Random Pharm 2 Questions Exam 1 - quizlet

What is the mechanism of action for the drug phenytoin (dilantin)?

Inhibits neuronal sodium channels

Phenytoin (Dilantin) is highly protein-bound, what could result from a drug interaction that reduces the percentage of phenytoin binding to protein?

Toxicity of phenytoin due to more free drug circulating in the system

Note: renal failure and/or low albumin affects this

True or False: Phenytoin is a CYP3A inducer?

True

Name some side effects to phenytoin (Dilantin)?

Lethargy, blurred vision, Hirsutism, Gingival Hyperplasia, Vit D deficiency, and osteomalacia

Our patient needs phenytoin for a generalized seizure, but they do not have a central line or a decent IV, what and how should we administer?

We should administer Fosphenytoin IM

What can happen if we administer phenytoin IV in the hand but the IV blows and it leaks into the surrounding tissue?

Purple glove syndrome

What is the mechanism of action of the anti-seizure medication carbamazepine (Tegretol)?

Blocks sodium channels

How must we dose Carbamazepine (Tegretol) in order for the patient to receive the correct amount of drug?

We must constantly increase the dose due to a metabolism autoinduction

What adverse reaction are carbamazepine and Oxcarbazepine notable for?

Hyponatremia due to SIADH

Besides a sodium level, which lab value should we monitor for on a patient taking carbamazepine (Tegretol)?

Liver enzymes

Patient comes into the ED for seizures, the family states that the patient was started on a new seizure medication prior. Lab work comes back showing a low sodium level? Which two anti-seizure meds are known to cause a low sodium count (hyponatremia)?

Carbamazepine (Tegretol)

Oxcarbazepine (Trileptal) (MORE COMMON)

What three mechanism of actions does Valproic Acid (Depakote) have?

Inhibits Sodium Channels

Inhibits Calcium Channels

Increases/enhances GABA

Which notable adverse reactions is Valproic acid know for possibly causing?

HINT: 2 of them

Pancreatitis and hepatotoxicity

Which antiseizure medication can cause pancreatitis?

Valproic Acid (Depakote)

If we are treating a young female (24 yrs old) with Valproic Acid (Depakote), what must we counsel our patient on before prescribing it?

To not get pregnant and to use contraceptive measures because of the risk of neural tube defects

Patient is presenting to the office for a follow up after been on valproic acid (Depakote) for some time, we do a blood check and notice that the level of the anti-seizure drug is low. What is the patient at risk for?

Having a seizure

Note: Always do therapeutic drug monitoring for Valproic Acid

What is the mechanism of action for Benzodiazepines?

Enhances GABAA to increase Chloride influx

Which Benzodiazepine is notable for being used intranasally?

Midazolam (Versed)

Which benzodiazepine is used as an oral agent for pediatric kids having seizures?

Clonazepam (Klonopin)

Is it safe to discontinue Benzodiazepines OR Barbiturates abruptly?

NO!

What is the mechanism of action of Phenobarbital (Luminal)?

Activating and opening GABAA channels which increases chloride influx

Which antiseizure drug is better used for neonates?

HINT: specifically neonates, not just peds in general

Phenobarbital (Luminal)

-rarely used in adults do to ADRs

Which anti-seizure drug is mainly used for refractory status epilepticus?

Pentobarbital (nembutal)

Which antiseizure drug do we stay away from mainly because of its chances of causing fatal aplastic anemia?

Felbamate (Felbatol)

Which antiseizure drug is the drug of choice for Absence Seizures?

What is the mechanism of action of this drug?

Ethosuximide (Zarontin)

Inhibits neuronal calcium channels

How is Gabapentin (Neurontin) and Pregabalin (Lyrica) eliminated out of the body?

100% renally eliminated

What is the major adverse drug reaction that Gabapentin and/or Pregabalin can cause?

CNS depression

What three mechanism of actions does the anti-seizure medication lamotrigine (Lamictal) do?

Inhibits sodium channels

Inhibits glutamate release

Modulates calcium channels

What is a notable adverse reaction to lamotrigine (Lamictal)?

Why might we choose this anti-seizure medication over others?

Stevens-Johnson Syndrome

-this medication tends to have less sedative effects than others

Valproic acid is a CYP2C9 and UGT inhibitor, How can this affect Lamotrigine specifically?

This will change the way we dose lamotrigine (lower dose) because Valproic Acid is blocking Lamotrigine's pathway for excretion leading to abnormal higher levels in the blood.

Which common pediatric anti-seizure medication has unique adverse reactions of child aggression, psychosis, and suicide attempts?

Levetiracetam (Keppra)

NOTE: this drug is a common first line therapy for kids with seizures

Topiramate (Topamax) is considered a carbonic anhydrase inhibitor? Which type of patients should we be concerned with taking this medication?

Those with a history of kidney stones

What is a very notable adverse drug reaction that can occur when taking Topiramate (Topamax)?

Impaired concentration

If a child is presenting to the office with a history of previous seizures and is complaining of an inability to focus at school, which anti-seizure medication is this patient most likely on?

Topiramate (Topamax)

Which anti-seizure medication can be notable for causing an increased PR interval?

Lacosamide (Vimpat)

Our patient is having status epilepticus, what is our initial first line of treatment?

Benzodiazepines (Diazepam, Lorazepam, Midazolam)

If our patient is having status epilepticus, we tried 2-3 doses of benzos but no response. What is our next course of action?

We can try Fosphenytoin, then Levetiracetam (Keppra), then Valproic acid

NOTE: Wood mentioned that after trying Benzos, you should probably consult with neurology to figure out which of these to try first

If our patient is having refractory status epilepticus with no improvement to any of our anti-seizure medications such as benzos and valproic acid, what should we consider next?

General anesthesia or Barbiturates such as Pentobarbital

Which two anti-seizure medications are notable for causing less drowsiness?

Lamotrigine and Valproic acid

Which two medications have black box warnings for life threatening rashes such as SJS/TEN?

Oxcarbazepine and Lamotrigine

Which 4 anti-seizure medications should we do therapeutic drug monitoring for?

Carbamazepine, phenobarbital, valproic acid, and phenytoin

Which neuro-protective medication (MAOI) for Parkinson's can show up as amphetamines on a urine drug screen?

Selegiline (Eldepryl, Zelapar)

Which two neuroprotective medications (MAOIs) for Parkinson's can potentially cause serotonin syndrome?

Selegiline and Rasagiline

Note: Rasagiline has fewer drug reactions and does not show up on a drug screen

Can we use MAO-B inhibitors as monotherapy for Parkinson's?

Yes

What is the theory behind how we can use MAOI's to help treat early signs of Parkinson's?

MAOI's help to prevent free radicals from damaging neurons in the brain

What type of foods should we tell our patient who is using MAOI's to stay away from due to possible serotonergic toxicity?

FANCY FOODS

Aged cheeses and meats

Fava beans

Red wine

Which specific types of drugs should we prescribe to a patient suffering from tremors secondary to Parkinsons?

Anticholinergics (Benztropine, Trihexyphenidyl, Diphenhydramine)

NOTE: These drugs can cause constipation, dry mouth, urinary retention, etc.... Use mnemonic for anti-cholinergics

Which drug can help manage levodopa induced dyskinesias?

Amantadine (Symmetrel)

What is the origin of Bromocriptine (Parlodel) in treating Parkinsons ?

What are the major side effects involved with this?

Infected rye

Think of his St. Anthony's fire reference

peripheral paresthesias, dyskinesias, and heart valve issues

Which non-ergot derivative can be used as a transdermal patch for the treatment of Parkinsons?

Rotigotine (Neupro)

What is our gold standard of treatment for Parkinsons?

Levodopa/Cardidopa (Sinemet)

Note: Not first line, try neuroprotective factors first

What is the main purpose of carbidopa?

To block enzymes in the blood stream (L-ADD) in order for levodopa to cross the BBB and get into the brain

Does levodopa have a dietary factor involved with taking the medication?

YES

Levodopa is absorbed by a saturable transporter in the small intestine

What kind of medications can we use in order to increase the half life of levodopa?

What is a unique side effects from these meds?

COMT inhibitors

Brown/Orange discoloration and enhanced dyskinesias

Which COMT inhibitor has a black box warning for hepatotoxicity?

Tolcapone (Tasmar)

NOTE: He said we never use this, use Entacapone instead

At what age would we consider sending patients straight to carbidopa/levodopa without trying other meds such as anticholinergics and dopamine agonists?

65 and above

What are some ways we can counteract dystonia and stiffness in patients on Levodopa/Carbidopa?

Bedtime dosing

Dopamine agonist

Rotigotine

Morning dosing

BOTOX*

How can we overall help treat Alzheimer's?

By enhancing acetylcholine and preventing the loss of cholinergic neurons

What are our three main cholinesterase inhibitors for the treatment of Alzheimer's?

Donepezil, Rivastigmine, and Galantamine

A patient presents to the office with Alzheimer's and is currently taking Tacrine for it. Your patient explains to you that she is very forgetful and sometimes has trouble taking it in time. Which cholinesterase medication could we switch her over to?

Donepezil (Aricept) because of the 70 hr half life

Why might we tend to use Rivastigmine over Donepezil and Galantamine when treating Alzheimer's?

Patient is taking ketoconazole, quinidine, or some sort of CYP 3A4 inhibitor/inducer

NOTE: Donepezil (Aricept) and Galantamine (Razadyne) is metabolized through CYP3A4

Which NMDA glutamate receptor antagonist is very well tolerated for the treatment of Alzheimer's?

Memantine (Namenda)

Which medication would we give to our patient who is undergoing a Multiple Sclerosis exacerbation?

IV methylprednisolone for 3-10 days

NOTE: Taper off after 1 week due to adrenal insufficiency

Which injectable multiple sclerosis agent can cause chest tightness, flushing, and dyspnea?

HINT: this agent mimics antigenic properties of myelin protein

Glatiramer Acetate (Copaxone)

Which monoclonal antibody prevents lymphocytes from crossing the BBB and is used to treat MS?

What is the black box warning associated with this?

Natalizumab (Tysabri)

--> Progressive multifocal leukoencephalopathy

Which oral MS medication should we monitor for bradycardia after the first dose?

Fingolimod (Gilenya)

Why would a patient who is taking Fingolimod (Gilenya) be at risk for reversible Lymphoma?

Because the drug is moving lymphocytes into lymphoid organs as apart of the mechanism of action.

Which oral MS medication has black box warnings for both hepatotoxicity and teratogenicity?

Teriflunomide (Aubagio)

25 y/o female presents to the office who has been on Teriflunomide for MS, she is looking to get pregnant this year. How would we make sure all of the medication is out of her system in order to prevent pregnancy issues?

We give a cholestyramine washout!

What should we test the patient for before giving Teriflunomide (Aubagio)?

Hint: other than liver enzymes and a pregnancy test

Tuberculosis!!

How can we pretreat a patient using Alemtuzumab (Lemtrada) for MS in order to prevent infusion associated reactions?

Tylenol, Benadryl, or corticosteroids

Which class of medications can be used for nausea/vomiting due to a migraine, but are very sedating?

Phenothiazines

(Promethazine, Metoclopramide, Prochlorperazine)

For mild/moderate migraines, what kinds of treatment should we use?

NSAIDS and simple analgesics

How can ergots treat moderate/severe migraines?

activates 5HT1D/1B receptors to vasoconstrict vessels

Which major side effect can occur from using ergots for migraines?

Ergotism

--> peripheral ischemia, cold extremities, paresthesias

What major contraindications are associated with using Ergots for migraines?

Coronary dx, hypertension, renal failure, and PREGNANCY

How long should we wait before taking ergots if we were taking triptans for migraines in the past?

24 hours (can cause vasospasms)

Can we give a patient with coronary artery dx triptans for their severe headache?

absolutely not

What is our gold standard first line triptan that we use in order to treat a moderate to severe migraine?

Sumatriptan (Imitrex)

Which triptans can we use to lower the recurrence and have a long half-life?

What is the downside?

Naratriptan (Amerge) and Frovatriptan (Frova)

--> The onset of action is very long (up to 4 hours)

Which notable triptan drug has an interaction with propranolol?

Rizatriptan (Maxalt)

Which triptan could we use if our patient cant tolerate sumatriptan and is considered the next best option?

Almotriptan (Axert)

If we have a patient who has HTN and angina symptoms, but has a severe headache. Which medications could we consider giving them?

Lasmiditan (Reyvow)

CGRP antagonists (gepants)

When would we absolutely taper off analgesic medication for those experiencing medication overuse headaches?

Those who have been taking the medication >12 days and for those who are pregnant

If a patient wants to prevent migraines but they also have asthma? what kind of medication should we prescribe them?

HINT: he said this will be a test question most likely

low dose selective beta blockers like atenolol

What kind of therapy would be best for a 18 year old kid who is currently on his way to a state baseball championship this year and wants to prevent his migraines that he has been experiencing?

Anticonvulsants such as topiramate or valproic acid

NOTE: topiramate can inhibit concentration so he'll stink at math

What kind of therapy would be best for a woman who is pregnant and cannot use beta blockers but wants to prevent migraines from happening?

Calcium channel blockers such as verapamil

Which medication is the ONLY one that can treat and prevent migraines?

HINT: going to be a test question, know it!

Rimegepant (Nurtec)

What is the drug of choice for migraines during pregnancy?

Acetaminophen

What is the best prophylactic therapy for cluster headaches?

Verapamil (calcium channel blocker)

Will gastric emptying time be faster or slower in infants less than 6 months of age?

Faster

Do we see alot of extended release drugs being used in pediatrics?

No, because their gastric emptying time is increased and so the drug will be excreted rapidly

How do neonates and infants differ from older kids and adults as far as blood flow to muscles and percent of water in the muscles?

Neonates and Infants have decreased blood flow and increased percent of water in the muscles

Do neonates/infants have good rectal absorption?

yes

What type of route should we use for medicine in neonates for emergent situations?

Intraosseous (IO)

What is the concern with using topical/patch drugs on neonates and infants?

Toxicity due to an underdeveloped stratum corneum

How does an increased amount of body water content (as seen in infants) affect the volume of distribution for hydrophilic medications?

Increases the volume of distribution for hydrophilic meds

If we have a higher amount of volume of distribution for hydrophilic meds, what do we need to do to adjust the dosing concentration on medications?

Increase the dose concentration

Can infants tolerate acetaminophen better than adults?

Yes!

For infants receiving aminoglycosides such as gentamicin, the half life is much longer than adults, how would this affect the way we do our dosing interval?

the dosing interval will be much longer

--> example: adult gets meds every 8 hours

Kid gets meds every 24 hours