Neurology

Neurology

NAPLEX

PG 89

Drugs used for Convulsive Disorders

NAPLEX

PG 89

The medication lorazepam (Ativan) has which of the following pharmacological activities?

a. sedative/hypnotic b. anticonvulsant c. muscle relaxant d. anxiolytic e. all of the above

Major Types of Convulsive Disorders

• Partial – generally involves only one hemisphere of the brain (initially) and asymmetrical: Simple-no loss of consciousness Complex-loss of consciousness

Phenytoin, carbamazepine, barbiturates, valproate

• Generalized – generally involves both hemispheres of the brain; bilateral/symmetrical: absence, myoclonic, clonic, tonic, tonic-clonic,

Valproate, lamotrigine, carbamazepine, ethosuximide

• Status epilepticus—30 minutes of continuous seizures or five

minutes of convulsive seizures.

Lorazepam is drug of choice; midazolam or propofol

PG 89

Anticonvulsant Drugs AED monotherapy is preferred, but some patients do

require combination therapy. First-line AEDs for partial seizures include carbamazepine, phenytoin,

lamotrigine, valproic acid, and oxcarbazepine.

First-line AEDs for generalized absence seizures include valproic acid and ethosuximide.

First-line AEDs for tonic-clonic seizures include phenytoin, carbamazepine, and valproic acid.

Alternative AEDs include gabapentin, topiramate, levetiracetam, zonisamide, tiagabine, primidone, felbamate, lamotrigine, and phenobarbital.

PG 89-91

PG 89-91

Which of the following medications is NOT an inducer of the liver CYP450 system?

a. carbamazepineb. phenytoinc. valproate

d. olanzapinee. phenobarbital

Valproic acid is available in which of the following dosage forms?

I. CapsulesII. LiquidIII. Tablets

a. I onlyb. III onlyc. I and II onlyd. II and III onlye. I, II, and III

A drug specific for petit mal is:

a. clonazepamb. diazepamc. flurazepam

d. lorazepame. oxazepam

Drugs to Treat Parkinson’s Disease

NAPLEX

PG 92

PG 92

Drugs to Treat Parkinson Disease

Causes of Parkinson disease

Disruption of dopaminergic / cholinergic balance

Characteristics of patients (TRAP)

Slow onset; Tremor, Rigidity, Akinesia, Postural instability

Drug therapy

Goals – Mainly palliative; attempt to inhibit cholinergic and attenuate dopaminergic action

PG 92

Drugs to Treat Parkinson Disease (cont’d)

Anticholinergic Drugs. Watch for dry mouth, constipation, urinary retention, intraoccular pressure

• Trihexyphenidyl (Artane)

• Benztropine (Cogentin)

• Biperiden (Akineton)

• Diphenhydramine (Benadryl)

Bradykinesia is best defined as:

a. slow movementsb. rapid heart ratec. narrowing of the pupil

d. excessive sweatinge. loss of desire for pleasurable

activities

Bradykinesia is best defined as:

a. slow movementsb. rapid heart rate (tachycardia)

c. narrowing of the pupil (miosis)

d. excessive sweating (diaphoresis)

e. loss of desire for pleasurable activities (anhedonia)

PG 92-93

Drugs to Treat Parkinson Disease (cont’d)Dopaminergic Agents

• Levodopa (Larodopa, Dopar) - watch for on-off effect and vitamin B6 decreases efficacy, iron increases absorption, nausea

• Levodopa/carbidopa (Sinemet) - wait 8 hours if converting from

levodopa. Cut levodopa dose to 25% of original.

• Amantadine (Symmetrel) - increases release of dopamine stores (hypersensitivity); antiviral properties - antiviral for flu

• Ergot-derived dopamine receptor agonists - stimulate dopamine

receptors; (a) bromocriptine mesylate (Parlodel), and (b)

pergolide mesylate (Permax)—withdrawn from market

PG 93

Drugs to Treat Parkinson Disease (cont’d)• Nonergot dopamine receptor agonists - stimulate dopamine

receptors; (a) pramipexole (Mirapex), (b) ropinirole (Requip), and

(c) rotigotine (Neupro Transdermal)

--- ropinirole approved for Restless Leg Syndrome

• COMT inhibitors - adjunct that extends the action of

levodopa/carbidopa; (a) Tolcapone (Tasmar), monitor hepatic

function, and (b) entacapone (Comtan), combo with Sinemet (Stalevo)

---no monotherapy

• MAO-B inhibitor-adjunct that decreases breakdown of dopamine; (a) selegiline (Eldepryl, Emsam, Zelapar), (b) rasagiline (Azilect)

---watch for MAO-inhibitor drug interactions

•Dopamine agonist for rescue; apomorphine (Apokyn)

What information should the doctor know prior to initiating Mirapex in a patient with Parkinson’s Disease?

I. Decrease the levodopa dose by 20-30% when initiating MirapexII. Patient must wear patch for 24 hours for efficacyIII. Monitor for serious cardiac side effects

a. I onlyb. III onlyc. I and II onlyd. II and III onlye. I, II, III

Alzheimer's Drugs

NAPLEX

p. 121

Drugs for Alzheimer’s Disease

Cholinesterase inhibitors: all enhance cholinergic activity• Donepezil (Aricept)• Galantamine (Razadyne) (Reminyl – D/C))• Rivastigmine (Exelon)

Glutamate antagonists• Memantine (Namenda)

Miscellaneous agents• Vitamin E• Selegiline (Eldepryl)

p. 121

Cholinesterase Inhibitors Dosing

Drug Starting dose

Time before Increasing dose

Increase dose by

Max dose

Donepezil (Aricept)

5mg QHS 6 weeks 5mg QHS 10mg QHS

Rivastigmine (Exelon)

1.5mg BID 2 weeks 1.5mg BID

6mg BID

Galantamine (Razadyne)

4mg BID 4 weeks 4mg BID Recommen-ded range of 16-24 mg a day.

• Dose dependent side effects require titration• Start low and take steps to avoid side effects

p. 121

Drugs for Alzheimer’s Disease

Adverse Effects

Cholinesterase inhibitors:• Hepatotoxicity• Cholinergic effects (N/D, anorexia, salivation)• Bradycardia• Headache

Glutamate antagonists• Hypertension• Tachycardia• Insomnia

p. 121

Reference Sources for Pharmacists

NAPLEX

PG 413PG

Literature Review Primary literature Original journal articles

(research reports, case reports, editorials); serves as information for development of secondary and tertiary literature resources

Secondary literature Indexing and abstracting services (e.g. MEDLINE, IPA, EMBASE, Cochrane)

Tertiary literature Textbooks and review articles; summarize and interpret primary literature

PG 413

References

USP-NF Official monographs for drug structure, solubilities, assays

and therapeutic category Limited info on dosage, dosage forms

USP DI (Micromedex) Three volume set

• I---DI for healthcare professionals (“package insert”) 11,000 drug products

• II---Advice for patients – easy to understand• III---Approved Drug products, legal requirements, Orange book

FDA Orange Book (electronic - 2004) Bioequivalence information

PG 413

References

Remington’s “Pharmacy encyclopedia” – pharmacology, theoretical

science, sterilization, practical pharmacy practice Facts and Comparisons

Rx and OTC by therapeutic category – monthly updates AHFS

Good info on drug pharmacology – intended for institutional Blue Book / Red Book

Drugs / OTC / Cosmetics Prices, NDC numbers, manufacturer address

PG 414

References Physician’s Desk Reference (PDR)

White pages—manufacturer index of products Pink pages—product names by trade name Blue pages—products by therapeutic category Yellow pages—generic and trade names with colored product ID

Martindale’s Comprehensive drug lists (think foreign products)

Merck Manual Describes diseases by symptoms

Merck Index Listing of chemicals

Drugs in Pregnancy and Lactation (Briggs) Gold standard

PG 414

A comparison of the relative daily cost of six brands of HCTZ can most easily be obtained by using the:

a. Martindale’s Extra Pharmacopeia b. Facts and Comparisons

c. Red Book/Blue Book d. Merck Index

e. Remington’s

A comparison of the relative daily cost of six brands of HCTZ can most easily be obtained by using the:

a. Martindale’s Extra Pharmacopeia (drug lists foreign)

b. Facts and Comparisons (therapuetics)

c. Red Book/Blue Book (prices & NDCs)

d. Merck Index (list of chemicals)

e. Remington’s (pharmacology)

Which of the following items is NOT presented in USP DI Volume III:

a. Description of therapeutic uses for drugsb. List of orphan drugs c. Description of good pharmacy compounding practices

d. Definition of official storage conditionse. The Federal Controlled Substances Act

Which of the following items is NOT presented in USP DI Volume III:

a. Description of therapeutic uses for drugsb. List of orphan drugs (Martidale)c. Description of good pharmacy compounding practices (“a handbook on compounding”)

d. Definition of official storage conditions(Remington's or AHFS)e. The Federal Controlled Substances Act (Guide to Federal Pharmacy Law)

Compilation of information concerning parenteral drug solutions are found in:

a. Goodman and Gilmanb. Martindale’sc. Merck Indexd. Remington’s e. Trissel’s

Solubility data for potassium gluconate will be found in:

I. Merck IndexII. USP-NFIII. Remington’s


Contraindications for a commercial prescription drug may be located in:

I. PDRII. Merck ManualIII. USP-NF


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