/cilastatin or pip/tazo
36
Anemia tx in cancer pts
-ESA agents can shorten survival and inc tumor progression = NOT rec in pts for curative care, only pallitive
--> initiate when Hgb < 20**
-use the lowest dose needed to avoid RBC transfusion
-need to make sure serum ferritin, TSAT and TIBC are normal or ESA wont work
37
Risk factors for chemo-induced nausea and vomiting
- female gender
-< 50 y/o
-dehydration
-hx of motion sickness and N/V
--> admin. antiemetics 30 mins before chemo
38
drugs used for low emetic risk
-1 drug (any except NK1-RA)
5ht3-RA (dolasetron, granisetron, ondansetron)
dexamethasone
prochlorperazine
metoclopramide
39
drugs used for moderate emetic risk
-2-3 drugs
NK-1RA + 5HT3-RA + dexamethasone [netupitant/palonosertron or fosnetupitant/palonosertron + dexamethasone]
5HT-RA + dexamethasone
Palonosteron + olanzapine + dexamethasone
40
drugs for high emetic risk
-3-4 drugs
*olanzapine + netupitant/palonosertron or fosnetupitant/palonosertron + dexamethasone
-palonosteron + olanzapine + dexamethasone
-netupitant/palonosetrone or fosnetupitant/palonosertron + dexamethasone
41
NK-1 RA: aprepitant (Emend), Fosaprepitant,
-inhibit substance P, augmenting the antiemetic activity of 5HT-3 receptor antagonists
42
5HT-3 receptor antagonists: odansertron (zofran), granisetron (Sancuso), Palonosteron
CI: do not use with apomorphine
Warnings: inc in QT interval, serotonin syndrome
SE: headache, constipation
43
Dexamethasone (for chemo N/V)
CI: systemic fungal infections
SE: inc appetite, fluid retention, insomnia
--> higher doses inc BP and blood glucose
44
Dopamine Receptor Antagonists (Prochloperazine, promethazine, metoclopramide, olanzapine, haloperidol)
BBWs:
-prochlorperazine: inc mortalilty in elderly
-promethazine: do not use in children < 2 y/o, do not give via intra-arterial or SC
-metoclopramide: tardive dyskinesia, dec dose with renal impairment
-haldol: QT prolongation
Warnings: symptoms of parkinsons disease can be exacerbated
SE: sedation, lethargy, EPS, seizures
45
Chemo induced diarrhea (meds)
-Irinotecan: causes cholinergic excess, including diarrhea with abdominal cramping
-Atropine --> can be given to PREVENT acute diarrhea
-Pilocarpine: causes salivation, used for xerostomia (dry mouth) caused by some cancer drugs- also used for lacrimation (tears) and is used for dry eyes
46
Hand-foot syndrome management
-occurs with tx with capectabine, flourouracil- due to small amounts of chemo dripping into the capillaries of the hands and feet
-limit daily activity to reduce friction and heat exposure to hands and feet
-emollients (aquaphor, udder cream and bag blam) are used to retain moisture, topical steroids and pain medications can also be used
-cooling hands and feet with cold compress may provide temp. relief of pain and tenderness
47
Treatment of tumor lysis syndrome
S&S: acute hyperkalemia, hypocalcemia, and hyperuricemia = AKI
-allopurinol 400-800 mg/day
-if get a skin rash from allo, can use febuxostat
-Rasburicase is used for initial tx in pts with high risk (WBC > 100,000)
-both should be given IV w/ normal saline
48
Hypercalcemia of malignancy
-1st line: IV bisphosponate (pamidrone, zoledroonic acid)
--> severe cases: calcitonin can be added (for up to 48 hrs)
-can also use denosumab (Xgeva)
49
HER2 overexpression & TX
-HER2/neu oncogene promotes breast tumor growth: overexpression amplifies cancer cell growth and survival
* Trastuzumab (Herceptin): binds to the HER2 receptor, preventing dimerization --> Mbas can trigger severe reaction- premedicate with (dexameth (steroid), diphenhydramine (antihistamine) & acetaminophen)
50
SERMS: Tamoxifen (soltamox), raloxifene (Evistal)
-used for premenopausal ER+ breast cancer
BBW: inc risk of uterine or endometrial cancer, thromboembolic events
CI: do not use with warfarin, hx of DVT/PE (use venlafaxine to treat hot flashes if needed)
SE: hot falshes, vaginal bleeding, dec bone density
--> TERATOGENIC,
Raloxifene (IM): used in women for breast cancer prevention and osteoporosis prevention/tx
**contin for at least 5 yrs
51
Aromatase inhibitor: Anastrozole (Arimdex), Letrozole (femara)
-blocks conversion of androgens to estrogen --> used in post menopausal women
-higher risk of osteoporosis and. CVD
Ci: pregnancy
SE: hot flashes, myalgias (painful muscles)
**contin for at least 5 yrs
52
common drugs used to treat metastatic breast cancer
-capecitabine
-carboplatin
-cyclophhosphamide
-docetaxel
-paclitaxel
-doxorubicin
-methotrexate
53
GnRH agonists (Leuprolide (Lupron), goserelin (Zoladex)
-LHRH hormones agonsits; reduce testosterone through a negative feedback mechanism, causing an initial surge in testosterone, followed by gradual reduction
--> dec bone density; supp w/ calcium/vit D
--> cause tumor flare: prevent w/ concurrent use of an antiandrogen (bicalutamide) for several weeks
SE: hot flashes, impotence, gynecomastia, bone pain, QT prolongation
54
Antiandrogen, first generation: Bicalutamide (Casodex)
-competitively inhibit testosterone from binding to prostate cancer cells--> used in combination with a GnRH agonist
CI: do not use in females
SE: hot flaashes, gynecomastia
55
What chemo drugs are cell cycle INDEPENDENT (AAP: all awesome pharmacists)?
--> tumor killing not dependent on the phase of the cell cycle
-Alkylating agents (cyclophosphamide, Ifosfamide)
-Anthracyclines (doxorubicin, Mitoxantrone)
-Plantinum Compounds: Cisplantin, Caroplatin)
56
What chemo drugs are S-phase (DNA replication) dependent? (AT)
-Antimetabolites (methotrexate, pemetrexed, Fluorouracil, Capecitabine)
-Topoisomerase I Inhibitors (Irinotecan, Topotecan)
57
BSA formula (Mosteller Equation)
BSA = st[(ht cm * wt kg) / 3600]
in --> cm = in * 2.54
lb --> kg = lb/2.2
Male norm = 1.9
Female norm = 1.6
58
Alkylating Agents (cell cycle independent)
-work by cross-linking DNA strands + inhibiting proteins and DNA synthesis
--> can cause DNA mutations that lead to "secondary malignancies"
-cyclophosphamide + ifosfamide: produce a metabolite (acrolein) that concentrates in the bladder & can cause hemorrhagic cystitis
***must always dispense ifosfamide with mensa!
59
Alkylating Agents drugs
-cyclophosphamide --> SE: SAID
-ifosfamide (Ifex)
-Carmustine --> use non-PVC bag and tubing
-Busulfan --> SE= pulmonary toxicity
BBW: hemorrhagic cystitis
60
Platinum-based compounds facts
-cross-link DNA and interfere w/ DNA synthesis and cell replication
--> have toxicities similar to heavy metal poisoning = peripheral sensory neuropathy, ototoxicity & nephrotoxicity
61
Platinum-based compounds: Cisplatin
-nephrotoxicity, ototoxicity
*amifostine (Ethyol) is give to prevent nephrotoxicity
**HIGHLY emetogenic (give 3 N/V drugs)
****Limit dose to 100 mg/m2/cycle
SE: myelosuppression
62
Platinum-based compounds: Carboplatin
-myelosuppression is dose related
**dosed based on calvert formula: (Target AUC) (eGFR + 25)
AUC= 2-8, GFR capped at 125, may use crcl
63
Anthracycline Facts
-associated with cardiotoxicity (HR and cardiomyopathy)
-strong vesicants --> dexrazoxane is used as an antidote for accidental doxorubicin (Totect) extravasation
-protect from light during administration
64
How to reduce Doxorubicin Cardiotoxicity
-keep track of lifetime cumulative Doxorubicin dose = 450-550 mg/m2 [dose in mg/m2/cycle * total # of cycles]
-Dexrazoxane may be considered when the doxorubicin cum dose > 300 mg/m2
65
Anthracycline drugs: Doxorubicin (Adriamycin)
-potent vesicant
BBW: myocardial toxicity, vesicant, myelosuppression
--> color is RED (causes discoloration of urine, tears, sweat & saliva)
**do NOT exceed more than lifetime dose of 450-550 mg/m2
--> Dexrazoxane (Totect, Zinecard) for extravasation and cardioprotection)
SE: N/V
66
Anthracycline Drugs: Mitoxantrone
BBW: myocardial toxicity
--> drug is BLUE: causes blue urine, sclera and other body fluids
67
Vinca Alkaloids facts
-cause peripheral sensory and autonomic neuropathies (constipation)
*for IV use only, fatal if given by other routes (Vincristine --> also has CNS toxicity, CAPPED AT 2 MG/DOSE)
-vinblastine and vinorelbine associated with bone marrow suppression
-potent vesicants = antidote --> hyaluronidase and warm compress
68
Topoisomerase I inhibitor: Irinotecan (Camptosar)
-block th coiling and uncoiling of the double-stranded DNA helix during the S phase
"I ran to the can"--> acute anticholinergic symptoms (add atropine to the bag)
-delayed diarrhea (treat with loperamide)
BBW: myelosuppression, diarrhea
69
Topoisomerase II inhibitor: Bleomycin & Etoposide
-block the coiling and uncoiling of the double stranded DNA helic during the G2 phase
**max lifetime dose of 400 units d/t pulmonary toxicity risk & NOT mylosupressive :)
SE: hypersensitivity risk
-E capsules: need to be refrigerated
-infusion rate-relates hypotension: infuse for at least 30-60 mins
70
Taxanes drug facts
-inhibit the function of microtubules during the M phase
-peripheral sensory neuropathies + infusion-related hypersensitivity reactions & fatal anaphylaxis can occur w/ all (except abraxane- albumin bound)
SE: alopecia
**give taxanes before platinum-based compounds
71
Taxanes Drugs : PDC
-Paclitaxel: premedicate w/ diphenhydramine, steroids, H2RA
-Paclitaxel (albumin bound): no need to premedicate
-Docetaxel: premedicare with steroids for 3 days--> causes severe fluid retention
-Cabazitaxel: premed with diphenhydramine, steroid, H2RS (famatodine)
72
Pyrimidine Analog antimetabolites: Fluorouracil, 5-FU
-give w/ Leucovorin to inc efficacy (helps fu to bind more tightly to its target enzyme)
BBW: sin inc in INR
SE: hand-foot syndrome, diarrhea, muscositis
--> uridine triacetate (vistogard) can be given as antidote for overdose or toxicity due to DPD deficiency
73
Pyrimidine Analog antimetabolites: Capesitabine (Xeloda)
-oral prodrug of fluorouracil: 2 divided doses 12 hrs apart, given w/ water within 30 mins of a meal *take for food*
--> dihydropyrimidine dehydrogenase (DPD) deficiency inc risk of severe toxicity
SE: hand-foot syndrome, diarrhea, muscositis
--> uridine triacetate (vistogard) can be given as antidote for overdose or toxicity due to DPD deficiency
74
Folate antimetabolites facts
-block purine and pyrimidine biosynthesis during S phase
-folic acid +/- vitamin b12 may be required to reduce toxicity (myelosuppression, mucositis, diarrhea)
**w/ high doses of methotrexate --> give leucovorin/levoleucovorin "rescue" must be given
75
Folate antimetabolite: Methotrexate (Trexall)
-high dose (500 mg) requirs leucovorin
-hydration with IV sodium bicarb given to: alkalinize the urine & decrease nephrotoxicity
*Glucarpidase (voraxaze) given as antidote that rapidly lowers drug levels
DDI: NSAIDs, salicylates, PPIs
BBW: myelosuppression, renal damage, hepatotoxicity, tetratogencity
SE: nephrotoxicity, nausea, mucositis
76
Misc cancer drugs: Tretinoin
-do not use in pregnancy
-1st line for retonoic acid-acute promyelocytic leukemia syndrome
77
Misc cancer drugs: Arsenic trioxide
-worst/most QT prolonging drug
78
Misc cancer drug: Everolimus
-mTOR inhibitor: inhibits downstream regulation of vascular endotheilail growth factor (VEGF) reducing cell growth, metabolism, proliferation and angiogenesis
-SE: mouth ulcers, stomatitis, rash
79
Misc cancer drugs: Immunomodulators
-lenalidomide, pomalidomide, thalidomide
*cause the WORST birth defects = REMS drugs--> baby missing long bones in arms and legs
80
VEGF inhibitor: Bevacizumab (Avastin)
-impairs wound healing: do NOT administer for 28 days before or after surgery
BBW: severe/fatal bleeding , GI perforation
81
HER2 Inhibitors: Trastuzumab (Herceptin)
-only used for over expression of HER2 genes (HER2/NEU)
-cardiotoxicity
82
EGFR Inhibitor: Cetuximab (Erbitux)
-requires testing for KRAS wild type & EGFR + (used for NSCLC)
SE: acneiform rash (blisters and painful)--> indicates that a pt is expected to have a better outcome, treat with topical emollients (steroids, abx)
83
Leukocyte cluster of differentiation CD antigens : Rituximab (Rituxan)
-premedicate with diphenhydramine, acetaminophen, steroids
-test for B-cell antigen CD20; must be CD20 positive to use
BBW: hep B reactivation, PML*, SJS/TEN
84
Tyrosine Kinase Inhibitors: Imatinib (Gleevec)
*must be philadelphia chromosome (BCR-ABL) positive to use
-oral drug
BBW: QT prolongation, vascular occlusions
SE: fluid retention, skin rash, diarrhea, hypothyroidism
-take with food*
85
DSM5 criteria for depression (M SIG E APS)
Mood*
Sleep
Interest/pleasure *
Guilt
Energy
Concentration
Appetite
Psychomotor agitation or retardation
Suicidal ideation
*must have symptoms 2 weeks and at least 5 symptoms, must have those 2
86
Drugs that can cause or worsen depression
-ADHD meds: Atomoxetine (Strattera)
-Analgesics: Idomethacin
-Antiretrovirals (NNRTIs): Efavirenz, Rilpivirine
-Cardiovascular meds: BBs (propranolol)
-Hormones: BC, steroids
-Others: antidepressanrs, benzos, interferons, Varenicline, Ethanol
87
What natural products are used for depression and what risks do they have?
-St. John's wort: serotonin syndrome, CYP450 inducer (makes BC less effective), photosensitivity
-SAMe: serotonin syndrome, bleeding risk
-Valerian: sedations
88
what are withdrawal symptoms of antidepressants?
BBW: suicidal thots and behaviors in peds and young adults
-anxiety, agitation, insomnia, dizziness, flu-like symptoms
89
TCAs for depression SE/Safety/Monitoring
CI: do not use with MAOIs, linezolid, IV methylene blue
SE: QT prolongation, orthostasis, anticholinergic: dry mouth, blurred vision, urinary retention, constipation, weight gain, falls (BEERS LIST)
90
TCA drug classes (2)
Tertiary amines: inc chilinergic effects, more effective
-Amitriptyline - give at QHS
-Doxepin- indicated for sleep as well
Seconday amines: more selective for NE, less SEs
-nortriptyline (pamelor)
91
SSRI safety in pregnancy
-warning of persistent pulmonary HTN of the newborn
-NO paroxetine due to cardiac effects
92
How to treat postpardum depression?
-breast feeding can help
-SSRI and TCAs are preferred (NO Dozepin)
-Brexanolone (C 4), has REMS, BBW for severe sedation
93
SSRI & SNRI SE/Safety
CI: do not use with MAOI, Linex=zolid, Pimozide (used for turrets)
Warnings: QT prolongation (QT > 440, > 500 = TdP), liver disease, SIADH/hyponatremia, fall risk (BEERs), bleeding risk
SE: sexual dysfunction, CNS effects, dry mouth, nausea
94
SSRI drugs (5)
Citalopram (Celexa): QT, MDD 40, elderly: 20mg
Escitalopram (Lexapro) QT, MDD 20, elderly 10 mg
Fluoxetine (Prozac): am dosing, long 1/2 life, no need to taper
Paroxetine (Paxil): sedation, take at pm [Brisdelle- usee for menopausal VS]
Sertraline (Zoloft) use in pts with cardiac risk
95
SSRI combination drugs (2)
-Vilazodone (Vibryd)- SSRI + 5 HRIa partial agonist- take with food
-Voritioxetine (Trintellix)- SSRI + 5 HT3 anta + 5 H1A agonist --> less sexual side effects
96
SNRIs (3)
-Venlafaxine (Effexor) : IR max dose = 375 mg, used for anxiety as well
-Duloxetine (Cymbalta): used for pain and anxiety
-Desvenlafaxine (Pristiq) only for depression
--> may increase BP, avoid in pts with uncontrolled BP
97
DDIs with SSRI/SNRI
-serotonin syndrome or hypertensive crisis: use a 2 week washout from MAOi
-QT prolongation: noted with citalopram, escitalopram and venlafaxine
-Additive bleeding risk: anticoadulants, antiplatelets, fish oil, 5 gs (ginkgo, garlin, ginger, ginseng, glucosamine)
-CYP450 2D6 inhibitors: duloxetine, fluoxetine, paroxetine and tamoxifen
98
Bupropion
-2nd line tx (use in pts who hd sexual SEs)
-dopamine and NE reuptake inhibitor
CI: seizure disorder (do not exceed 450 mf/day- risk inc with abrupt alcohol d/c), eating disorders (anorexia, bulimia), do not use w/ MAOi, IV methylblue or other forms of bupropion
Warnings: neuropsychiatric changes (mood, paranoia, aggression)
SE: dry mouth, insomnia, restlessness, weight loss (contrave)
99
MAOi drugs (4)
3rd line- inhibit enzyme monoamine oxidase, hich breaks down 5-HT, NE, EPI and DA
Nonselective:
-Isocarboxazid (Marplan)
-Phenelzine (Nardil)
-Tranylcypromine (Parnate)
Selective:
-Selegiline (Emsam) - patch for depression and ODT version for parkinsons
100
MAOi safety/SE
CI: DDIs, Drug-food interactions (tyramine rich = hypertensive crisis)
*use 2 week washout with: SSRI, SNRI, TCAs, bupropion
*use 5 week wash out with: fluoxetine
101
Misc antidepressants (3)
-Mirtazapine (Remeraon): TCA, SE: increased appetite, weight gain, sedation, QT
-Trazadone: adminster QHS, sedation properties (BEERS), SE: priapism, QT
-Nefazodone: BBW- hepatotoxicity, (less sedating than trazadone)
102
Selecting the best antidepressant: Cardiac/QT risk
**Sertraline preferred
-avoid high doses of citalopram and escitalopram
-watch for additive QT prolongation risk
103
Selecting the Best Antidepressant: Smoking cessation
-Bupropion SR (indicated for both depression and smoking cessation)
-MDD: 300 mg/day
104
Selecting the Best Antidepressant: Peripheral Neuropathy
Duloxetine
105
Selecting the Best Antidepressant: Seizures
**avoid Bupropion in pts with seizures and eating disorder
-do not use in pts going through abrupt withdrawal = inc seizure risk
106
Selecting the Best Antidepressant: Pregnancy
-psychotherapy for mild to moderate symptoms
-SSRI is preferred drug class (hypertension of newborn)
**DO NOT use paroxetine
107
Selecting the Best Antidepressant: Sexual Dysfunction
-SSRI and SNRI have higher risk
-Bupropion and mirtazapine have lower risk
108
treatment options for treatment resistant depression
-inc the dose of existing antidepressant
-change to a differnt antidepressant
-use a combo of antidepressants with diff mechanisms
--> augment with: Buspirone, atypical antipsychotic, lithium, esketamine and ECT
109
Atypical antipsychotics used from tx resistant depression
--> depression that does not improve following 2 full tx trials ( 4-8 weeks at a therapeutic dose)
- Aripiprazole (abilify)
-Olanzapine/Fluoxetine (Symbyax)
-Quetiapine (seroquel)
-Brexpiprazole (Rexulti)
BBW: elderly individuals w/ dementia - related psychosis are at an inc risk of death
110
Aripiprazole (abilify) SEs
anxiety, insomnia, akathesia (inability to stay still)
111
Olanzapine/fluoxetine (Symbyax) SEs
CI: do not use with MAOi, linezolid, IV methylene blue
AE: sedation, weight gain, increased lipids, increased glucose
112
Quetiapine (Seroquel AEs)
-sedation, orthostasis, weight gain, increased lipids, inceased glucose
113
Brexpiprazole (Rexulti) AEs
weight gain, akathisia (agitation - dose dependent)
114
Esketamine (Spravato)
*used for tx-resistant depression and depression with suicidality
BBW: sedation and dissociative or perceptual changes, potential for abuse and misuse
-REMS
115
schizophrenia positive symptoms
-hallucinations
-delusions
-disorganized thinking and behavior
116
schizophrenia negative symptoms
-flat affect
-poor hygiene
-lack of motivation (avolition)
-loss of speech (alogia)
-withdrawal
117
Long acting injection antipsychotics (nonadherence)
-Haldol Decanoate (q 4 w)
-Risperdal Consta ( q 2 w)- risperadone
-Invega Sustenna (q 4 w), Invega Trinza (q 3 months) - paliparadone
-Abilify Maintena (q 4 w)- less metabolic issues, not as sedating
118
Fast-acting Injection antipsychotics
--> used for acutely psychotic rn
-Haloperidol (shoot them up IM- Haldol + Ativan + benz or diphenhydramine)
-Fluphenazine
-Zyprexa
-Geodon
**do not use olanzepine and benzos together (orthostatsis)
119
Orally Disintegrating Tablets (ODTs) (cheeking)
-Abilify Discmelt
-Clonzapine Fazaclo
-Risperdal M-Tab
-Zypreza Zydis
-Saphris (sublingual)
120
*Meds/rec drugs that can cause psychotic symptoms
--> Anticholinergics ( high doses)
-dextromethorphan
-dopamine agonists
-Interferons
-Stimulants
-systemic steroids
--> Rec drugs
-bath salts
-cannabis
-cocaine
-LSD
-meth
-PCP
121
BBW with antipsychotics
-increased risk of mortality in elderly pts w/ dementia related psychosis --> cardiovascular and infections
(mainly d/t the over use of risperadone)
122
BBW for Clozapine
Must have failed 2 other APS or had bad AEs (TD)
-SEVERE Neutropenia (ANC > 1500 required to start, d/c if ANC < 1000)
--> must monitor q week x 6 months, q2 weeks x 6 months then q month for life
-seizures
-myocarditis and cardiomyopathy
123
BBW: Thioridazine and Ziprasidone
*HIGHEST QT prolongation: (Thioridazine < Haloperidol < Ziprasidone)
--> higher risk TdP w/ low potassium, magnesium
--> D/C with QT > 500 msec
--> Dizziness, palpitations, syncope: cardiac evaluation
124
1st gen APS (drugs and major SEs)
(L --> H Potency)
-Chlorpromazine
-Thioridazine
-Loxapine
-Perphenazine
-Haloperidol*
-Fluphenazine (comes in q 2 w IM)
-Thriothixene
-Trifluoperazine
AEs: Tardive Dyskinesia (elderly women at highest risk), dystonic reactions (young males at rik)
125
*Important AEs of second generation APs
-Metabolic SEs (weight gain, inc cloes, glucose)
-->highest risk = clozapine, olanzapine, quitiapine
-->Mod risk: Risperidone, paliperidone
-->Low risk: Aripipazole, Ziprasidone, Lurasidone and asenpine
-EPS:
-->Low risk: quetiapine
-Hematological effects:
--> high risk: Ziprasidone
-Inc Prolactin:
-->High risk: Risperidone, paliperidone
-Seizure:
--> high risk: Clonazipine
126
Antipsychotic drug interactions
-high levels of risperidone and paliperidone increase prolactin and cause EPS
-avoid drugs that lower seizure threshold w/ clozapine
-monitor for an increased risk of resp. depression and hypotension when adminstered with benzos ( DO NOT mix olanzapine with benzos)
-avoid other dopaime blocking agents such as metoclopramide ( do not want to use in the elderly- renal drug, 10 mg QID w/ meals E: 2.5- 5 mg): EPS and TD risk
127
2nd gen antipsychotics
--> block dopamine and serotonin receptors
-Aripoprazole (abilify) - Maintena (q month), Astristrada (Q 4-8 w)
-Clonzapine (Clozaril) *must fail 2 other therapies first
-Lurasidone (latuda): sedating *w/ at least 350 Kcal*
-Olanzapine (Zyprexa) -Relprevv (2-4 w lasting inj) *Q HS*
-Paliperidone (Invega): - Sustenna (q month) Trinza (Q 3 mon) Hafyera (Q 6 mon) *ghost tab in stool*
-Quetoapine (Seroquel)
-Risperadone (Risperdol): Consta ( q 2 weeks)
-Ziprasidone (Geodon): Geodon- acute injection *w/ food*
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Neuroleptic Malignant Syndrome
**medical emergency! (rare but very dangerous- most common w/ FGAs and D2 blockers
-intense muscle contractions that can lead to acute renal injury (rabdo), suffocation and death
Signs: hyperthermia, muscle rigidity (* lead pipe rigidity), AMS, tachy, Labs: inc creatinine phosphokinase, & WBCs
TX: taper off antipsychotic quickly, use muscle relaxant (Dantrolene) --> use alt drugs like quetiapine or clozapine after)
129
What is mania? (bipolar disorder)
Symptoms: inflated self-esteem, needs less sleep, more talkative than normal, jumping from topic to topic, easily distracted, increase in goal-directed activity, high risk, pleasurable activities
Definition: abnormally elevated or irritable mood for at least a week
Diagnosis: exhibits > 3 symptoms (if mood is only irritable, exhibits > 4 symptoms)
130
Drug treatment for Bipolar Disorder
-Lithium and antieplileptic drugs (valproate, lamotrigine, carbamazepine) treat both mania and depression w/o inducing either state
*antidepressants can induce or exacerbate a manic episode when used as monotherapy, so they should only be used w/ a mood stabilizer
131
acute treatment: manic episode
-1st line: antipsychotic (olanzapine, risperadone), lithium or valproate
--> combo of antipsychotic + lithium/valproate is preferred for severe episodes
132
Acute treatment: depressive episode
1st line: antipsychotic (quetiapine, lurasidone), lithium, valproate or lamotrigine can be added or used as alternative
133
second generation drugs used for Bipolar disorder
-aripiprazole (abilify, abilify mintena)
-olanzapine (zyprexa, Relprevv, Zydis)
-quetiapine (seroquel)
-risperidone (Risperdal)
-ziprasidone (Geodon)
-lurasidone (Latuda)
-olanzapine/fluoxetine (symbyax)
134
Lithium
-influencing the reuptake of serotonin, NE or by modulating glutamate levels
--> dose: 300-900 mg/day (BID-TID)
-therapeutic range: 0.6-1.2 mEq/L (trough)
> 1.5 = ataxia, coarse hand tremor, vomiting
> 2.5 = CNS depression, arrhythmia, seizure
135
Lithium SE/Safety
BBW: monitor serum levels for toxicity
Warnings: serotonin syndrome, renally cleared, avoid in pregos
SE: GI upset, cognitive effects, cogwheel rigidity, tremor, thirst, weight gain
136
Lithium levels INCREASE with:
- dec salt intake/sodium loss (with ACE/ARBs, thiazide diuretics)
- NSAIDs: aspirin and sulindac are safer options
137
Lithium levels DECREASE with:
-inc salt intake: caffeine and theophylline
138
Increase risk of neurotoxicity when Lithium is taken with:
(ataxia, tremors, nausea)
-verapamil, diltiazem, phenytoin and carbamazepine
139
*converting between lithium formulations
- 5 mL lithium syrup = 8 mEq of lithium ion
-8 mEq of lithium ion = 300 mg lithium carbonate tab/cap
140
Drugs to use with pregnant bipolar disorder:
AVOID: valproate, carbamazepine, lithium
Safe: lamotrigine, lurasidone (bipolar depression)
141
what conditions must be met for diagnosis of ADHD?
-several inattention or hyperactive-impulsive symptoms were present before the age of 12
-symptoms must have been present in 2 or more settings (home, school, work, w/ friends etc)
-symptoms interfere with functioning and are not caused by another disorder
142
pt-friendly formulations for stimulants
-when putting capsule contents in food, use a small amount of food, eat the food right away; do not chew the beads
-capsule
-chewable tablet (Vyanse)
-orally-disintergrating tab
- patch (Daytrana)
- suspension
143
Treatment of ADHD*
-stimulants are first line: (take in AM)
--> methylphenidate (concerta, Daytrana, Ritalin)
--> Lisdexamfetamine (Vyvanse)
--> Dexatroamphetamine/Amphetamine (Adderall)
-non-stimulants are second line: (take if risk of abuse)
--> Atomoxetine (Strattera)
-Add-on meds or can be used alone:
--> Guanfacine ER (Intuniv)
--> Clonidine ER (Kapvay)
-to help sleep at night:
--> Clonidine IR (Catapres)
--> Diphenhydramine
--> melatonin
144
Stimulants BBW/CI/Warnings
BBW: high potential for abuse and dependence
CI: do not use within 14 days of MAOi (hypertensive crisis), HF, marked anxiety, tension, agitation, glaucoma
Warnings: inc HR and BP (cardio events), priapism, exacerbation of preexisting psychosis, inc risk of seizures, loss of appetite, serotonin syndrome
145
Stimulants in ADHD: methylphenidates
-Ritalin (IR tab)
-Concerta (ER TAB): qam
-Ritalin LA (ER cap) Qam
-Daytrana (patch): apply 2 hrs before desired effect, remove after 9 hrs, alt. hips daily
146
Stimulants in ADHD: Ampetamines
-Dextroamphetamine/Amphetamine (Adderall) --> misuse and sudden death
-Lisdexamfetamine (Vyvanse): capsule, chewable tab, low abuse potenial
147
non-stimulant option for ADHD: selective norepinephrine reuptake inhibitor
Atomoxetine (Strattera) : BBW of suicidal ideation, no MAOi within 14 days, do not open capsule (ocular irritant)
148
Non stimulat options for ADHD: Central Alpha-2A adrenergic receptor agonists
-Clonidine ER (Kapvay) qhs
-Clonidine IR (Catapres) for HTN
-Guafacine ER (Intuniv)
--> dose dependent cardio events, sedation and drowsiness
-do not d/c abruptly
149
*drugs that cause anxiety
-albuterol (if used too frequently or incorrectly)
-Antipsychotics (apripiprazole, haloperidol)
-Bupropion
-Caffeine (in high doses)
-Decongestants (pseudoepherdrine)
-Illicit drugs (LSD, coke, meth)
-Levothyroxine
-Steroids
-Stimulants
-Theophylline
150
Drug tx for anxiety: 1st line
-SSRI/SNRIs (slow titration, takes 4-6 weeks)
-Escitalopram (Lexapro)
-Fluoxetine (Prozac)
-Paroxetine (paxil)
-Sertraline (Zoloft)
-Duloxetine (Cymbalta)
-Venlafaxine (Effexor)
151
2nd line tx for anxiety
-Buspirone (use in combo with antidepressant)
-TCA: Amitriptyline, Nortriptyline (Pamelor): not FDA approved
-Hydroxyzine (Vistaril): sedating, use for short term
-Pregalin (Lyrica) & Gabapentin (Neurontin): not FDA approved, can be used in pts with annxiety and neuropathic pain
152
Special situations for anxiety tx
Propranolol (Inderal): not FDA-approved for anxiety but can reduce symptoms of stage fright or performance anxiety
-10-40 mg 1 hr prior to event
153
Benzos better to use in elderly (LOT)
L: lorazepam (anxiety)
O: oxazepam (anxiety)
T: temazepam (insomnia)
154
Benzos in anxiety
-Alprazolam (Xanax)
-Clonazepam (Klonopin)
-Diiazepam (Valium) : alcohol withdrawal
-Lorazepam (Ativan) : alcohol withdrawal
CI w/ opioids, severe liver disease, addictive
155
*select drugs that can worsen insomnia
-alcohol
-antiretrovirals
-Apriprazole
-Atomoxetine
-Bupropion
-Caffeine
-Decongestants (pseudoephedrine)
-Diuretics (due to nocturia)
-Fluoxetine
-Steroids
-Stimulants
-Varenicline
156
Need help falling asleep?
-Eszopiclone
-Ramelteon
-Zalplon
-Zolpidem
157
Need help staying asleep?
-Doxepin
-Eszopiclone
-Survorexant
-Zolpidem
158
Need help falling and staying asleep?
-Eszopiclone
-Zolpidem
159
Hypnotics for sleep disorders
-C-IV! --> non benzos that increase GABA at the benzodiazepine receptors
-Zolpidem (Ambien)
-Zaleplon (Sonata)
-Eszopiclone (Lunesta)
AEs: CNS depression (next day impairement if < 7-8hrs of sleep), inc risk of resp depression, parasomnias (weird events while asleep)
160
Orexin-receptor antagonist for sleep disorders
C-IV: blocks promotion of wakefullness
-Surovexant (Belsomra)
CI in narcolepsy
Warnings: sleep driving, abnormal thinking/behavior, sleep paralysis
161
Melatonin Receptor Agonist for sleep disorders
-Ramelteon (Rozerem)
-Tasimelteon (Hetlioz) --> for non 24 hr sleep cycle ppl (like the blinds)
162
Benzodiazepine use in insomnia
-C-IV, short term only!
-potentiate GABA
-Temazepam (Restoril)
Warnings & SE: drowsiness, ataxia, lightheadedness, anterograde amnesia,
-BEERS, but this one is on LOT = safer in olds
163
Treatment for Restless Leg Syndrome
Dopamine agonists:
--> Pramipexole (Mirapex)
--> Ropinirole (Requip)
--> Rotigotine (Neupro) daily patch
AEs: orthostasis, somnolence
-Gabapentin encarbil (Horizant) --> approved fro RLS and postherpetic neuralgia (take with food)
164
Drug tx for narcolepsy
Stimulants: C-IV
-Modafinil (Provigil)
-Armodafinil (Nuvigil)
--> Sodium oxybate (Xyrem) : C-III, REMs, "date rape drug" --> helps you sleep at night so you dont fall asleep during the day
165
Dopamine blocking drugs that can worsen parkinsons disease *
-Prochloperozine and other phenothiozines (used for psychosis, nausea, agitation)
-Haloperidol or droperidol
-2nd gen Ags (risperidone and paliperidone)
-Metoclopramide (can accumulate in elderly)
166
TRAP (motor) symptoms of Parkinsons Disease*
T: tremor when resting
R: rigidity in legs, arms, trunks and face (mask-like face)
A: akinesia/bradykinesia (lack of/slow start in movement
P: postural instability (inbalane/falls)
Others:shuffle walk, muffled speech, constipation, incontinence, frozen
167
Parkinsons disease: tx for related psychiatric conditions
-Depression/Anxiety: SSRI/SNRI, TCA (desipramine, nortriptyline)
-Psychosis: quetiapine (AE: metabolic syndrome, orthostasis)
168
PD tx: Carbidopa/Levodopa (Sinemet)
-this becomes dopamine
-separate from iron and protein rich food ( dec absorption)
SE: Nausea, dizziness, hallicunations, psychosis
DDI: phenothiazine, metoclopramide
--> use entacapone (Comtan) to make the drug last longer (200 mg with each dose of c/L)
169
PD tx: Dopamine agonists
-Pramipexole (Mirapex) .125 mg TID
-Ropinirole (Requip) .25 mg TID
-Rotigotine (Neupro) patch- avoid in sulfite allergy, causes sweatyness
SE: somnolence, orthostasis, dyskinesia, dizziness, N/V
170
PD tx: rescue therapy- Apomorphine (Apokyn)
-injection for those with severe diease (are frozen), lasts 45-90 mins
SE: SEVERE N/V, hypotension
-monitor supine and standing BP
-start antiemetic 3 days prior to dose: Trimetholbanzamide
**DO NOT USE ZOFRAN!
171
what drug is best used for a younger pt with only parkinsons tremor?
-Benztropine (Cogentin) - has milder SEs
*do not use in the elderly
172
Alzheimer's disease symptoms *
-memory loss/getting lost
-difficulty communicating, repeating words and information
-difficulty with planning and organizing
-poor coordination and motor function
-personality changes
-inappropriate behavior
-paranoia, agitation, hallucinations
173
Drugs that can worsen dementia *
- antiemetics (promethazine)
-antihistamines (diphenhydramine, dooxylamine)
-antispychotics (chlopromazine, aripiprazole)
-barbituates (phenobarbital, butalbital)
-benzos (alprazolam, clonazepam)
-central antichilonergics (benztropine)
-skeletal muscle relaxants (baclofen)
-CNS depressants: opioids
174
what antipsychotic is FDA approved for agitation and psychosis in dementia?
Brexpiprazole (Rexulti)
--olanzapine is used off label as well
BBW: for increased mortalitiy and associated with increased rate of cog decline
--> LAST LINE in those with severe symptoms (lowest dose, shortest time)
175
Acetylcholinesterase Inhibitors for Alzeimers disease
-can be used in ALL stages of disease, help to prevent ACH breakdown
-Donepezil (Aricept) : ODT, patch (7 days, fridge stored- back, butt or thigh), QTC*, use qhs
-Rivastigmine (Exelon): patch (daily, store at room temp- back, arm, or chest) , capsule
-Galantamine
Warnings: cardiac effects (bradycardia)
AEs: GI effects (titrate slowly- can go away after 3-4 weeks of use), insomnia
--> use w/ caution in pts < 55 kg
176
NMDA Blockers for Alzheimers Disease TX
-moderate to severe disease (w/ ach inhibitor combo therapy)
-well tolerated
--> combo capsule: Namzaric (memantine + donepezil) - do not crush or chew, pt should already be stable on 10 mg donepezil before making this switch
177
Drugs that can lower the seizure threshold*
-Analgesics: opioids (tramadol, meperidine)
-Anti-infectives: quinolones, carbapenems, cephalosporins, penicillins, lindane, mefloquine
-Psychiatric medicatoins: bupropion, clozapine (other antipsychotics), lithium, TCAs
178
Siastat AcuDial Dispensing *
rectal gel for seizures- **Pharmacist must dial and lock correct prescribed dose
1- twist cap to adjust dose, confirm correct dose is visible in dosing window
2- lock dose by grasping locking ring at the bottom of syringe barrel and pushing it upward
3- green "READY" band is revealed
179
acute seizure management
1- 0-5 mins: time the seizure, start ECG, )2 prn, BG, labs
2- 5-10 mins: give IV lorazepam, diazepam or IM midazolam (rectal diazempam, intranasal/buccal midazolam)
3- 20-40 mins: IV fosphenytoin, valproic acid, levetiracetam
180
Antiepileptic drugs: Lamotrigine (Lamitacl)
-Na channel blocker
-start with 25mg daily dose for 2 weeks
BBW: SJS, toxic epidermal necrolysis --> inc risk w/ higher dose/escalation + valproate use
Warnings: asceptic meningitis, DRESS, cardiac rhythm abnormalities
SE: rash, alopecia, N/V, tremor, insomnia
**always use a starter kit (if missed for 6 days --> need to use this)
181
Lamotrigine orange kit
"original"
-standard lamotrigine starter dose
--> use if not taking an interacting drug
182
Lamotrigine Blue Kit
"below"
-lower lamotrigine starter dose
--> use if taking valproate (slows lam metabolism)
183
Lamotrigine green kit
"grow"
-higher starter dose
--> use if taking enzyme inducer (leads to dec levels of lam)
-enzyme inducers = carbamazeoine, phenobarbital, phenytoin/fosphenytoin, primidone
184
Antiepileptic drugs: Levetiracetam (Keppra)
-Ca chennel blocker, inc GABA)
Warnings: psychiatric reaction (psychosis symptoms, somolence, fatigue)
SE: behavior changes, dizziness, weakness
--> IV:PO ratio = 1:1
-no sig drug interactions
**preferred in: peds, pregnancy, when you have pts on multiple drugs (ex: BC)
185
Antiepileptic drugs: Topiramate (Topamax)
-Na channel blocker (also used for migraine ppx)
Warnings: fetal harm, acid/base issues (hyperammonemia, esp when taken with valporate), oligonidrosis (reduced perspiration), angle closure glaucoma
SE: CNS depression, weight loss
--> can dec efficacy of BC
186
Antiepileptic drugs: Valpoic acid, Divalproex (Depakote)
-inc GABA (used for bipolar + migraine ppx
BBW: hepatic failure, pancreatitis, fetal harm (neural tube defect)
Warnings: thrombocytopenia, hyperammonemia (tx with carnitine or lactulose)
SE: somnolence, tremor, weight gain, N/V, alopecia
***therapeutic range = 50-100 mcg/mL
--> can inc levels of: lamotrigine, phenobarbital, phenytoin, warfarin
--> drugs that dec VP levels: carbepenems, estrogen-containing contraceptives
187
Antiepileptic drugs: Lacosamide (Vimpat)
*C-V
Warnings: cardiac effects (prolongs PR interval, inc risk of arrhythmias), dizziness, ataxia
SE: blurred vision, tremor, euphoria
--> IV:PO = 1:1
-use caution with drugs that affect PR interval (BB, CCB, digoxin)
188
Antiepileptic drugs: Carbamazepine (Tegretol) and Oxcarbazepine (Trileptal)
both block NA channels, skin warnings, higher risk w/ HLA-B1502 allele (in Asians)
C:
-can be used in trigeminal neuralgia
BBW: serious skin warnings, aplastic anemia, agranulocytosis
CI: myelosuppression (dec blood cells)
Warnings: fetal harm, hyponatremia
--> therapeutic range: 4-12 mcg/mL
-autoinducer
O:
-not an auto inducer
-no aplastic anemia, agranulocytosis warnings
189
Antiepileptic drugs: Phenytoin (Dilantin) & Fosphenytoin (Cerebyx)
--> IV:PO ration = 1:1 (1 mg = 1.5 mg fos)
BBW: hypotension, cardiac arrhythmias w/ rapid infusion
Warnings: extravasation = purple glove syndrome (edema/pain of skin), avoid use in HLB1502 + pts, fetal harm
SE:
--> acute: ataxia, diplopia, nystagmus (dose related)
--> Chronic: gingival hyperplasia, hair growth, herpatotoxicity
190
IV Phenytoin*
-slow infusion (< 50 mg/min)
-monitor for BP, ECG, + resp
-dilute in NS, stable for 4 hours (DO NOT REFRIG)
-filter required
191
IV Fosphenytoin*
-slow titration (< 150 mg/min)
-monitor for BP, ECG, resp
-lower risk of purple man syndrome
192
NG tube phenytoin
-enteral feedings dec phenytoin absorption
-hold feedings 1-2 hour before and after admin
193
Phenytoin correction*
(Total phenytoin measured) / (0.2 * albumin) + 0.1
--> only used for pts with albumin < 3.5 g/dL with crcl > 10 ml/min
194
Antiepileptic drugs: Phenobarbital (Sezaby)
C-IV*
--> therapeutic range: 20-40 mcg/mL (adults)
Warnings: resp. depression, fetal harm, potenial for drug dependence
SE: residual sedation, dependence, tolerance
-primidone is a prodrug
-strong enzyme inducer
-can lower levels of hormonal BC
195
Antiepileptic drugs: AE cousins: Carbamazepine, oxcarbazepine & eslicarbazepine *
-rash
-hyponatremia
-enzyme induction
196
Antiepileptic drugs: AE cousins: phenobarbital & primidone
-sedation
-enzyme inducers
-overdose risk (dependence/tolerance)
197
Antiepileptic drugs: AE cousins: Gabapentin & pregablin
-mild euphoria
-somnolence
-peripheral edema
-weight gain
198
Antiepileptic drugs: AE cousins: Topiramate and zonisamide
-weight loss, metabolic acidosis
-nephrolithiasis
-oligohidrosis/hyperthemia
199
Take you vitamins on AEDs*
All: calcium and vitamin D
Women of childbearing age: folate
Valproic acid: possibly carnitine
-lamotrigine and valproic acid: if alopecia occurs, sup with selenium and zinc
200
AED: enzyme inducers
-carbamazepine
-oxacarbazepine
-phenytoin
-fosphenytoin
-phenobarbital
-primidone
201
SED: enzyme inhibitor
-valporoic acid (inc lamotrigone)
202
AEDS in pregnancy
-teratogenic risk: (neural tube defects)
highest = valproate
lowest = levetiracetam
--> give daily folate, calcium, and vit D supplementation
-dec oral contraceptive efficacy
-ASM monitoring (anti seizure meds decline during prego, need dose adjustments)
203
AEDs in children
-CNS depressants (cog, difficulty, coordination issues)
-AEs:
--> topiramte and zonisamide: increase sweating = hyperthermia, dec sun exposure
-rash (lamotrigine)
-formulations= ODT, chewables or oral solutions
