MCPC Exam 2 Preparation

Positive Symptoms

Delusions, hallucinations, disorganized thinking and speech, disorganized or abnormal motor behaviors (including catatonia)

negative symptoms

blunted affect, avolition, anhedonia, poor self-care, social withdrawals, speech poverty

mesolimbic pathway

increase in DA causes positive symptoms

mesocorticoal pathway

DA hypoactivity causes cognitive and affective symptoms

nigrostriatal pathway

EPS and TD sid effects

Tuberoinfundibular pathway

hyperprolactinemaia drug SE

BBW antipsychoitics

increased mortality in elderly dementia-related psychosis

warnings antipsychotics

fall risk- orthostatic, hypotension, syncope

NMS: medical emergency, can occur at any point in tx

EPS, Tardive Dyskinesia, hypoerprolactinemia, cognitive and motor impairments, CV effects

NMS tx

d/c offending agent, supportive care, bromocriptine (PO), or dantrolene (IV/PO)

akathisia

anxiety, restlessness, irresistable urge to move

-tx: propranol, benzos

dystonia

sustained skeletal muscle contraction and rigidity

-tx: d/c agent, diphenhydramine, benztropine, benzos

pseudo-parkinsonism

rigidity, tremor, bradykinesia, shuffled gait

-tx: diphenhydramine, trihexyphenidyl, benztropine, amantadine

tardive dyskinesia

rhythmic involuntary movements (usually in the face, trunk, extremeties)

-tx: d/c offending agent, velbenazine, deutetrabenazine

Valbenazine

Ingrezza

Deutetrabenazine

Austedo

haloperidol

haldol

fluphenazine

prolixin

loxapine

Adasuve

Typical Antipsychotics

beneficial for positive s/sx, higher risk of EPS

atypical antipsychotics

beneficial for negative s/sx, higher risk of metabolic AE

aripiprazole

abilify

brexipiprazole

Rexulti

cariprazine

Vraylar

clozapine

clozaril

iloperidone

fanapt

Lumateperone

Caplyta

lurasidone

Latuda

olanzapine

Zyprexa

olanzapine/samidorphan

Lybalvi

paliperidone

invega

quetiapine

Seroquel

risperidone

Risperdal

ziprasidone

Geodon

haloperidol, fluphenazine, aripiprazole, olanzapine, paliperidone, risperidone

long acting injectables

PO>IM>>IV

routes for acute agitation and aggression

PO doseage forms

haloperidol, aripiprazole, asenapine, quetiapine, risperidone, olanzapine

IV/IM dosage forms

haloperidol, droperidol, loxapine, olanzapine, ziprasidone

polypharmacy

responsible for 39% of delerium cases

asenapine

fastest onset of oral meds

haloperidol

slowest onset of oral meds

inhaled loxapine, midazolam

fastest onset of parenteral options

step up approach

start with antacids (do not heal erosions) or H2RAs and lifestyle mods and increase

step down approach

start with PPIs and lifestyle modifications and decrease

antacids

neutralize and raise intragastric pH resulting in decreased activtion of pepsinogen and increased LES pressure

H2RAs

blocks histamine 2 receptors in gastric parietal cells thereby decreasing gastric acid secretion (reversible blockade)

cimetidine

H2RA- inhibits CYP450 enzymes, drugs metabolized by these might be affected (theophylline, cyclosporine, nifedipine, propranolol, phenytoin, warfarin)

PPIs

accumulate in acidic region of parietal cells, where they undergo acid-catalyzed conversion to a reactive sepecies. Reactive species irreversibly interactions w/ H-K-ATPase; resulting in long-lasting impairment of acid secretion

omeprazole

Prilosec

-class C pregnancy (all others B)

omeprazole + sodium bicarbonate

Zegerid

lansoprazole

Prevacid

rabeprazole

Aciphex

pantoprazole

Protonix

esomeprazole

Nexium

Dexlansoprazole

Dexilant

promotility agents

used to improve gastric emptying in select patients; typically in addition to acid-suppressive therapy

peptic ulcer disease

caused by H. pylori, NSAIDs, critical illness, surgery, hypovolemia, malignancy, stress, tobacco use

duodenal ulcer

sharp, burning epigastric pain, point tenderness

-pain 1.5-3 hours after meal

-eating lessens pain

-episodic

-nocturnal wakening

gastric ulcer

diffuse lower abdomnial pain, less localized

-pain precipitated by meals

-continuous pain

-obstructive sx

PUD triple therapy

Metronidzaole or amoxicillin, PPI, clarithromycin

PUD quadruple therapy

any PPI, pepto bismol, metronidazole, tetracycline or amoxicillin, or clarithromycin

stress ulcers

risk factors: icu, coagulopathy, shock, resp failure, hepatic/renal failure, burns, hypotension

-prophylaxis for those w/ risk factors

-IV H2RAs have most data, then PPIs, MAYBE consider sulcrafate

acute back pain tx

NSAIDs: ibuprofen, naproxen, diclofenac, meloxicam

SMR: methocarbamol, baclofen, metaxalone, cyclobenzaprine, orphenadrine, tizanidine

topical NSAIDs may be considered

tripgger point injection

Acute abdominal pain tx

prochlorperazine 10 mg IV push

droperidol 0.625 mg IV push

Diphenhydramine 25 mg IV push

dicyclomine 20 mg syrup, PO once or 20 mg PO once

mild-moderate: antacids, PPI, topicals, zofran, droperidol/haloperidol, metoclopramide

severe: opiates

renal colic tx

ibuprofen 800 mg PO

ketorolac 30 mg IV or 60 mg IM

diclofenac 50-75 mg IM

naproxen 500 PO

DOC for severe: morphine sulfate

TCAs, SNRIs, gabapentin/pregabalin, topicals

TOC for neuropathic pain

senna +/- docusate

DOC for prophylaxis of opioid induced constipation

docusate

do NOT use as monotherapy

bulk forming laxatives

avoid these in OIC

CKD EPI equation with race coefficient

overestimates GFR for African Ancestry

-accurate in other patients

CKD EPI original equation without race coefficient

underestimates GFR for African Ancestry

accurate in other patients

CKD EPI refit without race coefficient

underestimates GFR for African ancestry

overestimates in other patients

cystatin C only equation

most accurate for all patients, but unfeasable in implementation

creatinine cystatin equation with race coefficient

overestimates GFR for African Ancestry

-accurate in other patients

-2012

creatinine cystatin equation without race coefficient

undestimates GFR for African Ancestry

-accurate in other patients

-2012

creatinine cystatin equation without race

accurate GFR for African ancestry

overestimates in other patients

Carbamazepine

-therapeutic range 4-12 mcg/mL

-avoid in absence

-take w/ food to reduce an upset stomach

lamotrigine

-oral contraceptives significantly decrease serum concentration

-if greater than 5 half lives (6 days) go by without a dose, titration process must be restarted

brivaracetam

IV use is limited to 4 days of consecutive tx

zonisamide

CI in sulfa allergy

Trokendi XR (topiramate)

avoid alcohol 6 hours before and after doses

Qudexy XR (topiramate)

CI in pts with metabolic acidosis on warfarin

Lacosamide

prolongs PR interval and increases risk of arrrythmias

-collect ECG at baseline and at one SS in those with history of cardiac concerns or on other concomitant agents

ethosuximide

only used in absence seizures

-avoid in renal and hepatic dysfunction

tigabine

take w/ food

-may trigger a seizure in those w/o seizure disorder and with hepatic function

cenobamate

CI in pts with familial short QT syndrome

Rufinamide

CI in familial short QT syndrome

can decrease concentrations fo oral contraception

take w/ food

primidone

ci in pregnancy

can decrease concentrations of oral concentration

cannabidiol

-only oral solution

-indications: Lennox-Gestaut syndrome, Dravet syndrome, or Tb sclerosis complex

-warnings: hepatocellular injury

perampanel

CIII

pregabalin, phenobarbital, BZDs

CIV

brivaracetam, lacosamide, cannabidiol

CV

10-20 mg/L

therapeutic range for phenytoin

1-2 mg/L

therapeutic range for free phenytoin

use phenytoin correction calculation when albumin is ___ and CrCl is ___

sinus bradycardia and certain heart blocks

phenytoin is CI in ___

-decreased bone mineral density with use

50 mg/min

max infusion rate for phenytoin

150 PE/min

max infusion rate for fosphenytoin

7 mg/kg/day

Vm value of Phenytoin for an average person (around 450 mg/day)

Dose * S= (Vmax * Css)/(Km + Css)

Michaelis Mentin equation

tablet, solution

phenytoin acid dose forms

S= 1