Will be on exam 3

Question 1

In 2011, the Office of Inspector General released its “Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents” report, which described that the majority (83%) of ___________________ drug claims were for residents without _____________ indications for use

will be on exam

Answer 1

atypical antipsychotic; FDA-approved

Question 2

In 2005, the FDA mandated the addition of a “black box warning” to all atypical antipsychotics. Why?

will be on exam

Answer 2

Due to increased risk of mortality in older adults with dementia-related psychosis

Question 3

In 2005, the FDA mandated the addition of a “black box warning” to all atypical antipsychotics due to increased risk of mortality in older adults with dementia-related psychosis.

What happened regarding this warning in 2008?

will be on exam

Answer 3

Was expanded in 2008 to include all typical antipsychotics as well

Question 4

List the drugs that can induce seizures

will be on exam

Answer 4

BATHMIC
1) Bupropion
2) Alcohol, benzodiazepine or barbiturate withdrawal
3) Theophylline
4) Haloperidol and clozapine
5) Meperidine (opioid)
6) Illegal drug overdose (i.e., cocaine)
7) Carbapenem/ imipenem

Question 5

Medications that induce lamotrigine glucuronidation include what?

Will be on exam

Answer 5

1) Carbamazepine
2) Phenobarbital
3) Phenytoin
4) Primidone
5) Rifampin
6) Lopinavir/ ritonavir
7) Atanazivir/ ritonavir
8) Estrogen

Question 6

What is the one med that inhibits lamotrigine glucuronidation?

will be on exam

Answer 6

Valproic acid

Question 7

1) Oral contraceptives do what to lamotrigine metabolism?
2) What does this mean you need to do?

“big exam thing” (pretty sure this is on there since he emphasizes this drug so much)

Answer 7

1) Estrogen induces UGT and increases lamotrigine metabolism
2) Increase lamotrigine dose; may see doses of 150 mg to 200 mg PO BID

Question 8

Lamictal
1) Must be re-titrated if a patient misses more than ____ half-lives duration of medication.
2) Consider titration after missing _____ days of therapy w/ phenytoin, phenobarbital, primidone or carbamazepine
3) Consider after missing _______ days of therapy w/out valproic acid or an inducer
4) Consider after missing ______ days of therapy w/ valproic acid

He said “know if you need to re-titrate” when talking abt this section, so sounds like on exam

Answer 8

1) 5
2) 2.5
3) 5
4) 10

Question 9

What drug has a boxed warning for aggression, hostility, irritability, anger, and homicidal ideation?

“know this”

Answer 9

Perampanel

Question 10

Rufinamide (Banzel):
1) Is contraindicated in what?
2) When should you use caution?

“unique”

Answer 10

1) Severe liver impairment or in familial short QT syndrome
2) With other drugs that shorten QT interval

Question 11

Why lorazepam at hospital and diazepam at home?

this is a test question

Answer 11

Lorazepam has the longest half life and longest efficacy. Also lipophilic and rapid acting.

Question 12

Monoamine oxidase B (MAO-B) inhibitors:
1) What from foods may reach excessive systemic levels and increase the pressor response following MAOi ingestion?
2) Give examples of these foods
will be on exam

Answer 12

1) Tyramine
2) Avocado, cheeses, cured meats, beer

MAOB inhibitors: Rasagiline, selegiline, safinamide

Question 13

For each of the following nonmotor Sx of Parkinson’s, list possible Txs:
1) Anxiety
2) Cognitive impairment
3) Depression
4) Drooling

“memorize this”

Answer 13

1) Venlafaxine, SSRIs
2) Eliminate anticholinergic agents, add cholinesterase inhibitor
3) Newer generation SNRI
4) Atropine SL drop, glycopyrrolate, ipratropium SL spray

Question 14

For each of the following nonmotor Sx of Parkinson’s, list possible Txs:
1) Dysphagia
2) Fatigue
3) Hallucinations/ psychosis

“memorize this”

Answer 14

1) Avoid anticholinergic meds
2) Armodafinil, modafinil
3) Dose reduction and/ or elimination of adj. meds, esp. anticholinergics. Consider adding pimavanserin (FDA approved for psychosis in PD too)

Question 15

For each of the following nonmotor Sx of Parkinson’s, list possible Txs:
1) Insomnia
2) Overactive bladder
3) RLS

“memorize this”

Answer 15

1) Non-benzo GABA-A agonists
2) Antimuscarinics
3) Gabapentin; dopamine agonist at bedtime

Question 16

Carbidopa/ldopa has what 3 adverse effects?

“specific”

Answer 16

1) Drowsiness
2) Dyskinesias
3) Nausea

Question 17

Only __________________ has an FDA-approved indication for PD psychosis

“This will be a test question”

Answer 17

Pimavanserin

Question 18

True or false: The first dose of antibiotics should not be withheld, even when lumbar puncture is delayed or neuroimaging is being performed.

“will be on exam”

Answer 18

True

Question 19

It is strongly recommended that the time from suspected diagnosis to initiation of antibiotic treatment should not exceed how long?

Answer 19

1 hour

“will be on exam”

Question 20

Out of all the carbapenems, ____________ is preferred for for S. pneumoniae meningitis

Answer 20

meropenem

(imipenem not preferred bc it causes seizures)

Question 21

Generally meningitis should be treated for about 2-3 weeks, but what are the exceptions?

Answer 21

If G negative or Listeria (listeria like 21+ days; G- can be 7-10 days)

Question 22

List 3 anticholinergic drugs used for Parkinson’s

(exam will make you identify a drug as anticholinergic)

Answer 22

1) Pimavanserin (approved for psychosis in PD)
2) Benztropine
3) Trihexyphenidyl

Question 23

Which of the following is a strong CYP inhibitor?: phenobarbital, lamotrigine, divalproex, oxcarbazepine

Answer 23

Divalproex (might need QOD dosing, 10 day buffer)

Question 24

Divalproex (valproic acid): does it inhibit or induce?

Answer 24

Inhibit [CYP2C9] (“super inhibitor”)

Question 25

When the HLA-B 1502 allele in Asian patients is mentioned, you should think of what epilepsy drug?

Answer 25

carbamazepine

Question 26

1) Aricept is the brand name for what? 2) How is this drug dosed?

Answer 26

1) **Donepezil** [AD drug, cholinesterase inhibitor] 2) **5mg Qday at night** (but start w. morning)

Question 27

What is the brand name of memantine?

Answer 27

Namenda/ Namenda XR [NMDA antagonist; AD drug]

Question 28

Explain how to dose memantine

Answer 28

1) Reg: start at 5mg Qday, then titrate weekly in 5mg intervals until you get to 10mg BID 2) XR: start at 7mg Qday, then titrate weekly in 7mg intervals until you get to 28mg Qday 3) If severely renally impaired (cl/cr 5-29): Use 5mg BID for Reg -14mg Qday for XR

Question 29

When should you use ethosuximide?

Answer 29

DOC for absence seizures; do NOT use for general tonic-clonic

Question 30

1) Which benzo is most appropriate for inpatient use for status epilepticus? 2) What abt outpatient?

Answer 30

1) IV lorazepam 2) Diazepam (Diastat PR, Valtoco NAS)

Question 31

Describe how to dose Lamictal (if not taken with valproate) for epilepsy

Answer 31

**Wks 1-2:** 50 mg Qday **Wks 3-4:** 50 mg BID **Wks 5-maintenance:** increase by 25-50 mg every 1-2 wks **Maintenance dose:** 50-100 mg BID

Question 32

1) What is a side effect of memantine? 2) What are side effects of cholinesterase inhibitors?

Answer 32

1) Hallucinations 2) Nausea, diarrhea, WL, GI issues, insomnia, vivid dreams, etc -Cholinergic toxicity: salivation, tearing and sweating, bronchoconstriction, tightness in the chest, wheezing, bradycardia, vomiting, increased gastrointestinal motility, abdominal tightness, diarrhea, and cramp -Donzepil can esp. cause nightmares

Question 33

List the standard doses for the following PD drugs: 1) Pramipexole (non-ergot dopamine agonist) 2) Ropinirole (practically the same as pramipexole) 3) Carbidopa/L-dopa

Answer 33

1) 0.125 mg TID, req. renal adjustments 2) 0.25 mg PO TID (titrate to effect; max dose 24 mg / day) 3) 25/100 mg TID

Question 34

List 2 monoclonal antibodies (for AD) and their adverse effects

Answer 34

1) Aducanumab (Aduhelm): **microhemorrhage, brain edema** (req. MRI) 2) Lecanemab (Leqembi): Same concerns for edema and microhemorrhage

Question 35

1) How would you Tx mild-to-moderate AD? (MMSE 10-26) 2) What 2 medications can work for any severity of AD? 3) What should you do for moderate-to-severe AD? (MMSE 0-20)

Answer 35

1) Galantamine or rivastigmine 2) Donepezil and Transdermal rivastigmine 3) Add memantine

Question 36

Generally ________________ plus any cholinesterase inhibitor are more effective for AD, but you don’t start that until you get to a MMSE score of 20 or less.

Answer 36

memantine

Question 37

When do you add memantine for AD?

Answer 37

Score of 20 or less on MMSE

Question 38

Alzheimer's: 1) What MMSE score is mild? 2) What is moderate? 3) What is severe?

Answer 38

1) 21-26 2) 10-20 3) 9-0

Question 39

Which 2 drugs are assoc. with gambling?

Answer 39

Ropinirole and pramipexole [Non-ergot dopamine agonists]

Question 40

How do you dose ceftriaxone?

Answer 40

125mg in kids, 250mg in adults IM

Question 41

1) What drug was grandfathered in? Explain what this means 2) What is the orphan drug act?

Answer 41

1) Phenobarbital (Lumina, C3); was automatically FDA approved bc it's an old drug 2) Congress passed the Orphan Drug Act of 1983 to stimulate the development of drugs for rare diseases (7yr market exclusivity, 50% tax credit, etc) (ex: Cannabidiol)

Question 42

What is the goal with epilepsy meds?

Answer 42

Ideally we want you on just one drug, if you’re on one drug and it’s not working, you want to increase the dose unless you’re maxed out, then you can consider dual therapy.