Clinical Pharmacy (PSMA) pt. 2

Migraine

is common, recurrent, primary headache of moderate to severe intensity that interferes with normal functioning and is associated with GI, neurologic and autonomic symptoms

• Chocolate

• Alcohol

• Nitrate containing foods

• Tyramine containing foods

• Fermented and pickled foods

• Caffeine/caffeine withdrawal

• Monosodium glutamate

Food triggers of migraine

STW-GLH

• Strong smells and fumes

• Tobacco smokes

• Weather changes

• Glare/flickering lights

• Loud noises

• High altitude

Environmental triggers of migraine

• Fatigue

• Excess/insufficient sleep

• Menstruation/menopause

• Skipped meals

• Stress and post-stress

• Strenous physical activity

Behavioral physiologic triggers of migraine

Migraine

• effect in the activity of neuronal calcium channels mediating neurotransmitter release in the brainstem areas that modulate cerebral vascular tone and nociception

• It will lead to vasodilation of intercranial extracerebral blood vessels with activation of the trigeminovascular system

• Ergot alkaloids

• Triptan derivative

Acute antimigraine drugs such as _____ and _____ are agonist of vascular and neuronal 5HT1 receptor subtypes

Serotonin receptors

• When these receptors are activated, they cause blood vessels in the brain to tighten (vasoconstriction) and stop the release of pain-causing neuropeptides.

• This leads to reduced pain signal transmission, helping relieve migraine attacks.

5-HT₁

specific serotonin receptors called ___ receptors found on blood vessels and nerves.

Migraine

• Recurring unilateral episodes of throbbing head pain

• Associated with nausea, vomiting and sensitivity to light, sound and/ or movement

Migraine aura (classic migraine)

A recurring headache that strikes after or at the same time as sensory disturbances

• Phonophobia

• Photophobia

• Hypersomnia

• Difficulty in concentrating

Examples of Neurological premonitory symptoms of migraine

DEAD-RIH

• Depression

• Euphoria

• Anxiety

• Drowsiness

• Restlessness

• Irritability

• Hyperactivity

Examples of Psychological premonitory symptoms of migraine

• Polyuria

• Diarrhea

• Constipation

Examples of Autonomic premonitory symptoms of migraine

FASTY

• Food cravings

• Anorexia

• Stiff neck

• Thirst

• Yawning

Examples of Constitutional premonitory symptoms of migraine

NC-HDG

• Neuroimaging

• Comprehensive headache history

• Headache evaluation

• Diagnostic and laboratory assessment

• General medical and neurologic examination

Clinical assessments for migraine

• Sleep (dark and quiet)

• Application of ice in head

• Behavioral intervention

Non-pharmacological interventions for migraine

PP-PENS

• Prophylactic therapy

• Preventive therapy

• Pre-treatment with anti-emetics

• Ergot alkaloids and derivatives

• NSAIDs and simple analgesics

• Serotonin receptor agonist

Pharmacological interventions for migraine

Simple analgesics and NSAIDs

First line treatment for mild to moderate migraine attacks

Prophylactic therapy

therapy for recurring migraine attacks

Preventive therapy

therapy for headache that occurs in a predictable pattern

Tension-Type Headache

• It is the most common type of primary headache and more common in women than men

• Pain is usually mild to moderate, bilateral, non-pulsatile

• Episodic headaches may become chronic

Headache

• It can originate from myofascial factors and peripheral sensitization of nociceptors

• Involvement of central mechanism

• Activation of supraspinal pain perception structures

Headache

• Premonitory symptoms and aura are absent

• Pain is usually mild to moderate, bilateral, non-pulsatile and in the frontal and temporal areas, but occipital and parietal areas can also be affected

• Mild photophobia or phonophobia may occur

• Pericranial or cervical muscles may have tender spots or localized nodules in some patients

Pain

An unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

• Neuropathic pain

• Functional pain

Two types of pain

Neuropathic pain

• Resulted from nerve damage (e.g., Postherpetic neuralgia and Diabetic neuropathy)

Acute pain

is usually a nociceptive but can be neuropathic

Chronic pain

can be both neuropathic and functional pain, for example, a pain that persist after the healing of acute injury

Functional pain

Refers to the abnormal operation of the nervous System (e.g., Fibriomyalgia, Irritable bowel syndrome, Tension-type headache)

Nociceptors

are pain sensing nerve cells. It can be located in either somatic or visceral

Thalamus

acts as relay station and passes the impulses to the central structure

Pain

• It will propagate the information to the spinal cord nearby

• The action potential will trigger the release pain neurotransmitter

  (substance P)

• It will ascends to higher centers

• Body will modulate the pain

  • Endogenous opiate system will be activated

  • Neurotransmitter such as enkephalins, dynorphins and Bendorphins will bind to the receptors mu, delta and kappa

Endogenous opioid system

• The body activates this system to reduce pain.

• This system releases natural pain-relieving

• B-endorphins

• Enkephalins

• Dynorphins

These substances bind to opioid receptors and help decrease the perception of pain

Pain

• Patient can have a distress from trauma or appear to have no noticeable suffering

• Acute pain

• Chronic pain

Acute pain

• Sharp or dull, burning, shock-like tingling, shooting radiating, fluctuating intensity, varying location and occur in a timely relationship with an obvious noxious stimulus

• can cause HTN, tachycardia, diaphoresis, mydriasis and palor

• there is no relation with comorbid conditions

Chronic pain

occurs without a timely relationship with a noxious stimulus

PPP-BM

• Patient medical history

• Pain scale

• PQRST characteristic

• Blood chemistry

• Medications

Clinical assessment for Pain

INOM

• Intrathecal and Epidural opioids

• Non-opioid agents

• Opioid agents

• Morphine

Clinical intervention for Pain

Non-opioid agents

• Given for mild to moderate pain

• Fewer side effects (GI problems)

Opioid agents

• Given for severe pain at high dose

• Partial agonist and antagonist- selectivity with the pain receptor site

• Might exhibit allergic reaction

Intrathecal and Epidural opioids

• are often administered with patient controlled analgesia

• Safe and effective (lesser side effect)

Morphine

• is the first line agent for moderate to severe pain

• Cause respiratory depression that why it’s given with Naloxone

• Motor deficits

• Mental deterioration

Parkinson’s disease has highly characteristic neuropathologic findings and clinical presentation. This includes what?

• Loss of neurons

• Presence of lewy bodies

Two known hallmarks in the substantia nigra pars compacta

Alpha-synuclein

The major component of lewy bodies

nigrostriatal dopamine

The degree of ___ loss has good correlation with loss and severity of motor function

thalamus

The inhibition of __ is resulted from inactivation of dopamine-1 and dopamine-2

nigrostriatal dopamine neurons

The tremor exhibited by the patients with Parkinson’s disease is due to degeneration of ___

• Bladder problems and constipation

• Thinking difficulties

• Swallowing problems

• Chewing and eating problems

• Depression and emotional changes

• Sleep problems and sleep disorders

Complications of Parkinsons

dementia (Thinking difficulties)

Cognitive problems such as ___ occurs in the later stage of Parkinson’s disease

depression and emotional changes

• In the very early stage, it is usually developed

• Receiving treatment for this can make it easier to handle the challenges of Parkinson’s disease

Swallowing problems

Saliva may accumulate in your mouth due to slowed swallowing, leading to drooling

Chewing and eating problems

• Late-stage of PD affects the muscle in the mouth which makes chewing difficult

• It can lead to choking and poor nutrition

Sleep problems and sleep disorders

People with PD often frequently waking up throughout the night, waking early or falling asleep during the day

MR-BIP

• Muscle Rigidity

• Resting tremor

• Bradykinesia

• Intellectual deterioration

• Postural instability

Clinical manifestations of Parkinson's Disease

Resting tremor

Tremor is present mostly in the hands and sometimes characterize as pin- rolling

Muscle rigidity

Increase muscle resistance to passive range of motion

DNM

• Deep Brain Stimulation (DBS)

• Neuroimaging

• Medical history

Clinical assessment for PD

Medical history

Medication that maybe a drug-induced parkinsonism

Neuroimaging

SPECT scan aka Dopamine transporter (DAT Scan)

Deep Brain Stimulation (DBS)

• Placing electrodes that are surgically implanted in the brain

• implant electrodes into specific part of the brain

• The electric pulses from the heart is send to the brain to reduce Parkinson’s disease symptoms

Dopamine Transporter (DAT Scan)

SPECT scan is also known as?

MAD-DACCC

• MAO-B inhibitors

• Amantadine

• Dopamine agonists

• Deep Brain Stimulation (Surgical procedure)

• Anticholinergics

• COMT inhibitors

• Carbidopa-Levodopa

• Carbidopa-Levodopa infusion

Pharmacological interventions for PD

Levodopa

protects the conversion of dopamine outside the brain

Carbidopa-Levodopa infusion

It is administered through the feeding tube

Dopamine agonists

Mimics the dopamine in the brain

MAO-B inhibitors

Help prevents the breakdown of brain dopamine by inhibiting the enzyme MAO-B

COMT inhibitors

It prolongs the effect of levodopa therapy by blocking an enzyme that breaks down dopamine

Anticholinergics

This medication help control the tremor associated with Parkinson’s disease

Amantadine

Provide short-term relief of symptoms of mild, early-stage Parkinson’s disease

DES

• Diet

• Exercise

• Speech-language pathologist

Non-pharmacological intervention for PD

Diet

Food high in fiber and drinking an adequate amount of fluids can help prevent constipation

Exercise

• Increase muscle strength, flexibility and balance

• Improve well-being and reduce depression or anxiety

TAMMY-P

• Tai Chi

• Alexander Technique

• Massage

• Meditation

• Yoga

• Pet Therapy

Alternative interventions for PD

Massage

Reduce muscle tension and promote relaxation

Tai Chi

It is an ancient form of Chinese exercise, tai chi employs slow, flowing motions that may improve flexibility, balance and muscle strength

Yoga

It can increase flexibility and balance

Alexander Technique

It focuses on the muscle posture, balance and thinking about how you use muscles and reduce muscle tension

Meditation

• It can reflect and focus your mind on an idea or image

• It may reduce stress and pain and improve your sense of wellbeing

Pet Therapy

Increase the flexibility and movement and improve your emotional health

Alzheimer’s Disease

• It is a progressive disorder that causes brain cells to waste away or degenerate

• It is the common cause of dementia

• The early signs of the disease will develop severe memory impairment and lose ability to carry out everyday task

• Current medications may temporarily improve symptoms or slow down the rate of decline

• There is no treatment that cures this disease

U.I.

• Uncharacteristic choices

• Ineffective response

Symptoms of Alzheimer’s Disease

• Making judgements and Decisions

IW-MAD-DAD

• Irritability

• Wandering

• Mood swings

• Apathy

• Delusions

• Distrusts in other

• Aggressiveness

• Depression

Symptoms of Alzheimer’s Disease

• Changes in personality and behavior

• Swallowing

• Malnutrition

• Balance Control

• Bowel Control

• Bladder Control

• Bedsores

Symptoms of Alzheimer’s Disease

• Disease Progression Symptoms

• Genetic

• Lifestyle

• Environmental factors

• Proteins

  • Plaque

  • Tangles

Causes of Alzheimer’s Disease

Genetic

Appears in middle ages

Lifestyle

Drug misuse

Environmental factors

Stress

Proteins (Plaque)

beta amyloid, a large protein leftover fragment which disrupts the cell to cell communications

Proteins (Tangles)

tau proteins, that initiates the neuron’s transport system of nutrients and essential materials are being deformed and cause “Neurofibrillary tangles” that causes disrupts the transport system

• Down syndrome

• Age

• Poor sleep patterns

• Sex

• Family history and genetics

• Lifestyle and heart health

• Past head trauma

• Mild cognitive impairment

Risk factors for Alzheimer’s Disease

• Can’t communicate the pain experiencing

• Can’t report symptoms of another illness

• Can’t follow prescribed treatment plan

• Can’t notice side effects

Complications of Alzheimer’s disease

Q-FEE

• Quit smoking

• Follow prescribed guidelines

• Exercise regularly

• Eat healthy

Preventions for Alzheimer’s disease

SLP-M

• Self-reporting

• Laboratory and imaging test

  • Thyroid hormone levels and vitamin deficiencies

  • MRI

  • CT

• Physical and Neurological exam

• Motor skills and cognitive function

Diagnosis for Alzheimer’s disease

MRI

may show possible brain shrinkage

CT

rule out strokes, tumors and head injuries

• Memantine (Namenda)

• Antidepressants

• Cholinesterase inhibitors

Pharmacological intervention for Alzheimer’s disease

Cholinesterase inhibitors

Boost Cell to cell communication

Memantine (Namenda)

Slows the progression