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NR 508 Pharmacology Final
Terms in this set (92)
1st line treatment for HTN (non-black, no CKD)
ACEI (arb), thiazide, ccb
1st line treatment for HTN for black pts (no ckd)
1st line option for HTN for anyone with CKD
Types of diuretics
thiazides, loop diuretics, k-sparing
preferred diuretic with renal impairment
diuretics - S/E & D/I
S/E All - hypokalemia, arrhythmia, metbolic alkalosis, fatigue, postrual hypotension, hyperlipidemia
S/E for k-sparing - hyperkalemia, gynecomastia, peptic ulcer)
S/E for thiazides - hyperglycemia & hypercalcemia
S/E for loop hypocalcemia
D/I All- digoxin (hypokalemia/toxicity risk), NSAIDs (reduce diuresis), lithium (toxicity risk), corticosteroids (enhance hypokalemia), anti-diabetic drugs (decrease anti-diabetic levels)
D/I for thiazides - BB's - increase hyperglycemia/ hyperlipidemia
D/I for loops - aminoglycosides = ototoxicity & nephrotoxicity
which diuretic causes post diuretic sodium retention
post-diuretic effect, a compensatory sodium-retention process that begins as the diuretic action wanes.
Diuretics that do not contain a sulfonamide derivative
also: amiloride, hydrochloride, eplerenone, spironolactone, and triamterene (safe for pt with allergy to sulfa)
CHF drugs including diuretic choices
First line: ACEI's or ARB, Beta-blocker, diuretics (loop & potassium sparing)
-ACEI's & ARB's decrease mortality
-if ACEI contraindicated: use ARB or Hydralizine & Isosorbide (decrease mortality/less effective than ACEI)
-Beta-blockers: decrease mortality, NEVER when active failure, ONLY after diuresed & other medications
-Digoxin: add if needed for systolic HF
if 1st line tx not enough.........
Spironolactone & Eplerenone
Nitrates and hydralazine (lower mortality in class 3&4 for African American)
Calcium channel blockers
(Can worsen hf use caution **BUT NEVER IN SYSTOLIC DYSFUNCTION - thats for digoxin)
(DA BD is aa sad)
Beta-Blockers (after acute)
Digoxin (Syst. HF/A-fib/diuretic failure)
Know migraine management and prophylactics
*NSAIDS or APAP
*Triptans (sumatriptan/imitrex, zolmatriptan/zomig, rizatriptan/maxalt)
-nasal, oral, subq
-use no more than 2d/wk
-C/I-recent use of MAOIs, ergots, or SSRIs, CVD, CAD, TIA, HTN, pregnancy
*Ergots (ergotamine tartrate/cafergot) not used often, expensive
-nasal, oral, rectal, IM, IV, siblingual
-CI-recent use of triptans, CVD, CAD, TIA, HTN, pregnancy
*beta blockers (metoprolol, propranolol, timolol)
- 2-3 months for effect- decrease frequency & severity by 50%
-A/E- drowsiness, exercise intolerance, depression
*anticonvulsants (valproate, topiramate) effective but major A/E
-valproate AE- dizziness, platelet dysfunction, hair loss, hepatotoxic, teratogenic
-topiramate AE- cognitive dysfunction, weight loss, renal stones
Herbal migraine management
Butter bur root. It should be PA free or could result in liver damage
Feverfew (Tanacetum parthenium) - Action: Antiinflammatory effects Uses: migraine prevention Interactions: Anticoagulants, antiplatelet drugs, aspirin (Pg. 99)
Alternative therapies that have been described in the evidence-based literature include feverfew, riboflavin, and magnesium (pg. 481)
What medications migraine medications to avoid in patients with asthma.
Beta Blockers such as Propranolol
cyproheptadine (Periactin) - The drug may produce an atropine-like action, so it must be used with caution in patients treated for bronchial asthma (pg. 487)
Know the common side effects of methylphenidate Ritalin
Nervousness, insomnia. Maybe controlled with dose reduction or omitting afternoon or evening dose. Other SE- decreased appetite, ABD pain, headache, depression, weight loss, rebound symptoms. Page 453
Also: Temporary slowing of growth rate/Height and weight should be monitored with long term use
ADHD management - stimulants including side effects alternatives, age they may be used, strattera, which is the longest acting stimulant?
UNDER AGE 6 IS OFF LABEL
HA, tics, appetite suppression, elevated BP
Stimulants: increase "background" dopamine levels in synapse. However, trials of stimulants fail to distinguish between those without ADHD.
Amphetamine Like Drugs (Methylphenidate, ritalin, metadate, concerta) 1st LINE OF Rx TREATMENT
*S/E: common - Nervousness, insomnia
less common- decreased appetite, abdominal pain, headache, depression, irritability, weight loss, and rebound symptoms, decreased growth velocity
Amphetamines - (Adderall, Vyvanse)
S/E:anorexia, weight loss, nausea, xerostomia, abdominal pain, diarrhea, and constipation.
armodafinil (Nuvigil), modafinil (Provigil),
Long Acting: Quillivant XR 12 hrs, adderall xr 8-12 hrs, Vyvanse 10-12 hrs,
Atomoxetine (straterra) - non-stimulant half-life is 4 hours in most but prolonged to 30 to 40 hours in poor metabolizers (7% of population).
Know the treatment of Alzheimer's and the education behind the medication management of the disease.
Donepezil (Aricept), Galantamine ER (Razadyne), Rivastigmine (Exelon), Memantine
*Donepezil- evening before bed; except for sleep disturbances/nightmares then day dose
** ChE inhibitors: all stages, delays progression & improve function
Memantine mod-severe- stage 5-7; can be added to ChE inhibitors
*may improve function.
ChE vs NMDA antagonist - when are each of them indicated? What is their benefit?
ChE - delay the progression & improve function
*All stages - Donepezil (Aricept) -
*mild-mod.- rivastigmine (exelon) & galantamine (Razadyne)
NMDA Antagonist - may improve pt function
*mod-severe stage 5-7 - Memantine (Namenda)
Parkinson Disease Drugs
Initial drugs/First line: Levodopa, Dopamine agonists, Rasagiline
∙Carbidopa/levodopa: most effective x slow, stiff, tremor; all pts eventually need; cause dyskinesias
∙Dopamine agonist (Apomorphine, Pramipexole, Ropinirole, Bromocriptine, Cabergoline)
- Pramipexole & Ropinirole mild-sev; mono/adjunct
-Apomorphine - late stage adjunct x on/off phen.
∙MAO-B inhibitors: (Selegiline, Rasagiline) - mod. effect - monotherapy delays need for dopas - adjunct with dopas decrease wear off
- Selegiline - mono x slow & stiff; adjunct x motor fluctuations; wearing off phenomena
Anticholinergics (Benztropine) reduce tremor, rigidity & drooling - S/E: confusion, hallucinations, dry mouth, blurred vision and urinary retention
-Amantadine - adjunct to dopas x slow, stiff & tremor, or if decreased dopa dose needed
∙COMT inhibitors (Tolcapone, Entacapone)-reduce motor fluctuations in patients w/ advanced disease; often used to treat wearing off w/ Sineme
FLU FLU PECS
Fluvoxamine (2 week flu - long 1/2 life)
Paroxetine (sex dysfunction)
SSRI's - increased nonfatal suicide attempts and increased >side effects x elderly
Serotonin syndrome: hyper, >HR, >BP, tremors, aggitation, sweat, myoclonus, HYPERTHERMIA (within 24hrs)
Duloxetine's approoved uses
Depression, anxiety, osteoarthritis and fibromyalgia and neuropathic pain.
Which SSRI is approved for use in children/teen?
Fluoxetine > 8 yrs
Fluoxetine is the only SSRI approved for depression in children*****
SSRI's x > 18 yrs use
Monitoring of depression
Assess response, S/E, increased suicidal thoughts
Acute phase 6-8 weeks (titrate dose up & return to baseline)
Continuation x 16-20 weeks (prevent relapse)
Maintenance x 4-9 months (after no relapse)
Side effects of antipsychotics, Serentil/mesoridazine
Serentil/mesoridazine is a first generation antipsychotic
-Most common side effects of antipsychotics are parkinsonian syndrome, akathisia, dystonia, neuroleptic malignant syndrome, and TD.
-General body: Polydipsia, systemic lupus erythematous-like symptoms.
-Hypersensitivity: Pruritus, dry skin, seborrhea, erythema, uritcaria, maculopapular
hypersensitivity reactions, asthma, laryngeal edema, hair loss.
-Respiratory: increased depth of respiration. laryngospasm, bronchospasm, dyspnea, suppression of cough reflex.
-Cardiovascular: hypotension, hypertension, tachycardia, bradycardia, light-headedness, faintness, dizziness, cardiac arrest, syncope, quinidine-like effect (increased QT interval, ST depression, and changes in AV conduction).
-GI: Dyspepsia, increased appetite, increased weight, antiemetic.
-Hemic and lymphatic: agranulocytosis (rare), leukopenia, leukocytosis, anemia, thrombocytopenia, aplastic anemia, hemolytic anemia, pancytopenia
-Endocrine: lactation and breast engorgement in females, galactorrhea, mastalgia, amenorrhea, menstrual irregularities, changes in libido, hyperglycemia, hypoglycemia, glucosuria, raised cholesterol, SIADH, hyponatremia.
-CNS: headache, weakness, tremor, twitching, tension, jitteriness, fatigue, slurring, insomnia, vertigo, drowsiness.
-Autonomic: Dry mouth, nasal congestion, n/v, paresthesia, anorexia, pallor, perspiration, constipation, diarrhea, frequency or incontinence, polyuria, enuresis, priapism, ejaculation inhibition, male impotence.
-Hepatic: Liver dysfunction
-Behavioral effects: exacerbation of psychotic symptoms including hallucinations, catatonic-like states, lethargy, restlessness, hyperactivity, agitation, bizarre dreams, depression, paranoid reactions.
Lab monitoring required with Clozaril
Clozapine: Monitor weekly CBC with differential, in keeping with the manufacturer's protocol. The manufacturer maintains a confidential register (800-448-5938); patients must be enrolled and have a baseline white blood cell (WBC) count and absolute neutrophil (ANC) count before initiation of therapy. Treatment should not be initiated if the baseline WBC is <3500/mm3 or ANC is <2000/mm3. Issue of weekly supplies of the drug is dependent on the results of the weekly white blood cell count; the results are sent to the national registry via forms supplied by the manufacturer. If after 6 months of weekly monitoring, the WBC has continuously remained ≥3500/mm3 and the ANC has remained ≥2000/mm3, the monitoring of blood counts through the registry may be reduced to every 2 weeks for 6 months. If acceptable WBC and ANC counts (WBC ≥3500/mm3 and ANC ≥2000/mm3) have been maintained during the second 6 months of continuous therapy, WBC and ANC may then be monitored every 4 weeks starting at the end of the 12 months and thereafter. page 557, Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for the Primary Care Provider. Saint Louis: Elsevier Health Sciences.
Side effects of carbamazepine and lab monitoring
D/C x liver dysfunction (baseline & periodic LFT)
CBC/UA - baseline then Q3MO x 1 yr (d/c x wbc <2500)
SIADH (edema water intoxication & <NA)
eye exams x opacities
s/e: Dizzy/Drowsy/N/V, anticholinergic (mild but caution for intraocular pressure), aplastic anemia, Rash, Stevens-Johnson, confusion, hypersensitivity/photosensitivity, leukopenia
**** induces its own metabolism
Know first line treatment for generalized seizure management not adjunct therapies
Peds- 1st =phenobarbital
o Carbamazepine ( tegretol) miscellaneous class
o Phenobarbital ( luminal) Barbiturates class
o Phenytoin ( Dilantin) Hydantoins class
o valproate ( depakene) GABA analogs ( new drug)
Evaluation of incontinence
A focused history with a careful physical examination is essential for determining the cause of incontinence. Transient or reversible causes should be ruled out (Table 34-1). A bladder diary is a helpful diagnostic tool that reveals toileting habits, fluid intake, and leakage episodes. Urinalysis and postvoid residual are essential laboratory tests. Further evaluation by specialists may involve urodynamic and imaging tests. (Edmunds 393)
Meds for erectile dysfunction know which have an quick onset of action.
which has quickest onset: tadalafil (Cialis), sildenafil (Viagra), avanafil (Stendra) or vardenafil (Levitra)?
PDE5 inhibitors sildenafil (Viagra), tadalfil (Cialis), vardenafil (Levitra), avanafil (Stendra) are the 1st line unless contraindicated. Tadalfil (Cialis) lasts longest, 36 hours and is better absorbed with food. vardenafil (Levitra) has a shorter ...See More
Treatment for hyperthyroid
Hyper: Decreased TSH and elevated T4 and T3
treat with methimazole (Tapazole) or propylthiouracil (PTU)
Know the treatment and labs for Hyperthyroid and Hypothyroid (know normal TSH and T4 labs as well as pattern seen with hypo vs hyperthyroidism)
Normal TSH: Newborn: <20 mcg/ml
Adult: 0.30-5.5 mcg/ml
Normal T4: Newborn: 6.4-23.2 mcg/ml
Child: (1-10yrs old): 6.4-15 mcg/ml
Adult: 5-12 mcg/ml
Hyper: Decreased TSH and elevated T4 and T3
Hypo: elevated TSH and decreased T4 and T3
Treatment for hypothyroid
Hypo: elevated TSH and decreased T4 and T3
-treat with levothyroxine (T4) (synthroid, Levothroid, Levo-T)- thyroid supplement
- dosage of all thyroid medications must be individualized
- dosage is based on lab finding and the patient's clinical response
Side effects of hyperthyroid meds
methimazole (Tapazole): Priutus, rash, uricaria, hepatitis, n/v, ha, paraesthesia, vertigo, agranulocytosis, aplastic anemia, hypoprothrombinemia, leukopenia, thrombocytopenia
propylthiouracil (PTU): skin discoloration, rash, uricaria, hepatitis, n/v/d, diminished taste, drowsiness, ha, vertigo, agranulocytosis, aplastic anemia, hypoprothrombinemia, leukopenia, thrombocytopenia
how to prescribe oral diabetic medications/what labs to monitor for patient receiving oral diabetic medication
Monitor weekly for the first month and later monitor monthly or as indicated. Monitor HgbA1C at baseline and every 3 months to evaluate control. Monitor urine at least annually with microalbuminuria (start on ACEI or ARB if present). Monitor lipids annually or more often if treatment has been initiated.
first line medication management in Type II Diabetes
first line oral diabetes management in a patient with and without renal disease
With: second generation sulfynlureas (i.e., Glipizide), nonsulfonylurea secretagogues (nateglinide /Starlix), thiazolidnediones (Avandia, Actos), alpha-Glucosidase inhibitors (acarbose /Precose)
Without: Metformin, thiazolidnediones (Avandia, Actos), second generation sulfynlureas (Glipizide), nonsulfonylurea secretagogues (nateglinide /Starlix), alpha-Glucosidase inhibitors (acarbose /Precose)
metformin -Side effects & vit. defiency
side effects- b12 deficiency, n/v/d, chills, rash, no wt. gain, dyspnea, lactic acidosis, hypoglycemia, metallic taste
contraindicated- renal dysfunction, metabolic acidosis, dka, hold for iodine contrast imaging
moa-decreases hepatic glucose production
acarbose - MOA
MOA- must be taken with food.....inhibit pancreatic a-amylace and membrane bound intestinal a-glucoside hydrolysis enzymes.... prevent the breakdown of complex starches to glucose.
acarbose - side effects
contraindicated- dka, cirrhosis, IBS, intestinal obstructions
s/e: flatulence, diarrhea, abdominal pain
warning-carcinogenic x renal tumors
canaglifozin - MOA
sodium-glucose transport inhibitor type 2 (sglt-2) inhibits renal glucose reabsorbtion
From our discussion board gluscouria = Canaglifozin is working
canaglifozin - side effects
side effects- increased risk of foot amputations, uti's, diuresis, hypotension, increased ldl, adverse cardiac events, dka, reduced bone density
Otitis media treatment (1st line med and dose)
per lecture slide: 1st line treatment-Amoxicillin 80-90mg/kg/day divided BID for 5-10 days. Alternative-Augmentin, cefuroxime, cefdinir, cefpodoximine, ceftriaxone IM. *if recent amoxicillin use, Augmentin is 1st line. If PCN allergy-TMP/SMX, axithromycin, clindamycin. If no improvement in 2-3 days, change to Amox/Clav, Ceftriaxone IM x 3 days, clindamycin and consider referral to specialist. Otorrhea with tympanostomy tubes-quinolone otic drops. check hearing if effusion persists for 3 months or longer or at any time if significant hearing/language problem.
Otitis externa treatment
ciproflaxin drops with corticosteroid
1st line treatment for impetigo
Oral dicloxacillin is the first choice. Bactroban may also be applied topically for mild lesions.
Systemic antibiotics usually are required. However, mupirocin (Bactroban) can be used for topical treatment of mild impetigo.pg 658
Otorrhea - management for pt with tympanostomy tubes
Otitis Media with Effusion (OME) & when to check hearing
Evaluation and tx for IBS including specific medications and their side effects, assessment of abdominal pain,
• Increased dietary fiber (25 g/day)
• Antispasmodic (anticholinergic) medication—short term
• TCAs—long term
• Loperamide—short term; often used for breakthrough diarrhea
• Antidepressants (TCAs)—long term
• Alosetron (ordered by GI specialists) if resistant to all other interventions
What iron deficiency is associated with over-consumption of milk in toddlers?
iron deficiency anemia
test with ferratin level
Oral candidiasis/thrush - infant's treatment
1st line treatment: fluconazole 6 mg/kg x1 then 3-12 mg/kg x 2 week minimum (pg. 723)
Salt substitutes - Side effects
Vitamins for vegetarians
protein, iron, calcium, vitamin D, vitamin B12, and omega-3 fatty acids
Nicotine nasal spray - tapering instructions
useful for patients with severe cravings and wants immediate relief. Fastest nicotine delivery, most closely resembles nicotine effects of smoking. highest potential for prolonging addiction. use 1-2 doses per waking hour for 3-6 months, consider taper period by halving number of doses per week. pg785. Also 1-2 0.5 mg sprays each nostril/hour. Do not exceed 5 sprays/ hour or 40/sprays day. gradually reduce rate over 6-8 weeks pg 786
Rocky Mountain Spotted Fever - Treatment
doxycycline 100 mg po bid × 7 days
chloramphenicol 50 mg/kg/day IV q6h × 7 days
Know the indications for the use of Vancomycin
Vancomycin IV is used most often in serious or life-threatening staphylococcal or streptococcal infections. The primary care use of vancomycin is for pseudomembranous colitis caused by C. difficile. It is given in oral form when treatment with metronidazole is contraindicated or ineffective
Prevents synthesis of the bacterial cell wall by blocking peptidoglycan strand formation.
Vancomycin - MOAq
Prevents synthesis of the bacterial cell wall by blocking peptidoglycan strand formation.
It works by preventing synthesis of the bacterial cell wall by blocking peptidoglycan strand formation. pg668
Cephalosporins - MOA
Cephalosporins are β-lactam antibiotics that have the ability to resist bacterial enzymes, specifically β-lactamase. They have a similar mechanism of action to that of penicillin and interfere with cell wall synthesis through inhibition of the synthesis of the bacterial peptidoglycan in the cell wall. The antibiotic binds to the enzymes that build/maintain the cell wall. This makes the cell wall osmotically unstable. Cephalosporins are bactericidal and usually are effective against rapidly growing organisms. Cephalosporins differ in terms of which enzymes they affect. pg 678
Acetaminophen - side effects
When acetaminophen is used as directed, adverse effects are rare. Hypersensitivity presents as skin eruptions, urticarial and erythematous skin reactions, and fever. Research suggests acetaminophen may increase asthma prevalence in children.
Extremely rare hematologic reactions include hemolytic anemia, leukopenia, neutropenia, and pancytopenia. Other reactions are hypoglycemia and jaundice. Adverse effects are usually dose dependent. Hepatic toxicity may occur following intake of >7.5 g within 8 hours. Alcoholics and patients on hepatic metabolizing medications are more susceptible to hepatic toxicity. This is very important because hepatic toxicity can be caused by binge drinking.
Acetaminophen s/sx of toxicity
Symptoms that appear in the first 24 hours are nausea, vomiting, drowsiness, lethargy, malaise, and confusion.
non-selective should only be used if pt. not responsive to cox2 selective nsaids and/or acetaminophen (up to 4000 mg/day)and after risk analysis for GI complications. pg. 407
NSAIDS - Side effects
Topical NSAID's - Uses
Selective vs. non-selective NSAID's
Osteoarthritis - Management
PPT= Aspirin and Celecoxib (cox-2)
Non-pharmacologic= Nonpharmacologic treatment includes proper exercise with rest periods. A supervised walking program can improve functional status. Recommend weight loss to overweight patients to reduce strain on joints. The patient must be realistic about the limitations of medications and about his own prognosis. (Edmunds 409)
Pharmacologic= Acetaminophen may be effective in treating the pain of OA because many patients have minimal inflammation. Patients with mild OA should be started on acetaminophen. If this is not effective, NSAIDs can be used. NSAIDs are more effective than acetaminophen for OA of the knee or hip. They are also more effective in moderate to severe disease. Some patients' conditions can be managed via long-term acetaminophen therapy with short-term use of NSAIDs for flareups. Because of the decreased risk of GI toxicity, COX-2 inhibitors are useful for long-term management of OA in elderly patients.
Intraarticular injection of steroids can be provided on a limited basis. Topical creams such as capsaicin can also help with the pain. Surgical measures such as hip or knee replacement may be necessary in joints that are seriously affected. (Edmunds 409)
Acetaminophen - indications for children
Acetaminophen is used commonly for pain and fever in children and generally is well tolerated. Use caution to avoid overdosage.
Acute overdosage of acetaminophen can result in hepatotoxicity and is life threatening. Toxicity is likely to occur if a patient takes more than 250 mg/kg in a single dose or greater than 12 g within a 24-hour period. After 24 hours up until 72 hours, symptoms abate and liver toxicity (AST/ALT elevation) normally occurs. An increase in liver enzymes within 24 hours is a sign of permanent injury. Liver enzyme elevation usually peaks at between 72 and 96 hours after ingestion, along with other markers of liver function such as the INR and a total bilirubin concentration above 4. The last stage, which consists of recovery, lasts anywhere from 4 days to 2 weeks; recovery is complete in many cases.
The patient should immediately receive activated charcoal. Further treatment should take place in a hospital setting with the patient receiving N-acetylcysteine (NAC), the specific antidote for acetaminophen poisoning.
Acetaminophen is metabolized in the liver. Toxic metabolite is detoxified with hepatic glutathione. Hepatic necrosis can occur if glutathione stores have been depleted by long-term or toxic doses of acetaminophen. Children at increased risk for acetaminophen toxicity include those with diabetes, concomitant viral infections, a family history of hepatotoxic reactions, obese children, and chronically malnourished children.
Med Names for ACEI, ARB, CCB, & Thiazides
ARB = sartan
CCB = pine + vd (verapamil & diltiazem)
Thiazides = zide + MIC (metolazone, indapamide, chlorthalidone)
Diuretic uses and contraindications
Uses - HTN, CHF, edema, decrease calcium stones, (off label HCTZ = osteoporosis)
C/I - gout, renal failure, hypokalemia,
Management of edema:
-oxygen, Furosemide or Bumetanide, Nitro IV or paste to chest wall, Morphine IV.
-Dobutamine or Milrinone if still symptomatic after use nitrates, furosemide, morphine (after preload reduction)
-Beta-blockers & Spironolactone AFTER stabilization.
-Digoxin AFTER stabilization; if still symptomatic on beta-blockers, diuretics, ACEI's, and spirnolactone.
-ACEI or ARB for all patients w/ HF unless contraindicated.
What drugs can cause serotonin syndrome?
Stimulant Side effects
Headache, tics, appetite suppression, elevated BP, sleep disturbances, decreased growth
ADHD Nonstimulant alternatives:
Norepinephrine reuptake inhibitors (Strattera- atomoxetine) not controlled substance
S/E: "black box" warning increased suicide risk, vomiting, insomnia, headache, rhinitis, upper abdominal pain, decreased appetite, constipation, increased cough, flu syndrome
Half-life - Atomoxetine half-life is 4 hours in most patients, although this may be prolonged to 30 to 40 hours in poor metabolizers (7% of population).
• Clonidine derivatives eg guanfacine (intuniv)- these tend to be most effective in younger boys with hyperactivity symptoms and can be helpful with insomnia
• Buproprion (wellbutrin) (it is an off-label use) - consider in adolescent who also has depressive symptoms
wearing off phenomena
also called "end of dose failure" or "on-off" effects. Patients may experience after 1.5 to 2 hours with some products. On-off effect is a sudden loss of therapeutic effect.
One tx option is to give more frequent doses of levodopa or a sustained-release formulation.
effect of protein on absorption of levodopa
compete with amino acids for absorption in GI and transport into the CNS
initially eat with food - if GI s/e tolerable move to 30 minutes before meals. - limit protein with med
most effective x slow, stiff, tremor; all pts eventually need; cause dyskinesias
Dopamine agonist (Apomorphine, Pramipexole, Ropinirole, Bromocriptine, Cabergoline)
- Pramipexole & Ropinirole mild-sev; mono/adjunct
-Apomorphine - late stage adjunct x on/off phen.
Initial drugs/First line
Levodopa, Dopamine agonists, Rasagiline
reduce tremor, rigidity & drooling
s/e confusion, hallucinations, dry mouth, blurred vision and urinary retention
adjunct to dopas x slow, stiff & tremor, if decreased dopa dose needed, or on/off phenom.
COMT inhibitors (Tolcapone, Entacapone)
reduce motor fluctuations x severe; treat wearing off w/ Sinemet
arrhythmia's & seizures.
What is the side effect of antipsychotics that can lead to abnormal rhythmic movements? How should this be managed?
tardive dyskinesia (irregular, jerky movements tongue, face, mouth, or jaw) IRREVERSIBLE
Dystonias-(continuous spasms & muscle contractions)
akathisia (motor restlessness)
parkinsonism (characteristic symptoms such as rigidity)
bradykinesia (slowness of movement)
Assess for extrapyramidal symptoms at each patient encounter. Use of the Abnormal Involuntary Movement Scale (AIMS) is recommended
Approximately 15% to 20% of patients who are on long-term first-generation antipsychotic drugs develop TD. The only prevention is low-dose antipsychotics, administered only when necessary.
Monitor - taper or change if able - or give sedative like clonazepam
how to prescribe oral diabetic medications
How often should one obtain a TSH when initially treating hypothyroidism?
What dose of levothyroxine should be started in a patient who has coronary artery disease?
Why should we avoid use of chronic nitrofurantoin in older adults? (See Geriatric lecture)
Nitrofunantoin- Prolonged use increases risk for peripheral neuorpathy, pulmonary and hepatotoxicty. Avoid long term use and avoid in patients with CrCL < 60 mL/min
How to monitor methimazole therapy
Monitor every 3-6 weeks. Monitor for signs of infection and decreased pluse, BP, weight, elimination of nervousness and tremor. Potential for hepatoxicicity, AST, ALT, alkaline phosphatase, LDH, bilirubin, & PT.
hypothyroidism - will the child always need thyroid replacement?
Can possibly stop therapy at 3 years of age. Then recheck thyroid to see if it is still needed
TCA's - Trans/Chans/Ans (high risk/reward)
Trans - 2 neurotransmitters (SE, NE)
Chans - 2 channels (Na, Ca)
Ans - (/) Acetylcholine & Histamine
•TCA's: block reuptake x ne & se @ the presynaptic neurons/ block Na channels x heart & brain = arrhythmia's & seizures.
How to prevent osteoporosis
What class is erythromycin?
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