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TPX Neuro, Psych, & Sub abuse > Week 6: Stroke, Sleep > Flashcards

Week 6: Stroke, Sleep Flashcards

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1
Q

What is a Transient Ischemic Attack (TIA)

A

cerbral ischemic event lasting less than 24 hours (typically only minutes without apparent parmanent neurologic deficit)

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2
Q

What is Completed Stroke-

A

cerebral ischemic acute event with deficit that persists

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3
Q

Other types of ischemic strokes

a)Hemispheric Infarct
b)Lacunar Infarct
c)Microvascular Ischemic White Matter Lesions

A

a) stroke, usually caused by occlusions of carotid artery, leading to infarct of entire hemispheres of the brain. can be

b) blockage of arteries that supply deeper portions of the brain

c) occlusion of very small blood vessels in white matter. Pts. often times can be asymptomatic. treatment is controversial

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4
Q

Treatable Risk factors for Stroke

A

HTN

hypercholesterolemia

heart disease (espatrial fibrillation)

DM

cigarette smoking

excessive alcohol intake

phsyical inactivity

obesity

carotid bruit

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5
Q

Untreatable risk factors for stroke

A

age

sex

race

prior stroke

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6
Q

stroke pathophysiology

A

thrombus formation
1. asymptomatic atherosclerotic plaque

  1. platelet deposition
  2. occlusive thrombus formation
  3. plaque fissure-> red thrombus->embolism
    a.primary hemostasis-platelet plug
    b-coagulation->fibrin clot->thrombus

cardiogenic embolus-blood stasis->thrombus->ejected to brain

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7
Q

Clinical presentation of stroke/TIA

Carotid territory

A

unilateral weakness

unilateral sensory symptoms

aphasia- difficulty understanding peech or speaking, or both

monocular visual loss

transient global amnesia

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8
Q

Clinical presentation of stroke/TIA

vertebrobasilar territory

A

bilateral weakness, sensory, and/or visual complaints

  1. diplopia, ertigo, ataxia w.o weakness, dysphagia (difficulty swallowing)

hard to distinguaish a vertebrobasilar stroke from other differential diagnosis. one distinguishing factor is the rapidity of symptoms for a vertebrovascular stoke.

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9
Q

General SS of stroke

A

unilateral weakness
unilateral sensory symtpms

dysphasia

dysarthria (slurred speech)

vision disturbances

sudden confusion/mental status changes

facia droop

seizures (rare)

ataxia

loss of balance

verigo

dizziness

dysphagia

headache

vomiting

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10
Q

Phases of stroke care

A

Primary prevention

acute management of stroke

secondary prevention

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11
Q

primary prevention of stroke

A

modifiable risk factors
a. HTN, HLD, smoking, DM, a. fib, cad, obesity, post menopausal hormone therapy

nonmodiafiable risk factors:
a.age>55, race (black,hispanic), male gender, family hx of stroke/TIA, personal hx of stroke/tia

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12
Q

Who are at highest risk for having a stroke

A

patients who have had a previous stroke

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13
Q

General Treatment of an intial cerebrovacular event

A

ANTIPLATELET THERAPY
*small vessel lacunar
*Large Vessel Embolic
*Large Vessel thrombotic

WARFARIN THERAPY
Cardioembolic

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14
Q

General Platelet cascade in thrombus formation

A

fissure in lipid plaque recongnized by the body as injury activates platelets, adhere to fissure, followed by platelet aggregation on fissure.

recruit fibrin and RBC, causing a clot

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15
Q

Mechanism of Action of Anti-platelet Agents

A

a)Ticlopidine/Clopidogrel/ Praugrel: IRREVERSIBLY Block ADP receptors, inhibiting platelet aggregation

b)Aspirin: IRREVERSIBLY inhibits COX enxyme and thromboxane(potent activcator of platelet aggregation), leading to inhibition of platelets

c) Dipyridamole: REVERSIBLY increases plasma adenosine and inhibits platelet phosphodiesterase, causing inhibition of platelet activation and aggregation

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16
Q

Secondary stroke ppx

A

ASA
Ticlopidine
Clopidogrel
Prasugrel
Ticagrelor
ASA/ER dipyrdamole

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17
Q

Notes on PK of aspirin

A

~18-25% decreased risk of having another stroke

  • inhibition of plt. aggregation require ~97% of COX-1 inhibition

*in ~70% of pts. this is achieved with an aspirin dose of 80-100 mg

*older age and obese patient may require higher doses of aspirin to produce effect

*inhibition of thromboxane occurs pre-systemically in portal circulation

*enteric coated products are erratically absorbed from the GI tract

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18
Q

Ticlopidine vs. Aspirin

A

additional 21% risk reduction of having another stroke in comparison to aspirin

fatal toxicity risks, including diarrhea, rash, nausea, and gastritis, ulcer, GI bleeding

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19
Q

Clopidogrel vs Aspirin

A

CAPRIE study shows that clopidogrel has ~7% additional risk reduction of having another stroke, which is not statistically significant.

only statisticlaly significant finding from CAPRIE study was that clopidogrel had 23.8% relative risk reduction of PAD over aspirin

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20
Q

Dipyridamole ER vs. Aspirin

A

Dipyridamole ER (which has ~ same RRR as aspirin) not available in the US, only IR

ESPS2 study showed that inorder to achieve same time conc. of Dipyridamole ER with IR, pt must take IR 100 mg QID for the rest of their life, which would drastically increase risk of pt noncompliance.

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21
Q

Aggrenox vs. Aspirin

A

Aggrenox is Dipyridamole ER+ASA combo

ESPS 2 study showed 36.8% RRR vs placebo and 23% RRR vs ASA.

HOWEVER, PROFESS study showed there is no difference btw. aggrenox and clopidogrel

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22
Q

Overall, how to pick an antiplatelet agent best for the patient

A

Since there are no significant differences btw. anti-plt. choices, anti-plt agents used is based on whats best for individual patient.

A)base it on pt specific needs

consider..
side effect profile relative to your pts hx
(ex. Aggrenox can cause vascular headache, can cause GI problems->caution in GI problems..etc.)

the agent that produces an inhibition of aggregation in your specific patients (ex: some pts can be aspirin reisstant due to genetics)

can be used in lowest effective dose to reduce risk of bleeds

b) will aparticular agent be less than optimal for a particulr pt
*ex: ASA allergy
*pts on clopidogrel may have DDI w. agents that inhbit CYP2C19 such as CCBs, PPI’s etc.
*aggrenox therapy andmigraine hx
*aggrenox therapy and spastic colon or IBS

c)does your patient warrent dual anti-plt therapy
*Clopidogrel + ASA only has increased anti-plt effects in firt 30-90 days, then risk of bleeding outweighs beenfit
*coronary artery stenrs and new cerbral ischemia
*a. fib not able to take coumadin

d) are your pt plt. responding to their anti-plt agent
*ex: ASA or Plavix resistance

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23
Q

Individualized pharmacotherapy for anti-plt. choice

A

urgency of needing full antiplt. therapy

agent least likely o produce adverse effects
*headache hx
*spastic coloitis or ulcerative colitis/chrons
*gastric ulcer hx
*true aspirin alergy

agent least likely for drug interactions
*need for chronic NSAID, PPI, or CCB use

dual anti-plt therapy
*failure of monotherpay
*first 3-6 mo post troke w. high risk factors
*a. fib w. CI for anticoagulation

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24
Q

approach to ASA resistance

A

assurance compliance
*urinary salicyates

remove drugs that compromise ASA effects
*NSAIDS other than celecoxib(celebrex)
*some herbal supplements

change from EC to chewable ASA or alka seltzer
*particularly in older women

*change ASA dose where appropriate

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25
approach to plavix resistace
minimize use of other drugs that inhibit cyp3a4 AND CYP2C19 SUBSTITUTE DRUGS THAT HAVE LESSOR EFFECT ON THESE p450 is iso enzymes add meds that can induce CYP enzyme activity
26
common meds that influence CYP3A4 or CYP2C19
statins other than Rosuvastatin (crestor) CCBs, not BB, ACE, or ARBS *NOTE: IF CCB + clopidogrel is an issue in a pt, before switching the CCB, be sure pt is on CCB for htn and not rate control. if ccb used for rate control is changed, might do more harm in pt. Ambien, Lunesto (Sonata least likely) Gliburide, not glipizide or metformin Enablex, Ditropan, not detrol or sanctura PPI's
27
what to do if pt is truly resistant to both aspirin and clopidogrel
* ticagrelor *prasugrel BOTH OF THESE NOT FDA approved. *max ASA dose 100 mg daily w. ticagrelor
28
Signs and symptoms of sleep disorders
excessive daytime sleepiness (EDS) impaired daytime funcitoning irregular breathing increased movement during sleep irregular sleep and wake cycle difficulty falling asleep
29
common types of sleep disorders
insomnia sleepapnea narcolepsy circadian rhythm disorders parasomnia restless leg syndrome
30
What is insomnia
most common reported sleep disorder difficulty falling asleep, maintaining sleep, or non restorative sleep
31
categories of insomnia
transient insomnia: several days <3 months: short-term insomnia atleast 3 nights per week for >/=3 mo.: chronic insmonia
32
causes of transient insomnia
stress jet ag or shift work schedule change medical (chornic pain0 psychiatric (eg. anxiety, PTSD) pregnancy pharm. induced
33
causes of short term (<3 mo.) insomnia
untreated or undertreated transient insomnia acquired exacerbating behavior
34
common drrugs that can cause or worsen insomnia
alcohol, caffeine, nicotine anticholinergics SSRISNRIs alpha blockers beta blockers ACE and ARBS cholinesterase inhibitors bronchodilators CNS stimulants corticosterois decongestants diuretics H2RAs statins opioids
35
treatment goals for transient insomnia
orrect ynderlying sleep complaint, avoid AE of meds treatment: adequate bedtime doses of benzos for 2-3 weeks selection of specific med is patient dependent: *desirability for daytime anxiolytics *need fo rnext day early morningcognitive sharpness *interactions with other medications *d/c of problematic meds *pk profile of the BZDRA and specific insomnia complaints
36
tratment of short term insomnia goal
a treatment plan that will result in the pt sleeping normally w. no medications
37
non pharm treatment of insomnia
maintaine a regula sleep schedule establish a calm bedroom setting (quiet room, no bright lights, comfortable temp/) do not spend time in bed if awake imit intake of nicotine, caffeine, and alcohol exercise regulalrly but not close to bedtime have a light snack or warm bevarage befor ebedtime avoid watching the clock, remove bedroom clock if necessary
38
treatment oflongterm insomnia
proper dx of root/psychiatric cause of insomnia CBT for insomnia *preffered 1st line therapy for chronic insomnia in mos patients *CBT-I+/- meds> meds alone if rapid improvement is necessary, can use CBT-I_ meds initially w. plan to taper medication over time
39
Treatment options for insomnia BZDRAs
most commonly used trt. for insomnia fda approved for insomnia labels include a cuation for anaphylaxis, facial angioedema, and complex sleep behaviors agonist effects on gaba receptors includes newer non-benzo GABA agonists and traditional benzos always ake before bedtime use w. caution in elderly drowsiness, dizziness, confusion, risk of falls avoid w.alcohol withdrawal symptoms upon abrupt d/c i.e termors, muscle cramps, seizures
40
considerations for BZDRAs benzo hypnotics
CHOICE OF A PARTICULAR BZDRA IS BASED ON PK PROFILE AND PT. PRESENTATION reduce sleep larency increased stage 2 sleep and decrease delta sleep anxiolytic effect so not use in pts w. sleep apnea or substance abuse avoid alcohol and cns depressants side effects are dose dependent BBW: concaminant use with opioids can cause resp. depression,sedation, coma, and death *increased risk of abuse, misuse, and addiction *continued use can lead to clinically significant physical dependence
41
considerations for BZDRAs Non benzo GABA agonists
CHOICE OF A PARTICULAR BZDRA IS BASED ON PK PROFILE AND PT. PRESENTATION "Z" drugs more selective increase total sleep time less disruptive of sleep stages geenrally have less withdrawls. tolerance, and rebound insomnia associated w. parasomnic episodes w. amnesia BBW: can cause complex sleep behaviors(i.e sleep walking, sleep driving, and engaging in other activities while now fully awake. d/c immediately if develops.
42
Estazolam Schedule: Benzo vs Z drug: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule: CIV Benzo vs Z drug: Benzo Indication: sleep onset or maintenance. short term mgt of insomnia characterized by difficuly in falling asleep, frequent nocturnal awakenings, or/or early morning awakenings PK(t1/2 &tmax): *tmax:2 t1/2: 10-24 hrs AE: hypokinesia considerations: CI in pregnancy or w. itroconazole or ketoconazole
43
Eszopiclone (Lunesta) Schedule: Benzo vs Z drug: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule: CIV Benzo vs Z drug: Z drug Indication: sleep maintenance or early morning awakenings PK(t1/2 &tmax): t1/2: 1 hr tmax: 6 hr (up to 9 in elderly AE: headaches, dysgeusia, nervousness/anxiety, xerostomia, infection, upset stomach considerations: *rapid absorption tat can be delyed w. food *can be used long term fo rup to 6 months *major cyp3a4 substrate *monitor w. concurrent use of cyp3a4 inhibitors (keto, itraconazole)
44
Zaleplon (Sonata) Schedule: Benzo vs Z drug: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule: cIV Benzo vs Z drug: Z drug Indication: short term trt of insomnia. does not reduce nighttime awakening PK(t1/2 &tmax): t1/2: 1 hr: could be delayed w. absorption tmax: 1 hr AE: headache, nausea, abdominal pain considerations: *cyp3a4 substrate ultra short acting, rapid onset avoid taking after a highfat meal delays absorption short term treatment
45
Zolpidem Schedule: Benzo vs Z drug: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:CIV Benzo vs Z drug: Z drug Indication: depends on formulation IR tablet or spray: sleep onset. off label for sleep maintenance ER tablet: sleep onset or maintenance SL tablet: dif. dose based on sex: take if more than 4 hours remain before waking and pt has trouble returning to sleep PK(t1/2 &tmax): t1/2: 0.6-4hrs tmax:1.4-8.4 hrs AE:headache and nausea, increased hypotension and falls in elderly considerations: avoid use in severe hepatic impairment minimal tolerance and rebound at recommended doses diff formulations have diff indications
46
Trazadone Schedule: Benzo vs Z drug: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:-- Benzo vs Z drug:-- Indication: offlabel use for sleep continuity PK(t1/2 &tmax): AE: caryover sedation, alpha adrenergic blockade(orthostasis) priapism is a rare side effect considerations: usefel in pts. w. hx of substance abuse and or depression when d/c taper dose over 2-4 weeks BBW: suicidal thoughts and behaviors, same risks as antidepressants
47
first gen antihistamines Schedule: Benzo vs Z drug: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:-- Benzo vs Z drug:-- Indication: OTC option for mild insomnia PK(t1/2 &tmax):-- AE: anticholinergics considerations: avoid in elderly tolerance to sedative effects develop quickly
48
Suvorexant (Belsmora) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:CIV Benzo vs Z drug:-- *dual orexin A and orexin B antagonist (DORA) Indication:sleep onset and maintening sleep by wurning off wake signaling PK(t1/2 &tmax): t1/2: 12 hrs onset: <30 min AE: DROWSINESS, dizziness, headache, sleep paralysis, abnormal dreams, URTI considerations: interactions w. cym3a4 inhibitors decrease dose w. mod. cyp3a4 inhibitors, CI w. strong 3a4 inhibitors CI in narcolepsy
49
Lemborexant (Dayvigo) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:CIV MOA: Dual Orexin A and Orexin B receptor antagonist (DORA) Indication: assists in getting to and maintainning sleep, turns off wake signaling PK(t1/2 &tmax): Onset:<30 min t1/2: 17-19 hours AE: drowsiness, dizziness, headache, complex sleep behaviors, abnormal dreams (nightmares) considerations: *decrease dose w. weak CYP3A4 inhibitors 8not recommend w. strong cyp3a4 inhibitors CI in narcolepsy *take at bedtime w. atleast 7 hrs beforeplanned time of awakening
50
Ramelteon (Rozeram) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:-- not controled MOA:meletonin receptor agonis selective for MT1(induces sleep) MT2 (regulates circadian rhythm) (MT1>MT2) Indication: isleep onset insomnia and for long term use PK(t1/2 &tmax): onset: 30 min t1/2: 1-2.6 hrs AE: headahce, dizziness, somnelance considerations: do not use in pts w. liver disease not controlled not as effective in pts who have beent reated already with a BZDRA CI: w. fluvoxamine
51
Melatonin Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:-- Dietary supplement not fda approved MOA: Indication: beneficial effects on sleep latency, shift workers, and jet lags PK(t1/2 &tmax):-- AE:- considerations: should not be used in pts w. autoimmune conditions on immune modulators and has been shown to alleviate some autoimmune conditions but exacerbate others less effectin pts whove used bzdraS
52
Doxepin Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Schedule:-- MOA: INHIBITS REUPTAKE OF SERETONIN AND NOREPINEPHRINE ANTAGONIZES h1 HISTAMINE RECEPTOR Indication: sleep maintenance insomnia PK(t1/2 &tmax): AE: considerations: lower than dose used for depression is used for sleep BBW for suicidality in pts <24 years do not tak w. in 3 hrs of a meal due to slower absoprtion
53
Considerations for pharmacotherapy for elderly and pregnant women
non pharm preffered initially, if oharm therapy is needed... Elderly *CBT-I *Ramelteon *Eszopiclone *Zolpidem *low dose doxepin Pregnancy *diphenhydramine *Doxylamine *low dose doxepin
54
Sleep apnea what is it
repeated episodes of cessation of breathing during sleep, followed by blood oxygen desaturation and arousal from sleep to restart breathing fragmented sleep and poor sleep architecture w.periodsof apnea and hypopnea
55
TYpes of sleep apnea
Dx w. polysomnography *Central (csa): impairment of resp. drive Obstructive(OSA): upper airway collapse and obstruction Mixed: CSA and OSA
56
CHaracteristics of Obstructive slepe apnea
multiple episodes of airway closure and cessation of breathing per hour can be caused by obesity, narrow airway, or other anatomical factors multiple awakenings and arousals perr hour w. apneas, gasping or both throughout the night significant o2 desaturations per hour associated w. MVA, depresison, increased cancer risk, stroke, and cva linked to CV AND cerebrovascular morbidity increased risk for drug resistant htn
57
treatment of sleep apnea
first line: standard of trt is nasal positive airway pressure during sleep through a cpap Weight management avoid all cns depressants (such as benzos or opioids) and drugs that can cuase weight gain. use extreme caution in apioid medications if cpap doesnt work, can use medication for excessive daytime sleepiness
58
Narcolepsy what is it
severly debiliating neurologic disease, oftenundiagnosed impairment of both oncet and offset of rem AND NREM
59
narcolepsy tetrad
excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis patho: loss of normal funciton of hypocretin orexin neurotransmitter system possibly due to autoimmune process
60
Narcolepsy treatment nonpharm pharm
non pharm: good sleep hygeine and scheduled daytime naps avoid drugs that can worsen daytime sleepiness (benzos, opiates, aps, ALCOHOL) pharm: focus on treatment of excessive daytime sleepiness (EDS) *modafanil or armodanil trt for eds *tca's, snris, ssris
61
Medications EDS in narcolepsy Modafinil Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Medications EDS in narcolepsy Schedule: C-IV MOA: unclear, effects on dopamine, GABA, 5HT Indication: EDS in narcolepsy PK(t1/2 &tmax): AE: headache, nausea, anxiety/nervousness, dizziness, dyspepsia, xerostomia, back pain, rhinitis considerations: Avoid use in regnancy may decrease effectiveness of contraceptives (cyp3a4 INDUCERS) use caution in pts. w. CV disease, esp not recommended in pts. w. left ventricular hypotrophy
62
Medications EDS in narcolepsy Amodafinil (Nuvigil) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Medications EDS in narcolepsy Schedule: c-iv MOA: r-enantiomer of modafinil, moa unclear Indication: EDS in narcolepsy PK(t1/2 &tmax): AE: headache, insomnia, dizziness, nausea, xerostomia considerations: avoid use in pregnancy may decrease effectiveness of contraceptives (CYP3A4 inducers) use in caution in pts. w. cv diease, esp not recommended in pts w. a history of left ventricular hypertrophy
63
Medications EDS in narcolepsy Solriamfetol (Sunosi) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Medications EDS in narcolepsy Schedule: C-IV MOA: dopamine and norepinehrine reuptake inhibitor Indication: EDS in narcolepsy PK(t1/2 &tmax): AE: headache, anxiety, insomnia, decreased appeptite nausea considerations: CI w. MAOI, do not use concurrently or w.i 14 days of MAOi
64
Medications EDS in narcolepsy Pitolisant ( Wakix) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Medications EDS in narcolepsy Schedule:-- MOA:antagonist/ inverse agonist at histmaine 3 rceptors Indication: EDS in narcolepsy PK(t1/2 &tmax): AE:headahce, anxiety, musculoskeletal pain, uri considerations:LOWER MDD FOR KNOWN CYP2D6 METABOLIZERS MAJOR CYP2D AND CYP3A4 INTERACTIONS CI IN SEVERE HEPATIC IMPAIRMENT
65
Medications EDS in narcolepsy Sodium Oxylate (Xyrem) Schedule: MOA: Indication: PK(t1/2 &tmax): AE: considerations:
Medications EDS in narcolepsy Schedule: C-III MOA: cns DEPRESSANT. GABAb receptor activity at noradrenergic and dopaminergic neurons Indication: PK(t1/2 &tmax): AE: ocnfusion, headache, dizzeness, weightloss/decreased appetite, urinary incontinance, drowsiness, depression, somnambulism, anxiety considerations: BBW: cns depression, abuse/misuse, restricted access. can only be obtained thruogh a REMS program *even tho a cns depressant, improves pt sleep so they are more well rested the next day dosed at bedtime after pt is in bed w. second dose 2.5-4 hrs later
66
List of meds used in cataplexy in narcolepsy
cataplexy (sudden loss of muscle tone) REM SUPRESSING DRUGS *Fluoxetine (SSRI) Venlafaxine (SNRI) Atomoxetine (SNRI) Clopiramine (TCA) Imipiramine (TCA) Nortriptaline (TCA) PITOLISANT SODIUM OXYBATE
67
Circadian Rhythm Disorders presentation
presents as either insomnia or hypersomnia commonly manifest as jet lag or shift work disorder
68
Jet lag treatment non pharm pharm
non pharm *napping (<30 min in length atleast 8 hrs before bedtime) times light exposure pharm : Meletonin ramelteon short acting BXDRA- risk for next day drowsiness takrdrug at target destination bedtimes to reduce jetlag and shorten sleep latency
69
Shift work disorder
difficulty . sleep or wakefuleness at times that are imposed by shifts running counter to the light dark schedule non pharm: sleep scheduling sleep hygeine naps before or during shift if possible esposure to bright lights at night and darkness during the day pharm: meletonin (0.5-5) ramelteon short acting bzdra. BE CAREFUL for risk of next day drowsiness modafinil and armodafinil to improve wakefulness
70
Parasomnias
abnormal behavior or physiological events that occur during sleep such as sleep walking, sleep driving, sleep terrors, sleep talking, nightmares, etc. sleep walking terrors and talking during NREM sleep may be due to a z drug w. alcohol or antidepressants
71
treatment of parasomniaas
protect the individual fromharm: safety latches on doors/ windows BZ, ssri, OR TCAs may be beneficial reduce stress, anxiety, and sleep deprivation to reduce nightmares
72
Restless leg syndrome
parasthesias felt deep in the calf muscles, thighs, and arms w. an urge to keep limbs in motion; often bilateral associated w. ckd, iron defiicnecy, vit. b or folate defiiciency, pregnancy, peripheral neuropathies
73
Rule out/ Treat Possible Causes of RLS
nutrition: iron supplementatino with Fe deficiency vit. B or folate deficiency reduce caffeine and alcohol use wieghtloss smoking cessation regular moderate exercise sleep withdraeal of meds which may cause RLA *centrally acting antihistamines (diphenhydramine, doxylamine, hydroxyzine, meclizine) AD(TCA'S SSRI, SNRI)(NOT buproprion) APS antinausea drugs that block dopamine (metoclopramide, promethazine)
74
non pharm treatment of RLS
treatment factors: age of pt severity, duration, and frequency of SS comorbidities SS releif: walking, biking, soaking limbs, leg massage activities to improve mental alertness at time of rest/boredom yoga or acupuncture?
75
pharm trt for RLS
intermittent symptoms; carbidopa-levadopa BZDRA: clonazepam most well studied chronic and persistent symptoms: Alpha-2delt calcium ligands *pregablin *gabapentin dopamine agonists *immediate-release pramipexole Ropinirole *rotigotine
76
considerations for specific classes of drugs for rls TREATMENT
dop. agonists *use lower doses compared to PD treatment augmentation is problematic, can cause increase in rls BZDRAS cautin: caryover sedation Alpha-2delt calcium ligands good choice for painful RLS gabapentin enacaribl 9Horizant) is FDA approved for RLS

TPX Neuro, Psych, & Sub abuse (7 decks)

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