Neuro Pharmacology- Exam 4

This agent chemically blocks nerve function via tissue destruction that lasts 2-36 months?

Chemical Neurolysis

What are the three benzodiazepines (one oral and two IV) used in the Tx of epileptics?

Clonazepam (Klonopin) oral, IV Lorazepam or Midazolam

A patient presents to your clinic with a PMH of MS. She reports drowsiness, fatigue, ataxia, and getting ill acutely when forgetting to take her medication (indicative of physical dependency). What anti-spasticity agent is your patient most likely taking?

Diazepam (Valium)

This drug's MOA includes binding and activating GABA receptors?

Diazepam (Valium)

This medication binds and activates GABA receptors and is indicated for spasticity associated with MS, SCI, SP and stroke.

Diazepam (Valium)

This benzodiazepine is a muscle relaxer, but is best for traumatic injury/acute musculoskeletal injury due to its sedative properties?

Diazepam (Valium) may "force" patient to rest.

True of False? Antiepileptic drugs only need to be used for a matter or weeks or months and can removed when symptoms resolve?

False. Therapy for epilepsy is lifelong and abrupt discontinuation can lead to seizures.

ADEs of this antiepileptic drug include: Diplopia, blurred vision, nystagmus, ataxia, dizziness, headache (Prevalence: 30-50%, May dissipate with chronic use), Minimal cognitive impairment, Nausea and vomiting, Agranulocytosis, HYPONATREMIA, RASH. Also used to treat bipolar disorder.

Carbamazepine (Tegretol)

This drug is classed under antidepressants for the Tx of insomnia, but is also an atypical antipsychotic. ADEs include hypertension, hyperlipidemia, hyperglycemia and weight gain?

Quetiapine (Seroquel)

This pharmacologic agent for insomnia is a melatonin receptor agonist that is taken 30 minutes before bed?

Ramelteon (Rozarem)

A patient is taking a SSRI and an ACE-inhibitor for hypertension, a statin for hyperlipidemia, and a proton Pump inhibitor for GERD. Which medication is most likely to cause insomnia?

SSRI

What are the main therapeutic concerns when in comes to antiepileptic medications?

Sedation (Balance of seizure control & adverse effects), Rash (Exacerbation by PT modalities & massage), Blood disorders (May lead to excessive bruising/bleeding), Bone health ((Long term use of AEDs (except Lamotrigine)—>Osteoporosis/osteomalacia))

A patient takes a selective serotonin reuptake inhibitor for depression, birth control pills, an ACE-inhibitor for hypertension and a statin for dyslipidemia. Which is most likely to contribute to her insomnia?

Selective serotonin reuptake inhibitor

This antiepileptic medication has ADEs that include: Dizziness & Depression, nervousness, and tremor that can be mild to moderate, transient and can result in CNS side effects that can be decreased by taking the medication with food?

Tiagabine (Gabitril)

ADEs associated with this anti-spastic agent include dizziness, dry mouth, HYPOTENSION and hallucinations?

Tizanidine (Zanaflex)

This anti-spasticity agent is a central alpha-2 agonist?

Tizanidine (Zanaflex)

ADEs of this antiepileptic drug include: Sedation, ataxia, confusion, dizziness, Paresthesias, Impaired concentration & memory, word finding difficulties. Also used for migraine prophylaxis.

Topiramate (Topamax)

Spasticity management medications are well-studied in multiple sclerosis (MS), spinal cord injury (SCI) and stroke, but what two pathologies have less data/research?

Traumatic brain injury (TBI) and cerebral palsy (CP)

Some adverse effects of this antidepressant agent used to insomnia include: serotonin syndrome, over-sedation, next-day sedation and ORTHOSTATIC HYPOTENSION?

Trazodone

This benzodiazepine indicated for Tx of insomnia has a quick onset and short half-life. This leads to a faster development of tolerance and more frequent rebound insomnia. Has less potential for daytime sedation?

Triazolam

This class of antidepressants for insomnia and two agents have ADEs including: next-day sedation, anticholinergic effect, CARDIAC conduction abnormalities and increased risk of falls in elderly patients?

Tricyclic antidepressants- Amitriptyline, Nortriptyline.

True or False? Lamotrigine (Lamictal) used to treat epilepsy is a sodium channel antagonist.

True

True or False? Ramelteon (Rozarem) for insomnia decreases sleep latency.

True

True or False? A patient with muscle spasm and low back pain would take cyclobenzaprine for treatment.

True. Cyclobenzaprine is a muscle relaxant.

A 36 year old male with a spinal cord injury is receiving PT to prevent muscle contracture. He has an intrathecal baclofen (Lioresal®) pump. Today he presents to PT and is agitated and seems to have more spasticity than usual. What is the PT concerned about?

Baclofen withdrawal

Your 62 year-old male patient who receives baclofen through an intrathecal pump presents with increased spasticity and signs of hyperthermia. He is agitated and is complaining of hallucinations. What do you suspect?

Baclofen withdrawal from pump complications or inadequate dosing.

This class of antiepileptic medications inhibit neurtransmission, thus lowering seizure threshold?

Barbiturates

True of False? A patient on herbal supplements should be cleared by a doctor before starting any antiepileptic drugs.

True. There are many drug-drug interactions associated with antiepileptic including herbal supplements.

This drug class and medication is indicated for skinny old people that can't sleep?

Antidepressants- Mirtazapine (Remeron). ADEs include: weight gain and next day sedation.

This is a good class of drugs to chose to treat insomnia in those who have a history of addiction and pain? Taken at bedtime (like all medications for insomnia) and causes next day sedation.

Antidepressants.

What drug class does diphenhydramine (Benadryl) belong to?

Antihistamine

What are two scales to measure spasticity?

Ashworth or Tardieu

What drug has the ADE of thrombocytopenia and what class of drugs does it come from to treat epilepsy?

Augment GABA: Valproic Acid (Depakote)

What is the risk of using insomnia medications like Advil PM and Tylenol PM during the day?

Both are combined with diphenhydramine (Benadryl) so can impair driving ability, cause sedation and increase the risk of falls in the elderly.

This anti-spasticity agent blocks acetylcholine release as a MOA?

Botulinum toxin (Botox)

This medication can last 3-6 months, but it's ADEs include new/worsening spasticity after the agent wears off and weakness of noninjected muscles?

Botulinum toxin (Botox)

This anti-spasticity medication takes about 4-7 days to see a response and is contraindicated in patients who require spasticity for balance, walking and posture.

Dantrolene (Dantrium)

This drug's MOA includes inhibiting calcium influx, thus interfering with excitation-contraction coupling process resulting in skeletal muscle relaxation?

Dantrolene (Dantrium)

This antiepileptic agent is a calcium channel blocker used only for absence seizures? ADEs are generally well-tolerated including: Fatigue, dizziness, GI upset, headache.

Ethosuximide

What is the goal of spasticity management?

Improve gait and ability to perform ADLs

Dantrolene may be combined with diazepam, but should be discontinued if what occur?

Increased spasticity

Usefulness is limited by ________ __________, so start with a low dose, slowly increase, and use lowest possible effective dose.

Adverse effects

Your 62 year-old male patient who receives baclofen through an intrathecal pump presents confused with decreased vital signs. He seems sedated and confused while complaining about not being able to urinate. What is your main concern with this patient?

Baclofen overdose due to a pump complication or overdosing.

What is the MOA of Dantrolene (Dantrium)?

Inhibits calcium influx

This anti-spasticity medication inhibits calcium influx causing interference with the excitation-contraction coupling process, thus resulting in skeletal muscle relaxation. It is useful in patients with stroke, CP, SCI and MS.

Dantrolene (Dantrium)

A patient is experiencing anticholinergic effects, daytime sedation, has impaired driving and has developed a tolerance. What drug for insomnia is your patient likely taking?

Diphenhydramine (Benadryl)

This is an over the counter medication that is relatively safe in the treatment of Insomnia? ADEs include anticholinergic effects, next-day sedation, impaired driving ability increased risk of falls in elderly patients.

Diphenhydramine (Benadryl)

Tylenol PM® contains diphenhydramine and acetaminophen. Which drug treats insomnia?

Diphenhydramine (Benadryl)

What is a main contraindication for Botulinum toxin and why?

Do not use modalities over the injections site for 10 days because you could spread the Botox to other locations.

What is the MOA for these drugs that treat epilepsy: Valproic Acid, Benzodiazepines, Barbiturates, Gababpentin, Pregabalin, Tiagabine?

Drugs that augment GABA

This eligibility test of dosing anti-spasticity medication is dependent on a repeated Ashworth screening where the patient is given an initial dose than subsequent doses every 2 hours for 8 hours. What is this test for and what would a positive outcome be?

Eligibility for intrathecal baclofen pump; a positive outcome would be a Ashworth score improved and maintained by 1 point or more plus lack of respiratory complications.

Some ADEs of this pharmacologic agent used to treat insomnia include: unpleasant taste, dizziness and hallucinations?

Eszopiclone (Lunesta)

This pharmacologic agent used to treat insomnia binds and activates GABA receptors. It decreases sleep latency & number of awakenings while increasing total sleep time and efficiency?

Eszopiclone (Lunesta)

What are some examples of SSRIs that can lead to drug induced insomnia?

Fluoxetine (Prozac®, Serafem®), Citalopram (Celexa®), Escitalopram (Lexapro®), Sertraline (Zoloft®), Paroxetine (Paxil, Paxil CR®), Vortioxetine (Brintellix)

What is the mechanism of action of zolpidem (Ambien)?

GABA receptor agonist

ADEs of this antiepileptic agent are Sedation, ataxia, dizziness, nystagmus, peripheral edema (Relatively minor). This medication is also used frequently for neuropathic pain?

Gabapentin (Neurontin)

Dantrolene (Dantrium) has minimal cognitive adverse effects, diarrhea, and the usually transient ADEs of drowsiness dizziness, weakness, malaise and fatigue. However, rarely what more serious ADEs are sometimes associated with this medication? Thus should be avoided in what patient population?

Hepatotoxiicty, cardiac or respiratory failure. Avoid in patients with severe underlying disease of liver, lungs or heart.

Complications of this method of anti-spasticity medication include infection, dislodgement, kinking or blocking of catheter, and pump failure?

Intrathecal baclofen pump

This method of dosing anti-spasticity medication is indicated for spinal cord spasticity patients who are unresponsive to or with intolerable adverse effects with oral treatment?

Intrathecal baclofen pump

ADEs of this antiepileptic drug include: Diplopia, ataxia, drowsiness, RASH, headache. Fewer drug interactions. Also, used to treat bipolar disorder and depression?

Lamotrigine (Lamictal)

This antiepileptic agent has an unknown mechanism of action and is generally well-tolerated?

Levetiracetam (Keppra)

You are treating a 75 year old patient for epilepsy. His PMH includes psychotic episodes. What drug would be the WORST chose to prescribe to this patient?

Levetiracetam (Keppra)- ADEs include hallucinations and psychosis in people with psychiatric disorders or the elderly.

ADEs of these two drugs that treat epilepsy are CNS depression (drowsiness, depression, confusion, mental slowing); RASH, blood disorders?

Phenobarbital & Primidone (metabolized to phenobarbital)

What the are two barbiturates used in the treatment of epilepsy?

Phenobarbital & Primidone (metabolized to phenobarbital)

ADEs of this antiepileptic drug include: Lethargy, fatigue, cognitive impairment, nystagmus, ataxia, anemia, Hirsutism, gingival hyperplasia, RASH, osteoporosis.

Phenytoin (Dilantin)

What drug class does Ramelteon (Rozarem) belong to?

Melatonin receptor agonist

What are some examples of stimulants that can lead to drug induced insomnia?

Methylphenidate (Ritalin), dexmethylphenidate, Dextroamphetamine, lisdexamfetamine, Amphetamine salts

In patients taking Sodium Channel Antagonists: Phenytoin (Dilantin), Carbamazepine (Tegretol), Lamotrigine (Lamictal); Barbiturates: Phenobarbital & Primidone a RASH can occur. As PTs we should be aware of exacerbations of these rashes and avoid ____________ & _____________ if a rash is present.

Modalities & massage

Your patient has suffered a recent MI after having a history of arrhythmias. Are skeletal muscle relaxants indicated to treat this patients lower back muscle spasms?

NO, contraindications include: recent MI, arrhythmias, heart block, CHF and hyperthyroidism.

Your patient has some residual hypertonicity in their L UE following a R MCA CVA 2 years ago. Could you prescribe Cyclobenzaprine (Flexeril) to treat this patient?

No, the skeletal muscle relaxants besides Diazepam (Valium) are ineffective for treating spasms/spasticity of CNS origin.

This drug's MOA binds toe GABA(b) receptors which is similar to another drug that treats spasticity?

Oral Baclofen (Lioresal)

Your 46 year-old patient just abruptly stopped taking this medication for spasticity and presents complaining of hallucinations, fever and just had a recent seizure. What medication was your patient taking?

Oral baclofen (Lioresal)

Long term use of antiepileptic drugs (except Lamotrigine) can lead to bone conditions such as?

Osteoporosis; Osteomalacia

ADEs of this antiepileptic drug are similar, but milder than carbamazepine including: Dizziness, sedation; HYPONATREMIA - Mild: subtle gait instability, nausea, malaise - Moderate: HA, lethargy, restlessness, disorientation - Severe: seizures, coma, respiratory arrest, death?

Oxcarbazepine (Trileptal)

What are the precautions that must be following after a Repeat Ashworth screening?

Patient must remain supine for two to three days to prevent headache and cerebrospinal fluid leaks.

What is a scale to measure spasms?

Penn scale

This Antiepiletic drug has similar ADEs to Gabapentin (Neurontin), but can also be used to treat fibromyalgia in addition to neuropathic pain?

Pregabalin (Lyrica)

What are the 2 drugs that have the ADE of hyponatremia and what class of drugs do they to treat epilepsy?

Sodium Channel Antagonists: Carbamazepine (Tegretol) & Oxcarbazepine (Trileptal)

What are the 5 drugs that have the ADE of rash and what two classes of drugs do they come from in the treatment of epilepsy?

Sodium Channel Antagonists: Phenytoin (Dilantin), Carbamazepine (Tegretol), Lamotrigine (Lamictal); Barbiturates: Phenobarbital & Primidone

Phenytoin, Carbamazepine, Oxcarbazepine, Lamotrigine and Topiratmate are all part of what drug class to Tx epilepsy?

Sodium channel antagonist

What is the mechanism of action of Phenytoin (Dilantin)?

Sodium channel antagonist- halt the formation of action potentials.

This benzodiazepine indicated for Tx of insomnia has an intermediate half-life?

Temazepam (Restoril)

What are the two benzodiazepines indicated in the Tx of insomnia?

Temazepam (Restoril) and Triazolam

ADEs of this antiepileptic agent include: Dizziness,Depression, nervousness, tremor - Mild to moderate - Transient - CNS side effects decreased by taking with food?

Tiagabine (Gabitril)

This herbal product for insomnia inhibits degradation of GABA?

Valerian

ADEs of this antiepileptic medication include: Minimal cognitive impairment. Most common: Nausea, vomiting, anorexia, weight gain. Thinning hair, hepatotoxicity, THROMBOCYTOPENIA. Causes birth defects?

Valproic Acid (Depakote)

This antiepileptic drug can cause minimal cognitive impairment, thrombocytopenia and causes birth defects?

Valproic Acid (Depakote)

Must be cautious when using medications to resolve excessive muscle tone because spasticity may mask underlying ___________ and spasticity may be required for the patient to remain __________.

Weakness; Upright

This pharmacologic drug to treat insomnia binds and activates GABA receptors and decreases time to sleep onset, does NOT increase sleep time or earl morning awakenings?

Zaleplon (Sonata)

This drug to treat insomnia can cause sleep walking, driving or eating and psychosis?

Zolpidem (Ambien)

This pharmacologic agent used to treat insomnia binds and activates GABA receptors?

Zolpidem (Ambien)

Your patient is an active alcoholic who has recently not been able to sleep. Besides getting her a Tx for her alcoholism you decide to prescribe her a pharmacological agent to treat her insomnia. Besides Benzpdiazepines, what other drug would you avoid with this patient?

Zolpidem (Ambien)- potential additive central nervous system effect with other CNS depressants (alcohol).