NR 566 Final Study Guide

SUCCINIMIDES Examples: Ethosuzimide, Methsuximide 1. Therapeutic Use 2. MOA

1. Used for tx of absence seizures in children and adults. 2. suppress szs by delaying calcium influx into neurons

LAMOTRIGINE Example Lamotrigine (Lamictal) 1. Therapeutic Use 2. Patient education

1. Used in the adjunctive tx of primary generalized tonic-clonic seizures and partial seizures in adults and children >2 years. NOT for use with valproic acid 2. Adherence, avoid alcohol, caution driving, avoid OTC meds, adequate hydration, report any new drugs/ADRs

Levodopa 1. Therapeutic teaching 2. MOA

1. although the drug is highly effective, beneficial effects diminish over time; sx may be well controlled during the first 2 years of treatment, by the end of year 5, the ability to function may deteriorate to pretreatment levels-reflects disease progression and not the development of tolerance to levodopa. 2. Levodopa reduces symptoms by increasing dopamine synthesis in the striatum; As dopamine, levodopa helps restore a proper balance between dopamine and acetylcholine.

Therapeutic Uses for Testosterone include

Hypogonadism (Male) Replacement Therapy (Male) Delayed Puberty (Male) Therapy in Menopausal Women Catabolic States (cachexia) Anemias Drug Therapy for Transgender Men

Overview of drug therapy

amantadine is not 1st line agent

Relative Contraindications to the Use of Combination Oral Contraceptives

Hypertension Cardiac disease Diabetes History of cholestatic jaundice of pregnancy Gallbladder disease Uterine leiomyoma Epilepsy Migraine

SE of OCs-Hypertension 1/2. f hypertension develops and OCs are determined to be the cause, two options are open: SE of OCs-Abnormal uterine bleeding 3. Spotting and bleeding can also occur with monthly cycle OCs, most often during 4. If a woman misses her period while taking monthly cycle OCs, .

(1) discontinue the OC (2) continue the OC and manage the hypertension with drugs. 3. the first 3 months when low-estrogen OCs are used. 4. the possibility of pregnancy should be assessed

Summary of Key Prescribing Considerations-Drugs for Gabapentin 1. Baseline Data 2. Monitoring 3. Identifying High-Risk Patients

1. Renal function 2. Renal function 3. Caution and dosage adjustment is recommended for patients with renal impairment. The risk for psych & and physical dependence is increased in patients with a hx of drug abuse

Mechanism of Action of OC 1. Combination OCs reduce fertility primarily 2. The estrogen in combination OCs suppresses, 3. progestin in combination OCs acts in the

1. by inhibiting ovulation. 2. release of FSH from the pituitary (and thereby inhibits follicular maturation) 3. hypothalamus and pituitary to suppress the midcycle luteinizing hormone surge, which normally triggers ovulation

Medications used to treat "off" times including "wearing off" experiences assoc with Levodopa 1. Gradual loss—"wearing off"—develops near the end of the dosing interval and simply indicates that drug levels have declined to a subtherapeutic value. Wearing off can be minimized in three ways: 2. Abrupt loss of effect, often referred to as the "on-off" is a 3. Drugs that can help reduce off times are 4. Over the course of treatment, "off periods" are likely to

1. (1) shortening the dosing interval, (2) giving a drug that prolongs levodopa's plasma half-life-COMT-I ie: entacapone, and (3) giving a direct-acting dopamine agonist. 2. phenomenon, can occur at any time during the dosing interval—even while drug levels are high. 3. COMT inhibitor, MAO-B inhibitor & DA agonist 4. increase in both intensity and frequency

Treatment of STIs/STDs-Chlamydia 1. Adults and adolescents 2. Children 2a. <45 kg 2b. ≥45 kg but <8 year old 2c. ≥8 year old 3. Pregnant women 4. Newborns: ophthalmia or pneumonia

1. (Rx on exam) Azithromycin, 1 g PO once or Doxycycline PO × 7 days 2a. (Rx on exam) Erythromycin base/ethylsuccinate, 12.5 mg/kg PO 4 times/day × 14 days 2b. Azithromycin, 1 g PO once 2c. Azithromycin, 1 g PO once or Doxycycline PO × 7 days 3. Azithromycin, 1 g PO once 4. Erythromycin base/ethylsuccinate, 12.5 mg/kg PO 4 times/day × 14 days

Considerations for other Testosterone Routes 1. nasal gel (Natesto); patients with nasal disorders or abnormalities 2. There has not been adequate testing for interactions 3. pellets are implanted subdermally in the 4. buccal tablets (Striant), are approved for 5. buccal Tablets are applied to the 6. Intramuscular testosterone esters; Unfortunately these

1. (e.g., chronic sinusitis, a severely deviated nasal septum) should not take this drug. 2. with other nasally administered drugs 3. hip area or abdominal wall lateral to the umbilicus 4. male hypogonadism, 5. gum area just above the incisor tooth 6. preparations produce testosterone blood levels that vary widely; As a result, patients may experience significant variations in libido, energy, and mood

1. List the Adverse effects for PDE-5 inhibitors 2. What are the most COMMON adverse effects

1. - Hypotension-especially when combined with alpha blockers - Priapism: (painful erection lasting more than 6 hours) - Nonarteritic ischemic optic neuropathy: resulting in irreversible blurring or loss of vision. The cause is blockage of blood flow to the optic nerve - Sudden hearing loss. 2. headache, flushing, and dyspepsia, may also cause nasal congestion, diarrhea, rash, and dizziness. About 3% of patients experience mild transient visual disturbances (a blue tinge to vision, increased sensitivity to light, blurring)

1. BPH is a common condition that develops in more than 2. BPH is a nonmalignant prostate enlargement cells 3. Overgrowth of epithelial cells causes

1. 50% of men by age 60 years and 90% by age 85 years. 2. caused by excessive growth of epithelial (glandular) cells and smooth muscle 3. mechanical obstruction of the urethra, whereas overgrowth of smooth muscle causes dynamic obstruction of the urethra.

Treatment of STIs/STDs-Bacterial Vaginosis 1 of 3 options 1. Metronidazole 2. Metronidazole gel (0.75%) 3. Clindamycin cream (2%),

1. 500 mg PO 2 times/day × 7 days 2. 1 full applicator (5 g) intravaginally once/day × 5 days 3. full applicator (5 g) intravaginally at bedtime × 7 days

1. Alzheimer's Disease is a progressive neurodegenerative disease that accounts for 2. The major known risk factor for AD is advancing age. In 90% of 3. 10 early warning signs and symptoms which include:

1. 70% of dementia cases 2. patients, the age of onset is 65 years or older; though it can occur as early as 40 3. memory loss, challenges in planning or solving problems, trouble understanding visual and spatial relationships, difficulty completing familiar tasks, disorientation, problems with word finding, misplacing things, impaired judgment, social withdrawal, and changes in mood

Physiologic Alterations Accompanying Menopause 1. Vasomotor Symptoms; hot flashes and night sweats) develop in approximately 2. Genitourinary Syndrome of Menopause; the urethra and vagina have the highest 3. Mental Changes; Many women report 4. Bone Loss; In the absence of estrogen, bone resorption accelerates, leading 5. Altered Lipid Metabolism; studies have shown increases in 6. Female Sexual Interest-Arousal Disorder

1. 70% of postmenopausal women. Episodes are characterized by sudden skin flushing, sweating, and a sensation of uncomfortable warmth. These episodes can occur at night, resulting in drenching sweats 2. concentrations of ERs; when estrogen levels decline during menopause, these structures begin to atrophy resulting in urge incontinence and urinary frequency; Urethritis and UTIs can also occur 3. cognitive changes such as difficulty in problem solving and short-term memory loss. Others experience depression or an increase in anxiety 4. to a 12% loss of bone density leading to Osteoporosis which can cause compression fractures of the vertebrae causing a decrease in height and produce a hump. In osteoporotic women, fractures of the hip and wrist can result from minimal trauma 5. LDL cholesterol & decreases in HDL cholesterol. which play a role in the increase in CV disease after menopause. 6. more common during this stage of life

Extrapyramidal Side Effects of Antipsychotic Drugs Early Reactions 1. Acute dystonia: onset/definition 2. Parkinsonism: onset/definition 3. Akathisia: onset/definition 4. Management of these symptoms: 5. What is a Late Reaction: onset/definition 6. Tx of late reaction

1. A few hours to 5 days; Spasm of muscles of tongue, face, neck, and back; opisthotonus (arching of neck) 2. 5-30 days; Bradykinesia (slowed movement), mask-like facies, tremor, rigidity, shuffling gait, drooling, cogwheeling, stooped posture 3. 5-60 days; Compulsive, restless movement; symptoms of anxiety, agitation 4. Anticholinergic drugs (benztropine); Reduce dosage or switch to a low-potency antipsychotic or For severe symptoms switch to a SGA 5. Tardive dyskinesia; Months to years; Oral-facial dyskinesias, choreoathetoid movements (twisting, writhing, worm-like movements of the tongue and face) 6. Best approach is prevention; no reliable treatment. D/C all anticholinergic drugs. Give benzodiazepines. Reduce antipsychotic dosage. For severe TD, switch to a second-generation antipsychotic

Treatment of STIs/STDs-Herpes Simplex Virus 1. First episode, genital herpes (med on exam) 2. Severe infection 3. Recurrent episodes 4. Daily suppressive therapy 5. Neonatal herpes

1. Acyclovir, 400 mg PO 3 times/day × 7-10 days (or longer) or Acyclovir, 200 mg PO 5 times/day× 7-10 days 2. Acyclovir, 5-10 mg/kg IV every 8 h for 2-7 days then PO acyclovir to complete at least 10 days 3. Acyclovir, 800 mg PO 2 times/day × 5 days or Acyclovir, 400 mg PO 3 times/day × 5 days 4. Acyclovir, 400 mg PO 2 times/day 5. Acyclovir, 20 mg/kg IV every 8 h × 14 days (for skin or mucous membrane infection) or × 21 days (for CNS infection)

Know examples of drugs in each major drug class & Adverse effects 1. Nonselective α1 Blockers examples include 2. MOA of Nonselective α1 Blockers 3. Adverse effects of Nonselective α1 Blockers include 4. Phosphodiesterase-5 Inhibitor examples include 5. MOA of Phosphodiesterase-5 Inhibitors 6. Adverse effects of Phosphodiesterase-5 Inhibitors 7. α1-a Blocker/5-α-Reductase Inhibitor examples include 8. MOA of α1-a Blocker/5-α-Reductase Inhibitor 9. Adverse effects of α1-a Blocker/5-α-Reductase Inhibitor include

1. Alfuzosin & Doxazosin & Terazosin 2. same as α1-a Blockers Benefits develop rapidly 3. Hypotension, fainting, dizziness, somnolence, and nasal congestion (from blocking α1 receptors on blood vessels) 4. Tadalafil (Cialis) 5. Smooth muscle relaxation in the bladder, prostate, and urethra Initial improvement is seen in 2 weeks 6. Hypotension, priapism 7. Tamsulosin/dutasteride 8. Same as 5-α-reductase inhibitors and selective α1-a blockers the α blocker can provide rapid symptomatic relief (by relaxing prostate-related smooth muscle) while, over time, the 5-α-reductase inhibitor can provide additional symptomatic relief (by shrinking the prostate) and may also delay disease progression. 9. Decreased libido and abnormal ejaculation (ejaculation failure, reduced ejaculate volume, retrograde ejaculation)

Cholinesterase Inhibitors ie: donepezil, galantamine, and rivastigmine 1. Therapeutic Use 2. Mechanism of action 3. Adverse effects

1. All ChE inhibitors are approved for mild to moderate sx, and one agent—donepezil—is also approved for severe sx; improvements are seen in QOL and cognitive functions (memory, thought, reasoning) 2. ChE inhibitors prevent the breakdown of ACh by ACh-esterase and thereby increase the availability of ACh at cholinergic synapses (they don't stop disease progression but they may slow it by several months) 3. all ChE inhibitors can cause typical cholinergic SE. GI—N/V, dyspepsia, diarrhea—occur often. Dizziness and HA are also common. The elevation of ACh at synapses in the lungs can cause bronchoconstriction. Accordingly, use with caution in pts with asthma or COPD. CV effects, although uncommon, are a serious concern. Increased activation of cholinergic receptors in the heart can cause symptomatic bradycardia, leading to fainting, falls, fall-related fractures, and pacemaker placement

Summary Of Key Prescribing Considerations TCAs 1. Therapeutic Goal: 2. Baseline Data: 3. Monitoring: 4. Identifying High-Risk Patients: TCAs are generally contraindicated in 4. Evaluating Therapeutic Effects: Assess patients for improvement in 5. Minimizing Adverse Effects: Educate patients regarding

1. Alleviation of symptoms of major depression. 2. ECG should be checked, espec in pts with known dysrhythmias or >40 years of age. 3. Periodic ECG should be completed. 4. pts taking MAOIs. Also use with caution in patients with urinary retention, cardiac disorders, and liver or kidney dysfunction. 5. symptoms, especially depressed mood and loss of interest or pleasure in usual activities. 6. orthostatic hypotension and anticholinergic effects, including dry mouth, blurred vision, constipation, and urinary hesitancy.

1. Preferred administration route of alprostadil and why Because of the inconvenient method of dosing, these drugs are second-line agents for ED.

1. Alprostadil has the same chemical structure as prostaglandin E1, which causes vasodilation When injected into the Intracavernous penile tissue it causes relaxation of smooth muscle (arterial, venous, and trabecular), causing a rapid inflow of arterial blood. The blood fills the vascular sinusoidal spaces of the corpus cavernosum, resulting in an erection

Foods high in tyramine 1. Vegetables: 2. Fruits: 3. Meats: 4. Sausages: 5. Fish: 6. Milk/Milk Products: 7. Foods with Yeast: 8. Beer/Wine: 9. Other Foods:

1. Avocados; fermented bean curd; fermented soybean; soybean paste 2. Figs; bananas (in large amounts) 3. Meats that are fermented, smoked, or otherwise aged; spoiled meats; liver (unless very fresh) 4. Fermented varieties: bologna, pepperoni, salami 5. Dried or cured fish; fish that is fermented, smoked, or otherwise aged; spoiled fish 6. Practically all cheeses 7. Yeast extract 8. Some imported beers, Chianti wine 9. Protein dietary supplements; soups (may contain protein extract); shrimp paste; soy sauce

Administration methods for transdermal preparations 1. The principal difference for Topical Solution is the application site: 2. Axiron is supplied as an alcohol-based solution 3. Axiron is applied to each axilla at the same time every morning. After

1. Axiron liquid is formulated specifically for application to the axilla 2. in a metered-dose pump; Rx doses are per actuation 3. 14 days or longer, blood levels of testosterone are measured and dosage is adjusted up/down as needed

How does this impact prescribing of OCs? Drugs whose effects are reduced by oral contraceptives 1. OCs can decrease the benefits of warfarin 2. By increasing levels of glucose, OCs can counteract the benefits of 3. Accordingly, when combined with OCs, warfarin and hypoglycemic agents may require

1. By increasing levels of clotting factors, OCs can decrease the effectiveness of warfarin 2. insulin and other hypoglycemic agents used in diabetes 3. increased dosage.

Drug selection 1. For a patient with fatigue, choose a drug that causes 2. For a patient with insomnia, 3. For a patient with sexual dysfunction, 4. For a patient with chronic pain, choose

1. CNS stimulation (e.g., fluoxetine, bupropion) 2. choose a drug that causes substantial sedation (mirtazapine). 3. choose bupropion, a drug that enhances libido. 4. duloxetine or a TCA, drugs that can relieve chronic pain.

Summary of Key Prescribing Considerations Dopamine Agonists 1. Baseline Data: Heart rate and blood pressure and general 2. Monitoring: Assess 3. Identifying High-Risk Patients: Use all DA agonists with caution in 4. Evaluating Therapeutic Effects: Evaluate for improvements in

1. CV assessment (especially if apomorphine or cabergoline are being considered) and neuro/motor—bradykinesia, akinesia, postural instability, tremor, rigidity—and the extent they interfere with ADLs (e.g., ability to work, dress, bathe, walk). 2. orthostatic V/S at each visit. Evaluate motor function and compare to baseline. 3. older-adult patients and in those with psychiatric disorders. Use pramipexole with caution in patients with kidney dysfunction. Avoid ropinirole during pregnancy. Use pramipexole and ropinirole with caution in patients prone to compulsive behavior. 4. ADLs and for reductions in bradykinesia, postural instability, tremor, and rigidity.

Estrogen-Interactions 1. Estrogens are major substrates of 2. In addition, they may decrease the effectiveness of some 3. Estrogens can also interact with

1. CYP1A2 and CYP3A4; inducers/inhibitors of these isoenzymes may raise/lower estrogen levels 2. antidiabetic drugs and thyroid preparations. 3. anticoagulants and other drugs that affect clotting.

Treatment of STIs/STDs-Uncomplicated gonococcal urethritis 1. Urethritis, cervicitis, proctitis 2. If a patient is allergic to azithromycin

1. Ceftriaxone, 250 mg IM once, plus azithromycin, 1 g PO once 2. a 7-day course of doxycycline may be substituted.

Know example SSRIs 1. Examples include 2. therapeutic use; SSRIs are the most 3. MOI

1. Citalopram (Celexa), Escitalopram (Lexapro) Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft) & Vortioxetine (Trintellix) 2. commonly prescribed antidepressants, they are indicated for major depression & other psychological disorders; Compared with the TCAs & MAOIs, they are equally effective, better tolerated, & much safer 3. They work by blocking neuronal reuptake of serotonin (5-HT )&thereby increase 5-HT in the synapse.

Contraindications of Estrogen 1. Estrogens should not be taken by patients with a history of 2. They should not be prescribed to women who 3. Patients with a hx of

1. DVT, pulmonary embolus, or conditions such as stroke or MI that occurred secondary to a thromboembolic event. 2. are pregnant or who have vaginal bleeding without a known cause. 3. liver disease, estrogen-dependent tumors, or breast cancer (except when indicated for management) also should not take estrogens.

Know examples of drugs in each major drug class & Adverse effects 1. 5-α-Reductase Inhibitors examples include 2. MOA of 5-α-Reductase Inhibitors 3. Adverse effects of 5-α-Reductase Inhibitors include 4. Selective α1-a Blockers examples include 5. MOA α1-a Blockers 6. Adverse effects of α1-a Blockers include

1. Dutasteride & Finasteride (Proscar) 2. Reduce dihydrotestosterone (DHT) production, which causes the prostate to shrink, reducing mechanical obstruction of the urethra. May also delay BPH progression. Benefits take months to develop. 3. Decreased ejaculate volume and libido. Teratogenic to the male fetus. 4. Silodosin & Tamsulosin (Flomax) 5. relaxes smooth muscle in the bladder neck, prostate capsule/urethra, thereby decreases dynamic obstruction of the urethra. Benefits develop rapidly. 6. Abnormal ejaculation (ejaculation failure, reduced ejaculate volume, retrograde ejaculation). Risk of floppy-iris syndrome during cataract surgery.

Ergot Alkaloids Examples: Ergotamine, Dihydroergotamine 1. Therapeutic uses 2. MOA: ergotamine acts directly to promote 3. Dosing considerations 4. Black Box Warning (drug interactions) 5. Physical dependence-Regular daily use of ergotamine, even in moderate doses, can cause

1. Ergotamine is used as a 2nd-line drug for stopping an ongoing migraine attack OR cluster HA in pts who have not responded to a triptan; 24-hour recurrence rate with dihydroergotamine is only 14% 2. constriction by agonist activity at subtypes of serotonin receptors 3. Ergotamine can be taken oral, sublingual, or rectal; dihydroergotamine is taken parenterally or nasal spray 4. Potent inhibitors of CYP3A4 are contraindicated & can raise ergotamine to dangerous levels, posing a risk for intense vasospasm. Cerebral and/or peripheral ischemia can result 5. dependence; precipitating withdrawal causing headache, N/V, and restlessness which may req hospitalization. Limit the use, If possible to no more than 2 or 3 times a week

Patient-Centered Care Across The Life Span Estrogens 1. Children 2. Pregnant women 3. Breastfeeding women 4. Older adults-Beers Criteria include estrogens among

1. Estrogens are not indicated for prepubertal children. 2. Estrogens are contraindicated during pregnancy. 3. Estrogens may affect infant development and may decrease both the quantity and quality of milk produced. 4. those identified as potentially inappropriate for use in geriatric patients. >65 (may increase dementia risk)

Prototype Drugs Drugs for Birth Control 1. Combination Oral Contraceptive 2. Progestin-Only Oral Contraceptive 3. Long-Acting Contraceptives

1. Ethinyl estradiol/norethindrone 2. Norethindrone-aka "minipills" 3. Subdermal etonogestrel implant (Nexplanon), Depot medroxyprogesterone acetate (Depo-Provera)

Monoamine Oxidase Inhibitors examples: Phenelzine & Isocarboxazid 1. MOA 2. Therapeutic Use-What type of pt is good for MAOIs

1. In the brain, MAO-A inactivates NE and 5-HT, whereas MAO-B inactivates dopamine. By inhibiting MAO-A/B, MOAIs increase the amount of NE and 5-HT available for release, and thereby intensify transmission at noradrenergic and serotonergic junctions 2. b/c MAOIs can be hazardous, they are generally reserved for patients who have not responded to SSRIs, TCAs; they are DOC for those with atypical depression

Major Drug Interactions of Levodopa Drugs that increase beneficial effects of levodopa 1. Carbidopa 2. Entacapone, tolcapone 3. Amantadine 4. Anticholinergic drugs Drugs that decrease beneficial effects of levodopa 5. First-generation Antipsychotic drugs Drugs that increase levodopa toxicity 6. MAO inhibitors (especially nonselective MAO inhibitors)

1. Inhibits peripheral decarboxylation of levodopa 2. Inhibit destruction of levodopa by COMT in the intestine and peripheral tissues 3. Promotes release of dopamine 4. Block cholinergic receptors in the CNS; help restore balance between dopamine and ACh 5. Block dopamine receptors in the striatum 6. Inhibit MAO; increase risk for severe levodopa-induced HTN

Combination therapy of PD 1. Combining _______ medications with levodopa in early treatment may delay motor complications. 2. Levodopa/carbidopa/entacapone is a triple combo drug with

1. MAO-B Inhibitors 2. entacapone as a COMT inhibitor

Management of PD Early stages 1. For patients with mild symptoms, treatment can begin with an 2. For patients with mild or moderate symptoms, Management of PD in moderate-late stages 3. For patients with more severe symptoms, treatment should begin with either 4. levodopa is the most effective agent BUT 5. Hence the choice must be tailored to the patient: if improving motor function is the primary objective, then 6. However, if drug-induced dyskinesias are a primary concern, then

1. MAO-B inhibitor. MAO-B inhibitors confer mild symptomatic benefit. 2. DA agonists are the drugs of first choice; Pramipexole may be used alone or in combo with levodopa in early stages of PD 3. levodopa (combined with carbidopa) or a dopamine agonist. 4. long-term use carries a higher risk for disabling dyskinesias. 5. levodopa is preferred. 6. a dopamine agonist would be preferred.

Adverse Effects of MAOIs 1. Central nervous system stimulation 2. Orthostatic hypotension 3. Hypertensive crisis from dietary tyramine

1. MAOIs cause direct CNS stimulation; Excessive stimulation can produce anxiety, insomnia, agitation, hypomania, and even mania 2. MAOIs reduce BP when admin in usual therapeutic doses. Pts should be informed about signs of hypotension (dizziness, lightheadedness) and advised to sit or lie down if these occur. 3. they can be the cause of severe HTN if the pt eats food that is rich in tyramine, which promotes the release of NE from sympathetic neurons. HTN crisis is characterized by severe HA, tachycardia, hypertension, nausea, vomiting, confusion, & profuse sweating--possibly leading to stroke & death

Selecting the Right Birth Control method 1. Effectiveness 2. Safety 3. Personal Preferences 4. Other Factors

1. Most Effective are subdermal implants, Intramuscular medroxyprogesterone acetate (Depo-Provera), Sterilization & Intrauterine device (IUD) - Reasonably effective are: Oral contraceptives (OC), Contraceptive ring, & Contraceptive Patch 2. OC contraindications: thrombus concerns, >35 years who smokers, & those with hx of breast carcinoma - OCs can cause significant side effects & Benefit/Risk analysis required 3. Improves consistent and correct use, Education increases consistent and correct use 4. Family planning goals, Age, Frequency of sexual activity Capacity for adherence - cost -access - developmental

Signs of Lithium Toxicity 1. Less than 1.5 2. Btw 1.5-2 3. Btw 2-2.5 4. More than 2.5

1. N/V, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, fine hand tremors 2. Persistent GI upset, coarse hand tremor, confusion, hyperirritability of muscles, ECG changes, sedation, incoordination 3. Ataxia, giddiness, excess dilute urine, serious ECG changes, fasciculations, tinnitus, blurred vision, clonic movements, seizures, stupor, severe hypotension, coma, death (usually secondary to pulmonary complications) 4. Symptoms may progress rapidly to generalized convulsions, oliguria, and death

Administration Considerations-Memantine (Namenda)​ 1. Memantine is the only 2. Mechanism of action 3. Drug interactions 4. Dosing considerations

1. NMDA-Antagonist approved to manage moderate to severe AD; it is NOT for mild AD 2. Prevents glutamate, an excitatory neurotransmitter, from binding at NMDA receptors. These receptors control activity throughout the brain by regulating how much calcium enters the nerve cell. An overproduction of NMDA receptors/excess glutamate can lead to excessive calcium entering the cell and disrupting information processing 3. should NOT be combined with another NMDA antagonist, such as amantadine-for PD or ketamine; Sodium bicarbonate and other drugs that alkalinize the urine can greatly decrease the renal excretion-toxicity 4. Start: 5 mg PO qd, incr by 5 mg/day no more frequently than q wk; Max: 20 mg/day

1. List other rare but serious SE of Conventional antipsychotics 2. Black Box Warning-Antipsychotic Drugs

1. Neuroleptic malignant syndrome (lead pipe" rigidity, sudden high fever >41°C), Orthostatic hypotension-not rare, Seizures, Agranulocytosis 2. When used to tx dementia-related psychosis in elderly pts, all FGAs & SGAs approx double the rate of mortality. Most deaths result from heart-related events (e.g., heart failure, sudden death) or pneumonia

Baseline assessment Considerations for OCs 1. If the history reveals an absolute contraindication to OC use 2. In women with relative contraindications 3. A full examination with pelvic exam is Some states in the United 4. States are allowing pharmacists to

1. OCs should not be prescribed. 2. OCs should be used with caution. 3. not needed to prescribe OCs. 4. prescribe OCs, thus eliminating the need for a healthcare visit.

1. Drugs for ED fall into two major groups: oral and nonoral. The oral agents include 2. The nonoral agents include 3. Four PDE-5 inhibitors are available: 4. MOA of PDE-5 inhibitors causes selective inhibition of PDE-5. By doing so, 5. Benefits of PDE-5 inhibitors can

1. PDE-5 inhibitors—are by far the most common treatments for ED. 2. include papaverine plus phentolamine & alprostadil 3. sildenafil, tadalafil, vardenafil, and avanafil. All are considered first-line therapy for ED. 4. it increases and preserves cGMP levels in the penis, thereby making the erection harder and longer lasting. 5. help a wide range of patients, including those with diabetes, spinal cord injury, and transurethral prostate resection as well as ED of no known physical cause

Treatment of STIs/STDs-Trichomoniasis 1. Metronidazole, 2 g 2. Tinidazole (Rx on exam)

1. PO once 2. 2 g PO once

Migraine Overview 1. Sinus 2. Cluster 3. Neck 4. Tension 5. Migraine 6. TMJ

1. Pain concentrated in the upper/lower nasal sinuses on the forehead and cheeks 2. occur in a series or "cluster" of attacks. Each attack lasts 15 minutes to 2 hours and is characterized by severe, throbbing, unilateral pain in the orbital-temporal area (i.e., near the eye) 3. Pain concentrated on the top/back of the head 4. usually a mild to moderate bilateral HA with a sensation of a tight band or pressure around the head. 5. throbbing head pain of moderate-severe intensity that may be unilateral (60%) or bilateral (40%); 4 to 72 hours (median duration, 24 hours; with or w/o an aura 6. Pain that is concentrated at the temples

Summary of Key Prescribing Considerations Phenytoin 1. Baseline Data: For all antiseizure drugs, obtain a 2. Monitoring: For all antiseizure drugs, ongoing monitoring includes 3. Identifying High-Risk Patients: (blank) is a concern for all antiseizure drugs. 4. Evaluating Therapeutic Effects: Teach the patient (or a family member) to maintain

1. Pregnancy test., assess seizure frequency and type and conduct a depression screening. For Phenytoin Screen for HLA-B*1502 allele variant for pts of Asian ancestry (increased risk for SJS/TEN) 2. evaluating frequency and type of seizures, degree of CNS change, and depression, suicidality, or behavior change. For Phenytoin: Obtain serum drug level and trough concentrations for dosage considerations. Assess for rash because this may progress to SJS or TEN. Assess for gingival hyperplasia 3. Depression; Pregnancy is a concern; however, benefits will outweigh risks. For Phenytoin: IV is contraindicated for pts with bradycardia or AV block. Oral may potentially worsen these conditions 4. a sz freq chart, indicating the date, time, and nature of all sz events. This record can be used to evaluate treatment, make dosage adjustments, and alter drug selections.

Summary of Key Prescribing Considerations Combination Oral Contraceptives 1. Therapeutic Goal: 2. Baseline Data: Assess for 3. Monitoring: 4. Identifying High-Risk Patients: Contraindications to use include 5. Evaluating Therapeutic Effects: If combination oral contraceptives are being used for menstrual symptoms, 6a. Minimizing Adverse Effects: Educate patients on proper protocol for missed doses 6b. Effectiveness of oral contraceptives can be reduced with

1. Prevention of unwanted pregnancy. 2. hx of HTN, DM, thromboembolism, cerebrovascular or cardiovascular disease, breast CA. UA pregnancy test 3. No routine monitoring required. 4. current pregnancy, hx of thromboembolus, breast CA, and women over 35 years of age who continue to smoke tobacco. Use with caution in women with diabetes, hypertension, and cardiac disease. 5. it is important to evaluate for decrease in cramping, menstrual flow, or duration of menses. 6a. (depending on medication type and cycle). 6b. some medications, including certain common antibiotics.

Patient-Centered Care Across The Life Span Progestins 1. Children 2. Pregnant women-High-dose therapy during the first 4 months of pregnancy has been associated 3. Breastfeeding women 4. Older adults-Progestins are only indicated if the patient is taking

1. Progestins are not indicated for prepubertal children. 2. with an increased incidence of birth defects (limb reductions, heart defects, masculinization of the female fetus). 3. Progestins may contribute to neonatal jaundice. 4. estrogen and has a uterus.

Summary of Key Prescribing Considerations (Atypical) SGA 1. Baseline Data: 2. Monitoring: 3. Identifying High-Risk Patients: Use with caution in patients with

1. Pt weight, baseline glucose levels, fasting lipid levels, CBC, electrolytes, hepatic function, cardiac function. 2. Regular CBC w/ clozapine for agranulocytosis. Pts with a hx of dysrhythmias: monitor for palpitations, QT prolongation, or electrolyte imbalances. 3. diabetes & in txing dementia-related psychosis in older adult patients.

1. Black Box Warning for Divalproex Sodium (Valproate) 2. Black Box Warning Carbamazepine/Lamotrigine 3. Black Box Warning antipsychotic drugs have an increased mortality in

1. Serious or fatal hepatic failure has occurred with use of Depakote ER. In addition, life-threatening pancreatitis has been reported. Depakote is also linked to increased fetal risk (neural tube defects, major malformations, IQ) 2. fatal dermatologic reactions—toxic epidermal necrolysis & SJS—have been reported. Also w/ carbamazepine aplastic anemia and agranulocytosis have occurred 3. Elderly patients with dementia-related psychosis

Drug Interactions of PDE-5 inhibitors 1. Nitrates are contraindicated for within 24 hrs of 2. α blockers are contraindicated for 3. CYP3A4 ie: ketoconazole, itraconazole, erythromycin, cimetidine, saquinavir, ritonavir, grapefruit juice; can suppress the metabolism of all 4 thereby 4. Class I and III antidysrhythmic drugs should NOT be used

1. Sildenafil & Vardenafil, 48 hrs within Tadalafil (Cialis), & 12 hrs of Avanafil, 2. Tadalafil (Cialis) & Vardenafil, use with caution in Sildenafil & Avanafil as they can result in symptomatic postural hypotension 4. increasing there levels, all req dosage reductions 5. with Vardenafil as it prolongs the QT interval

Transgender Woman (male phenotype) HT 1. Goals​ 2. Treatment ​ 3. Monitoring needs​ 4. Risks​

1. Stimulate dev of female secondary sex characteristics​; requires medication to decrease testosterone levels 2. estrogen, antiandrogens, gonadotropin-releasing hormone (GnRH) agonists, or others 3. Estradiol​, Testosterone​, Prolactin​, Triglycerides​ & Potassium ​if spironolactone used as antiandrogen​ 4. HT risks are the same as for HR pts. For estrogen, thromboembolic events remain the greatest risk factor

Transgender Man (female phenotype) HT 1. Goals​ 2. Treatment 3. Monitoring needs 4. Risks​

1. Stop menstruation​, Stimulate development of male secondary sex characteristics​ 2. testosterone as would be done in hypogonadism​ 3. Serum testosterone levels every 3 months until optimal, then 1-2 times a year​, Hb/Hct, cholesterol​ 4. Acne​, possible male-pattern hair loss​, Polycythemia​ Hypercholesterolemia​, Liver impairment​Thromboembolic disorders with increased risk of MI and stroke​

Major drug classes for Insomnia Suvorexant: Orexin Antagonist 1. examples 2. MOA 3. Therapeutic Use 4. Adverse Effects/Drug interactions

1. Suvorexant (Belsomra) 2. selectively blocks receptors for orexin, a neurotransmitter in the brain that promotes wakefulness 3. difficulty with sleep onset and/or sleep maintenance 4. common: somnolence, headache, dizziness, diarrhea, dry mouth; similar abuse potential of zolpidem; sched IV; ketoconazole, clarithromycin can increase the effect

Patient Education with progestin-only contraception 1. taking the pill at the same time every day is important to their effectiveness for instance, 2. progestin-only OCs are taken continuously. Use is initiated on If one or more doses is missed or taken greater than 3 hours after the scheduled dose, the following guidelines apply: 3. If one pill is missed, it should be taken as soon as remembered and 4. If two pills are missed, the regimen should be restarted and backup contraception should be used

1. Taking a pill even 3 hours late can reduce their efficacy and use of back up protection or emergency contraception is recommended if unprotected sexual intercourse occurred 2. day 1 of the menstrual cycle, and one pill is taken daily thereafter 3. backup contraception should be used for at least 2 days. The pills should be resumed as scheduled on the next day. 4. for at least 2 days. In addition, if two or more pills are missed and no menstrual bleeding occurs, a pregnancy test should be done.

Generalized Seizures 1. Tonic-Clonic Seizures (formerly grand mal seizures) 2. Absence Seizures (Petit Mal) are usually seen in 3. Atonic Seizures are characterized by sudden loss of muscle tone. If 4. Myoclonic Seizures consist of sudden muscle contraction that lasts 5. Status Epilepticus is defined as a sz that persists for 6. Febrile Seizures are common among children aged 6 months to

1. These szs manifest as major convulsions, characterized by a period of muscle rigidity (tonic phase) followed by synchronous muscle jerks (clonic phase); often preceded by loud cry; & are followed by a postictal state 2. young children & cease during the early teen year; characterized by LOC for a brief time (10-30 sec). Szs usually involve mild, symmetrical motor activity- eye blinking or NO motor activity at all 3. sz activity is limited to the muscles of the neck, "head drop" occurs. If the muscles of the limbs and trunk are involved, a "drop attack" can occur resulting in collapse 4. for just 1 sec. Sz activity may be limited to one limb (focal myoclonus), or it may involve the entire body (massive myoclonus) 5. 15 to 30 minutes or longer or a series of recurrent szs during which the pat does not regain consciousness 6. Five yrs. Febrile seizures typically manifest as generalized tonic-clonic convulsions; pts are NOT at high risk for developing epilepsy later in life

Absolute Contraindications to the Use of Combination Oral Contraceptives

1. Thrombophlebitis, thromboembolic disorders, cerebral vascular disease, coronary occlusion, or a past history of these conditions, or a predisposition 2. Abnormal liver function 3. Known or suspected breast cancer 4. Undiagnosed abnormal vaginal bleeding 5. Known or suspected pregnancy 6. Smokers older than 35 years

The Pathophysiology Underlying Motor Symptoms in PD 1. Motor symptoms result from damage to the extrapyramidal system, 2. When extrapyramidal function is disrupted, dyskinesias 3. dyskinesias that characterize PD are 4. In severe PD, bradykinesia may progress to 5. In PD, there is an imbalance between 6. imbalance results from degeneration of the neurons in the substantia nigra that supply 7. In the absence of dopamine, the excitatory influence of acetylcholine goes unopposed, causing excessive

1. a complex neuronal network that helps regulate movement 2. (disorders of movement) result 3. tremor at rest, rigidity, postural instability, and bradykinesia (slowed movement). 4. akinesia, the complete absence of movement 5. dopamine and acetylcholine 6. dopamine to the striatum. 7. stimulation of GABAergic neurons which contributes to the motor symptoms that characterize PD.

Treatment of delayed puberty 1. If puberty fails to occur at the usual age (15 years). 2. The DOC for short course therapy are 3. When is it appropriate to initiate androgen therapy (short course vs long-term

1. a familial pattern of delayed puberty; thus tx is NOT req but some providers will prescribe a short-term course of androgen therapy off label 2. Oral tabs: fluoxymesterone (Androxy, Halotestin) and methyltestosterone (Methitest) 3. If delayed puberty is caused by hypogonadism (pituitary, hypothalamic, or testicular failure) then lifelong tx will ensue

Adverse Effects (SNRI) Venlafaxine 1. use of venlafaxine late in pregnancy can result in 2. Abrupt discontinuation can cause an intense 3. Withdrawal symptoms can be minimized by

1. a neonatal withdrawal syndrome, characterized by irritability, abnormal crying, tremor, respiratory distress, & possibly seizures. Sx can be managed with supportive care & generally abate within a few days. 2. withdrawal syndrome. Symptoms include anxiety, agitation, tremors, headache, vertigo, nausea, tachycardia, & tinnitus; Worsening of pretreatment symptoms may also occur. 3. tapering the dosage over 2 to 4 weeks. Warn patients not to stop venlafaxine abruptly.

Patient Education Withdrawal Syndrome of SSRIs 1. Abrupt discontinuation of SSRIs can cause 2. The withdrawal syndrome can be minimized by

1. a withdrawal syndrome. Sx includes dizziness, HA, nausea, sensory disturbances, tremor, anxiety, and dysphoria. These begin within days to weeks of the last dose and then persist for 1 to 3 weeks. 2. tapering the dosage slowly (over several weeks); Resumption of drug use will make symptoms subside

Medication Overuse Headache 1. This is an issue with almost all 2. The treatment for MOH is to 3. With triptans, withdrawal headaches are 4. In contrast, with analgesics or ergots, withdrawal headaches are

1. abortive headache therapy; including analgesics (aspirin-like drugs, opioids), triptans, caffeine & ergotamine (but not dihydroergotamine), 2. stop taking all headache medicines 3. relatively mild and often resolve in a few days. 4. more intense and may persist for 2 weeks or more.

Promoting Patient Adherence 1. Educating patients and families 2. Monitoring: If the drug requires periodic measurement 3. Inform pts that, after a safe and effective dosage has been established 4. Deepening patient and family involvement by

1. about the chronic nature of epilepsy and the importance of adhering to the prescribed regimen 2. of drug levels or other lab studies, explain the purpose and the importance of keeping those appts 3. small deviations in dosage can lead to toxicity or to loss of seizure control. 4. having them maintain a seizure frequency chart

Adverse Effects of Testosterone 1. Virilization in Women, Girls, and Boys in characterized by 2. In young boys Virilization can cause 3. Other adverse effects include

1. acne, deepening of the voice, proliferation of facial and body hair, male-pattern baldness, increased libido, clitoral enlargement, and menstrual irregularities. Clitoral growth, hair loss, and lowering of the voice may be irreversible 2. growth of pubic hair, penile enlargement, increased 3. Premature Epiphyseal Closure, Hepatotoxicity, elevated Cholesterol Levels, Prostate Cancer, Abuse Potential (all androgens are sched 3), Risk for Thromboembolic Events including stroke, MI, DVT, and pulmonary embolism

Summary of Key Prescribing Considerations Lithium 1. Therapeutic Goal: Control of 2. Baseline Data: 3. Monitoring: Lithium levels should be measured 4. Identifying High-Risk Patients: Lithium should be avoided during 5. Evaluating Therapeutic Effects: Evaluate the patient for abatement 6. Minimizing Adverse Effects: Educate patients on signs of

1. acute manic episodes in pts with BPD and prophylaxis against recurrent mania and depression in pts with BPD. 2. CBC, electrolytes, hepatic function, cardiac function, and thyroid function. 3. every 2-3 days during initial therapy and every 3-6 months during maintenance. 4. the 1st trimester of pregnancy and used with caution during the remainder. Monitor use closely in pts with renal disease and pts on concurrent diuretic therapy. 5. of manic symptoms and mood stabilization. 6. toxicity, including N/V, tremor, confusion, blurred vision, and tinnitus.

Management of PD in advanced stages 1. Apomorphine is a nonergot dopamine agonist approved for the 2. the drug is not given by mouth it is

1. acute treatment of hypomobility during off episodes in patients with advanced PD. 2. admin subcut; The most common SE are injection-site reactions, hallucinations, yawning, drowsiness, dyskinesias, rhinorrhea, and nausea and vomiting rare but serious CV effects: MI & sudden death

Androgen therapy Therapeutic Effects 1. Testosterone Therapy in Menopausal Women can 2. When prescribed off label for this use, it must be prescribed at 3. Cachexia, which occurs in severely immunocompromised pts testosterone can 4. The DOC for cachexia, a anabolic steroid is 5. The Blackbox warning for Oxandrolone (Oxandrin)

1. alleviate some menopausal symptoms, especially fatigue, reduced libido, and reduced genital sensitivity 2. doses lower than men. The goal is to mimic premenopausal testosterone production—about 300 µg/day 3. decrease the risk for wasting and loss of muscle mass 4. Oxandrolone (Oxandrin) 5. Oxandrolone can cause peliosis hepatitis, a condition in which blood-filled cysts form in the liver, leading to liver failure; it also carries an increased risk for atherosclerosis increasing LDL and decreasing HDL.

Social Anxiety Disorder 1. SAD is characterized by 2. As a result, the person avoids the situation or, if it can't be avoided, 3. Two forms: in the generalized form, the person fears nearly all 4. The disorder typically begins during

1. an intense, irrational fear of situations in which one might be scrutinized by others, or might do something that is embarrassing or humiliating 2. endures it with intense anxiety: sx include blushing, stuttering, sweating, palpitations, dry throat, and muscle tension and twitches 3. social and performance situations. In the performance-only form, fear is limited to speaking or performing in public. 4. the teenage years and, left untreated, is likely to continue lifelong

Major drug classes for Insomnia Other hypnotics 1. Doxepin 2. antihistamines 3. melatonin

1. an old TCA with strong sedative actions; good for pts who have trouble staying asleep; blocks histamine receptors, contraindicated for pts with narrow-angle glaucoma or severe urinary retention, and pts on MAOI 2. diphenhydramine (Nytol) and doxylamine (Unisom); less effective than benzos and tolerance develops quickly (1 to 2 weeks) 3. Used as a hormone OTC supplement for insomnia and jet lag; can hasten sleep onset

Administration methods for transdermal preparations 1. AndroGel is supplied in a metered-dose pump & a 2. The gel is applied once 3. Patients should be instructed to squeeze the entire contents 4. patients should wait 5 to 6 hours before 5. testosterone should be measured 6. Testim is available in 5-g tubes; it is applied 7. To prevent the transfer of testosterone to others, patients should

1. and in unit-dose foil packets 2. daily (in am) to clean, dry skin of the shoulders, upper arms, or abdomen but not the genitalia 3. of the packet into the palms and then immediately apply the gel to the skin and rub it in. 4. showering or swimming 5. 14 days after the initiation of therapy and periodically thereafter. 6. once daily to skin of the shoulders or upper arms but not to the abdomen or scrotum 7. wash their hands and, after the gel has dried, keep the treated area covered with clothing

Role of androgens in treating anemia 1. Androgens are sometimes used in men and women to treat anemias that have been refractory to other therapy. Anemias most likely to respond include 2. Androgens help relieve anemia by promoting synthesis of 3. When women are given testosterone, the Hb levels increase by an average of

1. aplastic anemia, anemia associated with renal failure, Fanconi anemia, and anemia caused by cancer chemotherapy. 2. EPO, the renal hormone that stimulates the production of red blood cells, WBCs and platelets. 3. 4.3 g/dL. In contrast, because men have high testosterone levels, to begin with, the increase in plasma Hb is smaller—only 1 g/dL.

How to change patient from one form of contraceptive to another Switching to the Transdermal Contraceptive Patch ie: Xulane 1. For women not currently using OCs, the first patch should be 2. For women switching from OCs, the first patch should be applied

1. applied during the first 24 hours of the menstrual period. 2. on the first day of withdrawal bleeding.

Forms of Estrogen 1. Estrogen is available in conjugated and esterified forms. Esterified estrogens 2. Until mid-2016, synthetic conjugated estrogens A (Cenestin) and B (Enjuvia) were available; however, 3. Phytoestrogens (plant-based compounds)-commonly used by women as a 4. Phytoestrogens are not as potent as estradiol, but they carry some of the same risks. 5. Selective estrogen receptor modulators (SERMs) are drugs that activate ERs in some tissues and block them in others. These drugs were developed in an effort

1. are plant based; conjugated estrogens are natural preparations derived from the urine of pregnant horses. 2. the manufacturer has withdrawn them from the market 3. "natural" way to manage symptoms associated with menopause 4. Women should not use phytoestrogens if they have a history of thromboembolic events or a personal or family history of breast, uterine, or ovarian cancer. 5. to provide the benefits of estrogen (e.g., protection against osteoporosis, maintenance of the urogenital tract, reduction of LDL cholesterol) while avoiding its drawbacks (e.g., promotion of breast cancer, uterine cancer, and thromboembolism)

Menopause 1. is the associated loss of estrogen which typically begins 2. During the initial phase, the menstrual cycle becomes 3. Eventually, ovulation and menstruation

1. at approximately age 51 to 52 years, with 95% of women entering menopause between the ages of 45 and 55 years. 2. irregular, anovulatory cycles may occur, and periods of amenorrhea may alternate with menses 3. cease entirely

Prescribing Considerations in Special Populations for Hypnotics 1. Older populations 2. pregnancy

1. avoid using z-drugs or antihistamines in pts with dementia, cognitive impairment, or hx of falls. ​ consider melatonin as an alternative 2. avoid z-drugs when possible; use for shortest duration possible

Patient Education about Progestin SE from lecture 1. breakthrough (blank, blank & blank) may occur 2. report abnormal or

1. bleeding, spotting, and amenorrhea 2. prolonged vaginal bleeding >6mo

Stages of a migraine 1. Premonitory phase 2. Migraine aura: 3. Headache phase: 4. Recovery phase:

1. can be hours to days before onset of aura or HA. These symptoms may include tiredness, irritability, loss of concentration, stiff neck, and food cravings 2. 1/3 have aura sx at least some of the time that may last up to 1 hour. sx include: changes in sight ie, dark spots, colored spots, sparkles or 'stars', and zigzag lines, numbness or pins and needles, weakness dizziness or vertigo Sx can be visual, sensory, or motor. There are no assoc focal neurologic symptoms in migraine without aura 3. Throbbing pain; begins on one side and spreads to the entire head. May be accompanied by fatigue, N/V or dizziness. There may be hypersensitivity to anything touching the head. Symptoms may last from 4 to 72 hours (usually about a day). 4. Irritability, fatigue, or depression may take hours or days to resolve. Often, mirrors the sx of the premonitory phase

How to manage OCPs when the patient is on antiseizure medications 1. Eight antiseizure drugs decrease the effectiveness of OC 2. Advise pts that when taking these drugs they may need 3. Avoid (blank) unless it is absolutely necessary; if no other drug is effective 4. The lowest 5. Use just one 6. To reduce the risk for neural tube defects; 7. Because phenytoin, phenobarbital, carbamazepine, and primidone can decrease the synthesis of vitamin K-clotting factors

1. carbamazepine, eslicarbazepine, lamotrigine, oxcarbazepine, phenytoin, phenobarbital, rufinamide, and topiramate 2. higher doses of their OCs; most often increasing the dose of OC will NOT interfere with the antiseizure drug 3. valproic acid 4. effective dosage should be determined/maintained 5. drug whenever possible 6. pregnant pts should take supplemental folic acid before conception; at least 0.04 mg of folic acid daily 7. experts advocate administering vitamin K to the mother for 1 month before delivery and during delivery

Suicide Risks and Considerations Safety measures 1. Concerns about antidepressant-induced suicide apply mainly to 2. To reduce the risk for suicide, 3. Close observation is especially important during 4. Ideally, 5. In addition, family members or caregivers should

1. children, adolescents, and adults <25 years. 2. pts on antidepressant drugs should be observed closely for suicidality, worsening mood, and unusual changes in behavior. 3. the first few months of therapy and whenever antidepressant dosage is changed (incrd OR decrd). 4. The patient or caregiver should meet with the prescriber at least weekly during the first 4 weeks of treatment, then biweekly for the next 4 weeks, then once 1 month later, and periodically thereafter. Phone contact may be appropriate between visits. 5. monitor the pt daily, for decline: (anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, hypomania, and, of course, emergence of suicidality). If these symptoms are severe or develop abruptly, the patient should see his or her prescriber immediately.

Generalized Anxiety Disorder 1. is characterized as a 2. Most patients with GAD also have 3. GAD should not be confused with situational anxiety,

1. chronic condition of incontrollable worrying. Of all anxiety disorders, GAD is the least likely to remit 2. another psychiatric disorder, usually depression. 3. The hallmark of GAD is unrealistic or excessive anxiety about several events or activities (work or school performance) that lasts > 6 months

Pathophysiology of Alzheimer Disease Degeneration of Neurons 1. Neuronal degeneration occurs in the hippocampus early in AD, followed later by 2. The hippocampus serves an important Reduced Cholinergic Transmission 3. In AD, levels of ACh are β-Amyloid and Neuritic Plaques 4. Neuritic plaques are seen mainly in the Neurofibrillary Tangles and Tau 5. In AD an abnormal form of tau creates

1. degeneration of neurons in the cerebral cortex and subsequent decline in cerebral volume 2. role in memory. The cerebral cortex is central to speech, perception, reasoning 3. 90% below normal; ACh is an important transmitter in the hippocampus and cerebral cortex its critical to forming memories, and its decline has been linked to memory loss 4. hippocampus and cerebral cortex. 5. neurofibrillary tangles, a prominent feature of AD

Flaxseed how they interact with conventional drugs and common problems that can happen with each one 1. is commonly used to improve 2. adverse effects 3. Drug interactions 4. not to be confused w/ flaxseed oil,

1. digestive health or relieve constipation. Used to tx dyslipidemia as omega-3 supplement to lower total blood cholesterol and LDL; & to tx menopause sx 2. bloating, flatulence, abdominal discomfort​ 3. May reduce absorption of drugs; give 1 hr before or 2 hrs after most meds 4. which is a unique component w/ potentially different interaction properties

Patient Education about Estrogen SE from lecture 1. Nausea is common early in treatment but. 2. Menopausal HT with this hormone alone increases the risk for . 3. adverse effects include abnormal

1. diminishes with time. To reduce nausea: avoid cooking odors and warm, stuffy environments, consume dry foods and raw fruits and vegetables, use guided imagery with muscle relaxation, yoga, and music therapy 2. endometrial carcinoma 3. vaginal bleeding, hypertension, benign hepatic adenoma, and reduced glucose tolerance)

Pharmacokinetics of Phenytoin (Dilantin) 1. small changes in dosage can produce 2. Dosing Considerations 3. If a patient is taking phenytoin 300mg daily for seizures and their serum concentration is 8mg/L and they experience a considerable increase in seizure activity, their dose would only need to increase to

1. disproportionately large changes in serum drug levels. As a result, a dosage that is both effective and safe is difficult to establish 2. Dosing is highly individualized; b/c of the narrow therapeutic range, & the nonlinear relationship btw phenytoin dosage & plasma levels, after a safe and effective dosage has been established, the pat should adhere to it rigidly. 3. to 350mg daily.

How to initiate treatment (when in the cycle is it best to start- may vary based on type of contraceptive) 1. With only one exception, combination OCs are 2. Most 28-day cycle products are taken in a repeating sequence consisting of 3. The sequence is begun on either 4. With the first option, protection is 5. With a Sunday start, which is done to have menses occur on weekdays rather than the weekend, protection 6. With both options, each dose 7. Successive dosing cycles should

1. dosed in a cyclic pattern. 2. 21 days of an active pill followed by 7 days on which either (1) no pill is taken, (2) an inert pill is taken, or (3) an iron-containing pill is taken. 3. the first day of the menstrual cycle or the first Sunday after the onset of menses. 4. conferred immediately; hence no backup contraception is needed. 5. may not be immediate; hence an alternate form of birth control should be used during the first 7 days of the pill pack. 6. should be taken at the same time every day (e.g., with a meal or at bedtime). 7. commence every 28 days

Management of Panic Disorder 1. Two modalities may be employed: Medications used to treat 2. (blank) are first-line drugs for PD. 3. Drug therapy should continue 4. SSRIs can increase 5. What drugs can be used prn for acute attacks

1. drug therapy and CBT. Combining drug therapy with CBT is more effective than either modality alone; 70% and 90% of patients with PD respond well to tx 2. SSRIs; At this time, only three SSRIs—fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft); Other classes SNRIs, TCAs, and MAOIs may be used 3. at least 6 to 9 months. Stopping sooner is associated with a high rate of relapse 4. anxiety early in treatment 5. Benzos: alprazolam & clonazepam

Tx Overview of major depressive disorder 1. For patients with mild to moderate depression, 2. For those with severe depression, a combination of 3. Factors that may contribute to vulnerability include 4. Depression can be treated with three major modalities:

1. drug therapy and/OR psychotherapy can be equally effective 2. drug therapy and psychotherapy is better than either intervention alone. ECT can be used when a rapid response is needed or when drugs/psychotherapy have not worked. For all pts, aerobic exercise and resistance training can improve mood 3. genetic heritage, a difficult childhood, and chronic low self-esteem. 4a. (1) pharmacotherapy, 4b. (2) depression-specific psychotherapy (CBT or interpersonal psychotherapy), 4c. (3) somatic therapies, such as ECT and transcranial magnetic stimulation

Patient-Centered Care Across the Life Span Drugs for Erectile Dysfunction 1. Pregnant women-It is recommended that men taking Alprostadil 2. Older adults-Consider lower dosing

1. drugs use a condom if their partner is a pregnant woman. 2. when prescribing for adults age 65 and older.

Abortive Therapy/When to use abortive therapy 1. The objective of abortive therapy is to 2. Treatment should commence at the 3. oral therapy may be ineffective after an attack d/t N/V. Hence 4. For mild to moderate symptoms, 5. For moderate to severe symptoms, patients should take a 6. an opioid analgesic (e.g., butorphanol) should be reserved for 7. Antiemetics are important

1. eliminate HA pain and suppress associated N/V 2. earliest sign of an attack. 3. For tx of an established attack, a drug that can be administered by injection, nasal spray, or rectal suppository may be best 4. an NSAID (e.g., aspirin, naproxen) may be sufficient. 5. migraine-specific drug, such as a serotonin1B/1D agonist, or—less frequently used—an ergot alkaloid 6. tx in pts with migraines resistant to all others 7. adjuncts to migraine therapy

Estrogen-Adverse Effects 1. principal concerns with estrogen therapy are the potential for 2. endometrial hyperplasia and endometrial cancer can be resolved 3. Estrogens have been associated with what common SE 4. menopause may produce or uncover 5. Nausea is the most 6. (blank) a patchy brown facial discoloration, though not dangerous, may cause significant distress

1. endometrial hyperplasia, endometrial cancer, breast cancer, and cardiovascular thromboembolic events 2. by prescribing a progestin 3. Fluid retention with edema, gallbladder disease, jaundice, and headache; especially migraine headache 4. gallbladder disease. Jaundice may develop in women with preexisting liver dysfunction, especially those who experienced cholestatic jaundice of pregnancy 5. frequent undesired response to the estrogens 6. Chloasma,

Summary of Key Prescribing Considerations Phosphodiesterase-5 Inhibitors 1. Therapeutic Goal: PDE-5 inhibitors are used to 2. Baseline Data: Heart rate, blood pressure. Thorough 3. Monitoring: Heart rate, blood pressure. Eye examination to include 4. Identifying High-Risk Patients: PDE-5 inhibitors are contraindicated for men taking

1. enhance both the hardness and duration of erection in men with ED. 2. eye examination. Assess hearing. Evaluate pts for CV disorders, including stroke, hypo OR hypertension, HF, unstable angina, MI, and recent hx of severe dysrhythmia. 3. visual acuity, assessment of color vision, pupillary response, and fundoscopic exam. Assess for tinnitus, vertigo, and hearing loss. Assess for sx of pulmonary edema. 4. nitrates (ie: NTG) and should be avoided in men on α blockers. Avoid vardenafil—but not sildenafil or tadalafil—in men taking class I or class III antidysrhythmic drugs. For men with preexisting CV disease, consider carefully the risk assoc with sexual activity before prescribing a PDE-5 inhibitor or any drug for ED. Use PDE-5 inhibitors with caution in men taking CYP3A4 inhibitors and in those with NAION (blurred vision/blindness), coronary heart disease, and other CV disorders.

Drug Interactions with (MAOIs) 1. Indirect-acting sympathomimetic agents. 2. Interactions secondary to inhibition of hepatic monoamine oxidase 3. TCAs 4. Serotonergic drugs 4. Antihypertensive drugs

1. ephedrine, amphetamine, methylphenidate, cocaine, and even caffeine In pts taking MAOIs, these drugs can produce hypertensive crisis 2. Inhibition of MAO in the liver can decrease the metabolism of several drugs, including epinephrine, NE, and dopamine, use these drugs with caution 3. The combo of a TCA with an MAOI may produce HTN episodes or crisis; very limited use concurrently 4. Combining MAOIs with SSRIs/SNRIs and other serotonergic drugs poses a risk for serotonin syndrome 5. of MAOIs & antihypertensive agents may result in an excessive lowering of blood pressure.

Patient-Centered Care Across the Life Span Antiseizure Drugs 1. Children-most antiseizure drugs are safe, with the exception of 2. Pregnant women-(blank) can cause severe physical malformations and & decreased cognitive function & should only be Rx'd as last resort. 3. Breastfeeding women-Valproic acid and 4. Older adults-Beers Criteria list

1. eslicarbazepine. Children <2 years who take valproate are at higher risk for hepatotoxicity-can be fatal. Few studies have proved safety of all antiseizure drugs 2. Valproate; CanadA prohibits vigabatrin. Human fetal harm has also been documented for carbamazepine, lamotrigine, phenytoin, phenobarbital, and topiramate. For the remaining drugs, fetal harm has been documented in animal studies but not in humans. phenytoin, phenobarbital, carbamazepine, and primidone can decrease synthesis of vit K so supplement with vitamin K to the mother for 1 month before delivery and during delivery. 3. phenytoin are often DOC b/c they are highly protein-bound. Canada contraindicates vigabatrin for breastfeeding 4. carbamazepine, oxcarbazepine, and phenobarbital as possibly inappropriate for adults >65 years Additionally, phenobarbital is high-risk medication for patients >56 years. Because of increased risk for falls & sedation, lower initial doses is advisable.

How to prevent secondary exposure with gels 1. Gel users should wash their hands with soap and warm water after 2. Gel users should cover the application site with 3. Gel users should wash the application site before 4. Women and children should avoid skin-to-skin contact 5. Women and children who make accidental contact with a gel

1. every application. 2. clothing once the gel has dried. 3. skin-to-skin contact with another person. 4. with application sites on gel users. 5. application site should wash contaminated skin immediately

Other common herbal supplements 1. green tea 2. CBD 3. Goldenseal​

1. evidence suggesting memory improvement & weight loss, use cautiously with those on vasodilators & psychoactive meds 2. used to reduce blood pressure​; can have additive effect with other medications that lower BP such as metoprolol 3. decreases metabolism of morphine derivatives (fentanyl) This may increase adverse effects

Side effects of both 1st generation (FGA) and 2nd generation (SGA) antipsychotics 1. fall into two major groups: 2. 2nd gen carry a lower risk 3. Examples of FGA 4.. Examples of SGA include 5. MOA of FGA vs SGA 6. SGAs carry a reduced risk for EPSs, they carry a significant risk of

1. first-gen antipsychotics (conventional) and second-generation antipsychotics (atypical) 2. for EPS, including tardive dyskinesia. Accordingly, the atypical agents are preferred for BPD 3. Chlorpromazine (a low-potency); Haloperidol (a high-potency) 4. olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), aripiprazole (Abilify 5. All FGAs produce a strong blockade of dopamine in the central nervous system (CNS)/SGAs produce a moderate blockade of dopamine receptors and a much stronger blockade of serotonin receptors 6. metabolic effects—weight gain, diabetes, and dyslipidemia which can lead to CV events and early death

Monoamine Oxidase-B Inhibitors 1. The MAO-B inhibitors—selegiline and rasagiline—are considered 2. Black Box Warning Selegiline (two)

1. first-line drugs for PD even though benefits are modest 2a. as an Antidepressants/PD drugs is associated with an increased risk for suicide in patients younger than 24 years. 2b. carries an increased risk for hypertensive crisis in younger patients and is contraindicated for children younger than 12 years; foods high in Tyramine can increase this risk ie: home-brewed/tap Beer, Cheese (aged), Fava beans, Fish or meat that is cured/smoked & Soy products

Preventive Therapy β Blockers examples: propranolol-used most often, metoprolol 1. β blockers are Antiepileptic Drugs-examples: divalproex and topiramate 2. common SE of divalproex include 3. Black Box Warning-Divalproex 4. topiramate costs

1. first-line drugs for migraine prevention 2. fatigue, weight gain, tremor, bone loss, and reversible hair loss 3. Potentially fatal pancreatitis and hepatitis can occur; this is also contraindicated in pregnancy 4. much more than other drugs; Unfortunately, SE are common, especially paresthesias, fatigue, and cognitive dysfunction

Serotonin1B/1D Receptor Agonists (Triptans) examples: Sumatriptan, Zolmitriptan 1. are considered 2. Therapeutic Use 3. Dosing considerations Adverse effects 4a. Chest symptoms 4b. Coronary vasospasm 4c. Teratogenesis.

1. first-line drugs for terminating a migraine attack 2. relieves HA and assoc symptoms (nausea, neck pain, photophobia, phonophobia); Unfortunately, HA returns in about 40% of patients within 24 hours 3. Beneficial effects begin about 15 min after subQ or intranasal dosing and 30 to 60 min after oral dosing; also available in transdermal dosing 4a. About 50% of pts experience unpleasant chest sx, usually described as "heavy arms" or "chest pressure 4b. rarely, sumatriptan/other triptans can cause angina secondary to coronary vasospasm; avoid in pts with CAD & Prinzmetal (vasospastic) angina; Don't use in high-risk pts until you r/o CAD these include: postmenopausal women, men >40 years, smokers, HTN, hypercholesterolemia, DM, or a family hx of CAD 4c. Sumatriptan should be avoided during pregnancy.

Treatment of GAD 1. SSRIs and SNRIs are considered 2. Treatment usually 3. Buspirone is labeled only for short-term treatment of anxiety 4. Benzodiazepines are first-choice drugs 5. Prescribing considerations​ for Benzodiazepines

1. first-line treatment for GAD. Four antidepressants; venlafaxine (Effexor XR), duloxetine (Cymbalta), escitalopram (Lexapro) & paroxetine (2nd line), & Buspirone are approved for GAD 2. lasts 12 plus months 3. However, the drug has been taken for as long as a year with no reduction in benefit. 4. for acute anxiety; 6 are approved for anxiety. The most often Rx'd are alprazolam (Xanax) and lorazepam (Ativan); there is no proof that any one benzodiazepine is clearly superior to the others 5. ineffective for depression​, only use short term, extended use has a high risk for dependence and abuse​ potential, abrupt cessation can cause withdrawal symptoms (panic, paranoia, and delirium); taper

Kava-how they interact with conventional drugs and common problems that can happen with each one 1. FDA issued a warning 2. is used to relieve 3. Hepatotoxicity was so bad (11 reported US cases) that 4. Kava can have a counter interaction with 5. Adverse effects

1. for Kava as Harmful Supplements to Avoid 2. anxiety, promote sleep, and relax muscles; as a natural alternative to benzos 3. some patients required liver transplants. 4. alcohol, other anxiety medications, anticonvulsants, antipsychotic meds, and levodopa 5. Drowsiness. Avoid operating machinery or driving. Liver issues

Summary of Key Prescribing Considerations Cholinesterase Inhibitors 1. Therapeutic Goal: Improved cognition and function 2. Baseline Data: Assess cognitive and functional neurological status. 3. Monitoring: At each visit, assess 4. Identifying High-Risk Patients: Cholinesterase inhibitors should be prescribed cautiously for patients Evaluating Therapeutic Effects: Evaluate for improvement of cognitive and functional status.

1. for pts with AD by increasing availability of ACh at cholinergic synapses. 2. Assess for evidence of GI problems. Check baseline weight and basic respiratory and cardiovascular status. 3. orientation, cognition, and functional status. Check weight and examine for changes in respi, CV, or GI status compared to baseline. If significant adverse effects occur, consider the degree of benefit compared with adverse SE. 4. with a hx of Resp or PUD. Exercise caution when prescribing for patients with bradycardia or 1st AVB; benefits may not be worth the risks. Avoid prescribing to patients with higher degrees of heart block.

How to achieve an extended cycle with oral contraceptives 1. To achieve an extended schedule, the user would simply purchase 2. Many health care providers recommend taking combination OCs for an extended time rather than following the traditional 28-day cycle because

1. four packets of a 28-day product (each of which contains 21 active pills) and then take the active pills for 84 days straight. 2. doing so decreases episodes of withdrawal bleeding, AND the assoc sx that come with that ie: menstrual pain, premenstrual symptoms, headaches etc.

BPH signs & symptoms 1. Signs and symptoms of BPH include urinary hesitancy, urinary urgency, increased 2. There is no direct correlation between symptoms and 3. Long-term complications of BPH include

1. frequency of urination, dysuria, nocturia, straining to void, postvoid dribbling, decreased force and caliber of the urinary stream, and a sensation of incomplete bladder emptying 2. prostate size; therefore substantial enlargement may have no symptoms 3. obstructive nephropathy, bladder stones, and recurrent urinary tract infections

Preventive Therapy/when to use preventive therapy 1. Prophylactic therapy can reduce the 2. it is indicated for patients who have 3. benefits take

1. frequency, intensity, and duration of migraine attacks and can improve responses to abortive drugs. 2. frequent attacks (three or more/month), attacks that are especially severe, or attacks that do not respond adequately to abortive agents 3. 4 to 6 weeks to develop

TCAs 1. Therapeutic use 2. MOA

1. generally considered second-line drugs for Major depression owing to their SE; also used for Fibromyalgia, neuropathic pain, chronic insomnia, ADHD, OCD, & PD 2. block neuronal reuptake of two monoamine transmitters: NE and 5-HT; they also block muscarinic cholinergic receptors and can thereby cause an array of anticholinergic effects (dry mouth, blurred vision, photophobia, constipation, urinary hesitancy, and tachycardia

SE of OCs- Thromboembolic disorders. 1. Major factors that increase the risk for thromboembolism are 2. Several measures can help minimize thromboembolic phenomena: 2a. The estrogen dose in OCs should be 2b. OCs containing drospirenone or desogestrel should 2c. OCs should not be prescribed for 2d. OCs should be discontinued at least

1. heavy smoking, a history of thromboembolism, and thrombophilias 2a. no greater than required for contraceptive efficacy. In past hx OCs contained 100 µg of ethinyl estradiol Today's OCs contain no more than 50 µg 2b. generally be avoided because they may pose a higher risk for developing VTE. 2c. heavy smokers, women with a history of thromboembolism, or those with other risk factors for thrombosis. 2d. 4 weeks before surgery in which postoperative thrombosis might be expected.

Dosing considerations-donepezil 1. Donepezil is well absorbed after oral administration and undergoes 2. dosing for mild-moderate dementia 3. dosing for moderate-severe dementia

1. hepatic metabolism; it has a prolonged half-life (60 hrs). It takes about 15 days for donepezil to achieve steady state. 2. Start: 5 mg PO qhs x4-6wk, then may incr. to Max: 10 mg PO qhs 3. Start: 5 mg PO qhs x4-6wk, then incr. to 10 mg PO qhs x3mo, then may incr. to Max: 23 mg PO qhs

Alternative preventative medication options 1. A new FDA approved monoclonal antibody includes 2. This alternative therapy is only approved for chronic migraines (15 or more headache per month)

1. human immunoglobulin G2 erenumab (Aimovig); admin is subcut; SE include Constipation, muscle cramping & risk of antibody formations 2. Botulinum toxin; consists of 31 injections, made into muscles of the scalp, neck, and upper back

Summary of Key Prescribing Considerations Androgens 1. Therapeutic Goal: To manage 2. Baseline Data: Serum testosterone concentration, 3. Monitoring: Serum testosterone concentration, 4. Identifying High-Risk Patients: Androgens are contraindicated for 5. Evaluating Therapeutic Effects: Development of

1. hypogonadism and subsequent testosterone deficiency through testosterone supplementation. 2. CBC, lipid panel, liver function, prostate specific antigen (PSA). 3. lipids, liver function, and PSA after 1 year (refer to urologist if >4.0 ng/mL or >1.4 ng/mL above baseline) 4. pregnant women, for men who have prostate cancer or breast cancer, and for enhancing athletic performance. 5. secondary sex characteristics and restoration of energy, libido, and other symptoms of testosterone deficiency.

Preventive Therapy Tricyclic Antidepressants examples amitriptyline (Elavil) 1. Amitriptyline can cause Estrogens and Triptans examples; estrogen gel & patches (Divigel, Climara) 2. Menstrually associated migraine is defined 3. Dosing with

1. hypotension and anticholinergic effects (dry mouth, constip, urinary retention, blurred vision, tachycardia 2. as migraine that routinely occurs within 2 days of the onset of menses; trigger is the decline in estrogen levels that precedes menstruation 3. Perimenstrual triptans ie, frovatriptan, naratriptan, and zolmitriptan) is done for 6 days each month, beginning 2 days before the expected onset of menses

Serotonin1B/1D Receptor Agonists (Triptans) Drug interactions 1. Ergot alkaloids and other triptans 2. Monoamine oxidase inhibitors. 3. SSRI/SNRIs

1. if one triptan is combined with another or with an ergot alkaloid, excessive and prolonged vasospasm could result. Avoid use within 24 hours of another agent 2. MAOIs can suppress hepatic degradation of sumatriptan, increasing risk of Toxicity; avoid using with 2 wks of d/cing a MAOI 3. triptans directly activate serotonin receptors, and the SSRIs (fluoxetine [Prozac) and SNRIs( duloxetine [Cymbalta]) indirectly activate serotonin receptors which can cause serotonin syndrome Sx and include AMS (agitation, confusion, disorientation, anxiety, hallucinations, poor concentration) as well as incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever & Death

IUDs 1. Intrauterine Devices; Historically, due to the wicking ability of the old IUD strings, 2. The risk for PID is highest during the 3. Two main classes of intrauterine devices are currently in use: 4. The TCu380A can be used for up to 5. levonorgestrel containing IUDs can be used for

1. increased risk of pelvic inflammatory disease related to IUD use was a concern (but is no longer) 2. first 20 days after insertion; screening for Gonorrhea and chlamydia infection should be done prior to insertion 3. a hormone-free copper IUD (TCu380A or Paragard) and a levonorgestrel containing IUD 4. 10 years and likely longer. 5. (3 to 7) years depending on the dose form.

What are the most effective forms of contraception? 1. Depot medroxyprogesterone acetate (DMPA) is given by injection 2. It protects against pregnancy for 3. When injections are discontinued, return of fertility is delayed 4. DMPA poses a risk for reversible

1. intramuscularly or subcutaneously. 2. three months or longer by inhibiting the secretion of gonadotropin 3. by an average of 9 months 4. bone loss, but this risk does not outweigh the benefits of treatment.

Overview of Tx BPH 1. BPH can be managed in three ways: 2. The goal of therapy is to 3. 5-α-reductase inhibitors are most appropriate for men with very 4. α blockers are preferred for men with

1. invasive treatments, drug therapy, and "watchful waiting 2. relieve bothersome urinary symptoms and delay disease progression 3. large prostates (mechanical obstruction) 4. relatively small prostates (dynamic obstruction)

1. A panic attack is characterized by 2. Panic symptoms reach a peak

1. is an abrupt surge of intense fear or intense discomfort during which four or more of the following are present: • Palpitations, pounding heart, racing heartbeat • Sweating • Trembling or shaking • Sensation of shortness of breath or smothering • Feeling of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, lightheaded, or faint • Chills or heat sensations • Paresthesias (numbness or tingling sensations) • Derealization (feelings of unreality) or depersonalization (feeling detached from oneself) • Fear of losing control or going crazy • Fear of dying 2. in a few minutes and then dissipate within 30 minutes. Many patients go to an emergency department because they think they are having a heart attack.

Management of Insomnia What type of patient scenario would be appropriate for the administration of the following drugs? DFA (Difficulty tallying asleep); DMA (difficulty maintaining sleep) 1. Trazodone 2. Zaleplon 3. Flurazepam 4. Zolpidem

1. is an atypical antidepressant with strong sedative actions. The drug can decrease sleep latency (DFA) and prolong sleep duration; it does not cause tolerance or physical dependence; It's espec useful for txing insomnia from antidepressants that cause CNS stimulation 2. has a quick onset (15-30min); an ultrashort duration so its only useful for DFA 3. Its onset slower; 30-60min; it helps in DFA & DMS; it has a long duration 4. comes in two forms; immediate release and ER; both have an onset of 30 min; the ER has a long duration and is used to treat pts with DFA & DMS

What are the most effective forms of contraception? 1. A subdermal system (Nexplanon) for delivery of etonogestrel 2. Nexplanon consists of a single 4-cm rod implanted subdermally in the groove between 3. Etonogestrel then diffuses slowly and continuously, providing Drug Interactions 4. Agents that induce hepatic enzymes—(including blank)—may reduce the efficacy of Nexplanon. Accordingly, Nexplanon should not be used by women taking these drugs.

1. is available for long-term reversible contraception 2. the biceps and triceps in the nondominant arm. 3. blood levels sufficient for contraception for 3 years 4. such as barbiturates, phenytoin, rifampin, carbamazepine, topiramate, HIV protease inhibitors, and St. John's wort

Estrogen Therapeutic Uses: 1. Menopausal hormone therapy- When estrogen is used for this purpose, 2. Female hypogonadism-In the absence of ovarian estrogens, 3. Acne-Estrogens, in the form of 4. Cancer palliation-sometimes used for palliative therapy 5. Gender-affirmation therapy-for

1. it is usually accompanied by the use of progestins 2. pubertal transformation will not take place. (variety of causes see pg 428) This treatment promotes breast development, maturation of the reproductive organs, and pubic and axillary hair. This tx regimen consists of continuous low-dose therapy (for approx a year) followed by cyclic administration of estrogen in higher doses 3. oral contraceptives, can help control acne. Tx is limited to patients at least 14-15 years old who want contraception 4. in management of advanced prostate CA in men and in a select type of metastatic breast CA in men& women 5. transgender women; not approved by the FDA) but prescribed off-label

What do patients need to know about starting SSRIs? 1. After a drug has been selected for initial treatment, 2. If the initial drug is not effective, we have four major options:

1. it should be used for 4 to 8 weeks (to take effect); dosage will be low initially (to reduce SE) and then gradually increased 2a. Increase the dosage. 2b. Switch to another drug in the same class. 2c. Switch to another drug in a different class. 2d. Add a second drug, such as an atypical antidepressant

Harmful Supplements to Avoid 1. Comfrey used topically & orally for 2. Comfrey oral is 3. Ma Huang (Ephedra) is used for 4. High-dose ephedra has been associated

1. joint and muscle pain, inflammatory disorders​ 2. contraindicated-can cause venoocclusive disease which can lead to liver failure; may be carcinogenic 3. weight loss, it's a heart/CNS stimulant 4. with stroke, myocardial infarction, and death

Patient Education-Thrombosis and Thromboembolism 1. Women should be informed about the symptoms of thrombosis and thromboembolism (e.g.,.... Black Box Warning-Oral Contraceptive Pills 2. Cigarette smoking increases the risk of

1. leg tenderness or pain, sudden chest pain, shortness of breath, severe headache, sudden visual disturbance) and instructed to consult the prescriber if these occur. 2. serious cardiovascular side effects from combination oral contraceptive pills.

Drug Interactions Lithium 1. Diuretics promote sodium loss and can thereby increase the risk for 2. NSAIDs ie: ibuprofen, naproxen (Naprosyn), piroxicam (Feldene), indomethacin (Indocin), and Celebrex can increase lithium levels by 3. Anticholinergics can cause urinary

1. lithium toxicity; Renal excretion of lithium is reduced in the presence of low sodium, causing lithium levels to rise. 2. as much as 60% by suppressing prostaglandin synthesis in the kidney, NSAIDs can increase renal reabsorption of lithium, causing lithium levels to rise. ASA and sulindac do not increase lithium levels; If a mild analgesic is needed, ASA or sulindac are DOC. 3. hesitancy. Coupled with lithium-induced polyuria, this can result in considerable discomfort. Accordingly, patients should avoid drugs with prominent anticholinergic actions e.g., antihistamines, phenothiazine antipsychotics & TCAs

Purpose and timing of serum drug levels 1. Monitoring plasma drug levels is especially helpful when treating 2. By adjusting initial doses on the basis of plasma drug levels (rather than on the basis of seizure control), we can 3. Measurements of plasma drug levels are less important for 4. In addition to serving as a guide for dosage adjustment, knowledge of plasma drug levels can serve as an aid to

1. major convulsive disorders (e.g., tonic-clonic seizures); because these seizures occur infrequently, a long time may be needed to establish control 2. readily achieve drug levels that are likely to be effective (thereby establishing control quickly) 3. determining effective dosages for absence seizures. Because absence seizures occur very frequently 4. (1) monitoring patient adherence, (2) determining the cause of lost seizure control, and (3) identifying causes of toxicity

(SNRI) Venlafaxine 1. the first SNRI available, is approved for 2. MOA

1. major depression, generalized anxiety disorder, social anxiety disorder, and panic disorder; SSRIs are equally effective & probably safer. 2. The drug produces powerful blockade of NE and 5-HT reuptake and weak blockade of dopamine reuptake; does not block cholinergic, histaminergic, or α1-adrenergic receptors

Drugs Used for Depression 1. Drugs are the primary therapy for 2. In patients with mild to moderate depression, 3. drugs fall into five major classes: 4. All of these classes are

1. major depression. However, benefits are limited mainly to patients with severe depression. 2. antidepressants have little or no beneficial effect 3. SSRIs, SNRIs, TCAs, MAOIs, and atypical antidepressants 4. equally effective, as are the individual drugs within each class. Hence differences among these drugs relate mainly to side effects and drug interactions.

Summary of Key Prescribing Considerations SSRIs/SNRIs 1. Therapeutic Goal: Alleviation of symptoms of 2. Baseline Data: 3. Monitoring: 4. Identifying High-Risk Patients: Selective serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors are contraindicated for 5. Evaluating Therapeutic Effects: Assess patients for improvement in 6. Minimizing Adverse Effects: Educate patients that

1. major depression. In addition, some drugs may relieve sx of OCD, panic disorder, social phobia, generalized anxiety disorder, and chronic pain. 2. Serum sodium w/ older adults and pts on diuretic therapy. 3. Should monitor Serum NA in the same pt population 4. patients taking MAOIs and should be used with caution in patients taking other serotonergic drugs. 5. symptoms, especially depressed mood and loss of interest or pleasure in usual activities. 6. abrupt cessation of these drugs is not recommended. Patients should also report thoughts of suicide or self-harm immediately.

Drugs from other classes that can be used to treat BPD 1. Mood stabilizers: Drugs that relieve symptoms during (pp. 230-232) 2. Antipsychotics: Drugs given in BPD to help Although they can be used alone, 3. they are usually employed in 4. The 2nd gen (atypical) antipsychotics (blank&blank) are generally preferred to the 1st gen (conventional) agents (blank) b/c they carry 5. only 3 atypical agents are approved for long-term use to prevent the recurrence of mood episodes: (p. 233) 6. Antidepressants: In patients with BPD, antidepressants are almost always 7. NOTE: The use of TCA appears to promote more incidents of (pp. 229-230)

1. manic & depressive episodes, prevent the recurrence, & do not worsen symptoms of mania/depression or accelerate the rate of cycling. Ex: lithium, x2 antiepileptic: divalproex sodium (valproate) & carbamazepine, Lamotrigine indicated for long-term maintenance therapy of BPD 2. control ACUTE symptoms during severe manic episodes, even if psychotic sx are absent. They are also given LONG TERM to help stabilize mood. 3. combo with a mood stabilizer. 4. (olanzapine, risperidone); (haloperidol); a lower risk for EPS SE, including tardive dyskinesia. 5. aripiprazole, olanzapine, & ziprasidone. 6. combined with a mood stabilizer b/c of the long-held belief that when used alone they may elevate mood causing a hypomanic or manic episode. DOC are: atypical antidepressants: bupropion (Wellbutrin), SNRIs: venlafaxine (Effexor XR), & the SSRIs such as fluoxetine (Prozac) & sertraline (Zoloft). 7. mania, therefore they are not recommended in the treatment of BPD.

Patient-Centered Care Across the Life Span Drugs for PD 1. Children Juvenile PD in pts <18 years is extremely rare; therefore 2. Pregnant women- (blank & blank) are not associated with adverse outcomes; 3. Breastfeeding women-Bromocriptine and cabergoline 4. Older adults-The average age at PD diagnosis is

1. many drugs for PD have not been tested in children. Only amantadine, benztropine, and bromocriptine have approval for pediatric populations. Selegiline-MAOB-I is contraindicated in children younger than 12 years. 2. Bromocriptine and cabergoline; Animal reproduction studies demonstrated a possibility for fetal harm for all other drugs especially ropinirole 3. interfere with lactation. Anticholinergics-benztropine can suppress lactation. Breastfeeding is not recommended for women taking these drugs. 4. 62 years; so most RXs are written for older adults. Adverse SE tend to be more common and more serious in these pts. Beers criteria designate anticholinergic drugs (e.g., benztropine and trihexyphenidyl) as potentially inappropriate

Patient-Centered Care Across the Life Span Antidepressants 1. Children/adolescents 2. Pregnant women Use of SSRIs late in pregnancy may promote 3. Breastfeeding women are generally 4. Older adults Treatment with (blank & blank) is generally safe, providing less medication interaction and smaller side-effect profiles.

1. may increase the risk for suicide, especially during the early phase of treatment. 2. pulmonary HTN of newborn. Paroxetine and Fluoxetine may cause septal heart defects. Use of SSRIs in late pregnancy poses a small risk for NAS-withdrawal, charactrized by abnormal crying, irritability, tremor, and possible seizures. 3. safe in breastfeeding women. Sertraline has been shown to be especially safe. 4. SSRIs or SNRIs

Ginkgo biloba-how they interact with conventional drugs and common problems that can happen with each one 1. Used to improve 2. Interactions: It can suppress coagulation. Therefore patients taking 3. Pts at risk for seizures should 4. Adverse effects

1. memory, stop progression of dementia, and decrease intermittent claudication; off label use to tx erectile dysfunction, and disorders with decreased perfusion. 2. antiplatelets (aspirin) or anticoags (warfarin, heparin) should be cautious; Patients taking anticonvulsants, antipsychotics, antidepressants, cholinesterase inhibitors, decongestants, first-generation antihistamines, and systemic glucocorticoids should also avoid this herb (can lower seizure threshold) 3. avoid ginkgo because it can cause seizures 4. GI upset, HA, dizziness, vertigo can all occur; a rapid increase in dose should be avoided to avoid these symptoms. Spontaneous bleeding is another SE

Black cohosh how they interact with conventional drugs and common problems that can happen with each one 1. (old historical herb) is used for treating symptoms of 2. Adverse effects: 3. Avoid use in 4. Drug interactions

1. menopause, including hot flashes, vaginal dryness, palpitations, depression, irritability, and sleep disturbance; don't confuse with Blue cohosh 2. women taking black cohosh have developed liver inflammation; monitor baseline liver fxn w/ periodic rechecks; common SE include rash, headache, dizziness, and abdominal discomfort 3. pregnancy 4. may potentiate the effects of antihypertensive drugs, insulin, & estrogen. Use cautiously with other drugs that cause liver damage

What effect does CYP450 inhibitors or inducers have on OCs? 1. inducers of hepatic cytochrome P3A4 can accelerate OC 2. Women taking OCs in combination with any of these agents should be alert for indications of reduced OC blood levels, such as 3. If these signs appear, it may be necessary to either

1. metabolism and thereby reduce OC effects 2. breakthrough bleeding or spotting. 3. (1) increase the estrogen dosage of the OC, (2) combine the OC with a second form of birth control (e.g., condom), or (3) switch to an alternative form of birth control.

Major drug classes for Insomnia Barbiturates 1. examples 2. MOA 3. Therapeutic Use

1. methohexital, secobarbital, phenobarbital 2. bind to the GABA receptors & directly mimic the actions of GABA; unlike benzos they have no ceiling effect & can easily cause fatal respiratory depression 3. replaced by benzos for insomnia b/c of safer SE profile for benzos, Phenobarbital is used for seizures

Summary of Key Prescribing Considerations Triptans 1. Therapeutic Goal: Termination of 2. Baseline Data: Assess for possible underlying 3. Monitoring: No 4. Identifying High-Risk Patients: All triptans are contraindicated for 5. Evaluating Therapeutic Effects: Determine the size and frequency 6. Minimizing Adverse Effects: Sumatriptan can cause

1. migraine headache 2. causes of HA, including severe HTN, hyperthyroidism, tumors, or infection. 3. lab monitoring is necessary with this drug class. 4. pts with ischemic heart disease, prior MI, or uncontrolled hypertension. 5. of doses used and the extent to which therapy has reduced the intensity and duration of attacks. 6. birth defects. Interactions with ergot alkaloids, SSRIs, SNRIs, MAOIs should be considered.

COMT Inhibitors ie: entacapone and tolcapone 1. benefits derive from inhibiting metabolism of levodopa in the 2. Tolcapone, is a COMT inhibitor used only in 3. Black Box Warning-Tolcapone

1. periphery; these drugs have no direct therapeutic effects of their own 2. conjunction with levodopa—and only if safer agents are ineffective or inappropriate 3. increases the risk for Liver injury/failure which may be fatal. Close monitoring is required. Tolcapone should be dc'd if clinical sx of liver injury occurs or if AST or ALT elevation is twice the upper range of normal.

Summary of Key Prescribing Considerations Ergot Alkaloid 1. Therapeutic Goal: Termination of 2. Baseline Data: Assess for possible 3. Monitoring: 4. Identifying High-Risk Patients: Ergot alkaloids are contraindicated in 5. Evaluating Therapeutic Effects: Determine the 6. Adverse Effects: Toxicity (ergotism) can result from

1. migraine or cluster headache. 2. causes of HA, including severe HTN, hyperthyroidism, tumors, or infection. 3. No lab monitoring is necessary 4. pts with hepatic or renal impairment, CAD, and PVD. 5. size and frequency of doses used and the extent to which therapy has reduced the intensity and duration of attacks. 6. acute or chronic overdose. Signs include muscle pain, paresthesia, and cold extremities

St. John's wort how they interact with conventional drugs and common problems that can happen with each one 1. It is used by many for treating 2. Do not take med if 3. Combining St. John's wort and 4. Adverse effects

1. mild/mod depression. Also used for Menopausal Sx, wound healing/inflammation/pain and Somatoform disorders 2. pregnant or trying to conceive 3. certain antidepressants can lead to a potentially life-threatening increase in levels of serotonin; also avoid CYP450 drugs & p-glycoprotein drugs, 4. upset stomach, dry mouth, HA, fatigue, dizziness, confusion, sexual dysfunction, or sensitivity to sunlight. VERY hepatotoxic Also, St. John's wort is a stimulant and may worsen feelings of anxiety in some people. Can cause allergies in pts allergic to ragweed and daisies

Local vs. systemic estrogen options and why one would be chosen over the other 1. Oral-Owing to convenience, the oral route is used 2. Transdermal estradiol is available in four formulations: 3. Compared with oral formulations, transdermal formulations have four advantages: 4. Intravaginal options come as inserts, creams, and vaginal rings & 5. The other vaginal ring (Femring) is used for systemic effects to 6. Parenteral; is used only for emergencies d/t

1. more than any other. estradiol—is available alone and in combination with progestin 2. Emulsion (Estrasorb), Spray, Gels & Patches 3a. The total dose of estrogen is greatly reduced 3b. There is less nausea and vomiting. 3c. Blood levels of estrogen fluctuate less. 3d. There is a lower risk for DVT, pulmonary embolism, and stroke. 4. are used only for local effects, primarily treatment of vulval and vaginal atrophy associated with menopause. 5. control of hot flashes and night sweats as well as local effects-Tx of vulval and vaginal atrophy 6. acute, emergency control of heavy uterine bleeding

Traditional Antiseizure Drugs 1. Phenytoin (Dilantin) HYDANTOINS-(class) is our 2. Mechanism of Action Adverse Effects 3a. CNS 3b. Gingival hyperplasia 3c. Dermatologic effects (Asian subgroups high-risk) 3d. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS

1. most widely used antiseizure drug; active against partial seizures as well as primary generalized tonic-clonic seizures. 2. causes selective inhibition of sodium channels; blocks only hyperactive neurons while leaving healthy neurons unaffected 3a. levels > 20 µg/mL, can lead to toxicity causing Nystagmus, sedation, ataxia (staggering gait), diplopia (double vision), and cognitive impairment 3b. excessive growth of gum tissue) is characterized by swelling, tenderness, and bleeding of the gums. Can req gingivectomy; seen in about 20% of pts; folic acid helps reduce gingival overgrowth 3c. 2-5% of pts dev a morbilliform (measles-like) rash. Rarely, progresses to SJS or toxic epidermal necrolysis TEN; strongly assoc with genetic mutation HLA-B 1502 3d. strongly assoc with HLA-B 1502 causing hypersensitivity rxn characterized by skin eruptions, lymphadenopathy, fever, and multi-organ disfxn

Adverse Effects (SNRI) Venlafaxine 2. Venlafaxine can cause a variety of adverse effects. The most common is 2. Dose-dependent 3. Venlafaxine can also cause dose-related sustained 4. Some patients experience 5. Like the SSRIs, venlafaxine can cause 6. Like all other antidepressants, venlafaxine may increase the risk for 7. The combined use of venlafaxine with MAOIs

1. nausea (37% to 58%), followed by HA, anorexia, nervousness, sweating, somnolence, and insomnia. 2. weight loss may occur secondary to anorexia. 3. diastolic hypertension; blood pressure should be monitored. Sexual dysfunction may occur too. 4. sustained mydriasis, which can increase the risk for eye injury in those with elevated IOP or glaucoma. 5. hyponatremia, especially in older adult patients taking diuretics. 6. suicide, especially in children and young adults. 7. and other serotonergic drugs increase the risk for serotonin syndrome; B/c of this, use with an MAOI is contraindicated; they should be withdrawn at least 14 days before starting venlafaxine. When switching from venlafaxine to an MAOI, venlafaxine should be discontinued 7 days before starting the MAOI.

Effects related to estrogen or progestin imbalance. 1. Effects that can result from an excess of estrogen include 2. Progestin excess can increase 3. A deficiency in either hormone can cause 4. For women who experience androgenic effects (e.g., acne, hirsutism)-caused by progestin, switching to 5. When one combination OC is being substituted for another,

1. nausea, breast tenderness, and edema. 2. appetite and cause fatigue and depression. 3. menstrual irregularities. 4. an OC that has drospirenone or dienogest can help 5. the change is best made at the beginning of a new cycle

MOAs of progestin-only contraception 1. minipills are weak inhibitors of ovulation; henceforth 2. Under the influence of progestins, cervical glands produce a thick, 3. Progestins also modify the endometrium, making it

1. this is not their primary MOA for preventing pregnancy 2. sticky mucus that acts as a barrier to penetration by sperm. 3. less favorable for implantation.

Adverse Effects -Pramipexole a DA agonist 1. The most common effects seen when pramipexole is used alone are 2. When the drug is combined with levodopa, about 50% of patients experience 3. Pramipexole & Ropinirole has been associated with impulse control disorders ie: DDS, including 4. Risk factors for DDS include 5. providers should screen patients

1. nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, and hallucinations. 2. orthostatic hypotension and dyskinesias, & incidence of hallucinations nearly doubles. 3. compulsive gambling, shopping, binge eating, and hypersexuality. These behaviors are dose-related & begin about 9 months after starting 4. younger adulthood, a family or personal history of alcohol abuse 5. for compulsive behaviors before starting them on a DA agonist

Pathophysiology Migraine headache 1. Migraine headache is a 2. The role of CGRP is to 3. the role of 5-HT is to

1. neurovascular disorder that involves dilation and inflammation of intracranial blood vessels 2. to promote migraine, 3. suppress migraine

Cluster Headaches 1. cluster headaches differ in several ways: 2. Drug Therapy is directed at 3. 1st line therapy is 4. Abortive therapy can be achieved with

1. not preceded by aura, No N/V; they can be more debilitating, b/c of there freq; less common and occur mostly in males (5 : 1 ratio), No assoc family hx; management is different. 2. prophylaxis; & includes glucocorticoids (prednisone and dexamethasone), verapamil, and lithium 3. Verapamil inject in the back of the head; 2nd line therapy is lithium b/c of is adverse SE 4. sumatriptan or oxygen

Newer Antiseizure Drugs 1. Gabapentin has a broad spectrum of antiseizure activity. However, 2. Dosage Considerations 3. Significant Drug Interactions 4. Adverse Reactions- most common side effects are

1. only FDA-approved as adjunctive therapy of partial seizures (with or without secondary generalization); Also recommend as monotherapy of partial seizures; Two forms of gabapentin are not currently indicated for management of epilepsy & include ER (Gralise), for postherpetic neuralgia; & enacarbil (Horizant), for tx of restless legs syndrome 2. Absorption is not affected by food. However, as dosage gets larger, the % absorbed gets smaller. B/c intestinal transport system becomes saturated 3. Unlike most antiseizure drugs, its devoid of significant interactions 4. somnolence, dizziness, ataxia, fatigue, nystagmus, and peripheral edema. These are usually mild to moderate & diminish with continued drug use. Avoid driving/hazardous activities if unsure of impairement

Patient Education Dopamine Agonists 1. Patients should be informed that N/V can be reduced by taking 2. Pts should be informed about sxs of 3. The potential for 4. Forewarn patients that DA agonists can cause (blank) especially in older adults 5. Pts should also be aware that pramipexole, ropinirole, rotigotine, and apomorphine can cause 6. Patients of childbearing age should know that (blank) may harm the developing fetus and advised to use effective birth control.

1. oral DA agonists with food and told to notify their provider if the N/V persist or become severe. Patients taking apomorphine may be pretreated with trimethobenzamide (Tigan), an antiemetic. 2. orthostatic hypotension (dizziness, lightheadedness on standing) and advised to sit or lie down if these occur. They should also be told to move slowly when sitting up or standing up. 3. movement disorders (tremor, dystonic movements, twitching) should be explained; if these occur, patients should notify their provider. 4. hallucinations; , and instruct them to notify you if these develop. 5. sleep attacks. If they occur, pts should avoid potentially hazardous activities (e.g., driving) until they can be adequately managed. 6. ropinirole

Analgesics 1. Acetaminophen should be used only in combination with 2. Opioid analgesics include what agent

1. other drugs ie, aspirin, and caffeine (Exedrin), or naproxen or diclofenac 2. butorphanol nasal spray & should be used cautiously d/t the potential for dependence causing medication overuse headache (MOH)

Combination therapy of PD 1. The combination of levodopa plus carbidopa is 2. Carbidopa has no therapeutic effects of its own; however, it inhibits 3. Advantages of carbidopa 3a. By increasing the fraction of levodopa available for actions in the CNS, 3b. By reducing the production of dopamine at the periphery, carbidopa reduces 3c. By causing direct inhibition of decarboxylase, carbidopa eliminates concerns about decreasing the effects of levodopa by 4. Disadvantages of carbidopa 4a. When levodopa is combined with carbidopa, abnormal

1. our most effective therapy for PD 2. the decarboxylation of levodopa in the intestine and peripheral tissues, making more levodopa available to the CNS (roughly 8% more) 3a. carbidopa allows the dosage of levodopa to be reduced by about 75% (ie 500mg vs 100mg) 3b. carbidopa reduces CV responses to levodopa as well as N/V. 3c. taking a vitamin preparation that contains pyridoxine. 4a. movements and psychiatric disturbances can occur sooner and can be more intense than with levodopa alone.

Types of Seizures 1. Seizure can be divided into two broad categories: 2. In partial seizures, seizure activity undergoes 3. In generalized seizures, focal seizure activity is

1. partial (focal) seizures and generalized seizures 2. a very limited spread to adjacent cortical areas beyond the focus. 3. conducted widely throughout both hemispheres; Generalized seizures may be convulsive or nonconvulsive.

Administration methods for transdermal preparations 1. Testosterone is available in three transdermal formulations: 2. patches (Androderm) are indicated for 3. the gels have three advantages over patches: they 4. Black Box Warning-Testosterone Gel and Topical Solution 5. Why is secondary exposure a problem with gels?

1. patch, gel, and liquid 2. male hypogonadism; applied once daily to the upper arm, thigh, back, or abdomen; adverse effect is rash at the site of application 3. (1) cause less local irritation, (2) cannot fall off, and (3) produce more consistent testosterone levels. 4. Secondary exposure to testosterone gel on uncovered skin and on unwashed clothing has resulted in virilization in children & female partners 5. only 10% of an applied dose is absorbed; the other 90% remains on the skin after the gel dries

1. OCD is characterized by 2. An obsession is defined as a 3. Treatment; (blank) is probably more important in OCD than in any other psychiatric disorder 4. DOC for OCD 5. Therapy of an initial episode

1. persistent obsessions and compulsions that cause marked distress, consume at least 1 hour a day, and significantly interfere with daily living 2. recurrent, persistent thought, impulse (need for cleanliness or orderliness); whereas a compulsion a ritualized behavior or mental act in response to the obsession 3. Behavioral therapy 4. SSRIs are first-line drugs for OCD 5. should continue for at least 1 year; withdrawal should be done slowly; relapse is common

Treatment of hypogonadism 1. Hypogonadism is a condition in which the testes fail to 2. Benefits of testosterone therapy include 3. principal drugs employed for testosterone replacement 4. The routes used for Tx are

1. produce adequate amounts of testosterone. causes may be hereditary, pituitary failure, hypothalamic failure, and primary dysfunction of the testes. 2. treatment restores libido, increases ejaculate volume, and supports expression of secondary sex characteristics; Tx does NOT restore fertility 3. are testosterone itself and two testosterone esters: testosterone enanthate and testosterone cypionate 5. oral tablets, IM injection, buccal, transdermal, gel, nasal and implants (or implantable pellets)

SE of OCs- Cancer. 1. OCs present no known risk for cancer—with the important exception of 2. OCs protect against (blank & blank) CA and have no effect on (blank), which is caused by human papillomaviruses. 3. OCs do increase risk of breast CA for some women, specifically 4. estrogens can promote the growth of

1. promoting (not causing) breast cancer growth 2. ovarian and endometrial; cervical cancer 3. women who have the BRCA1 gene mutation BUT not the BRCA2 mutation 4. existing breast carcinoma; which is why this is a absolute contraindication

Physiologic and Pharmacologic Effects of Testosterone 1. endogenous androgens have only moderate effects in females. 2. Anabolic Effects; testosterone promotes 3. Erythropoietic Effects; Testosterone promotes synthesis of

1. promotion of clitoral growth and, perhaps, maintenance of normal libido. 2. growth of skeletal muscle. 3. erythropoietin, a hormone that acts on bone marrow to increase production of erythrocytes

Summary of Key Prescribing Considerations-5-α Reductase-Inhibitors 1. Therapeutic Goal: Reduction in 2. Baseline Data: 3. Monitoring: Repeat 4. Identifying High-Risk Patients: Do not prescribe for patients 5. Evaluating Therapeutic Effects: 6. Minimizing Adverse Effects: The most common adverse effect is sexual dysfunction. Because these changes can be permanent,

1. prostate size relieves symptoms of bladder outlet obstruction 2. PSA 3. PSA at 6 months; if there is no decrease, evaluate for prostate cancer. Repeat PSA periodically. 4. suspected to have prostate cancer 5. Anticipate symptom improvement after 6-12 months. 6. the patient should return for possible dosage adjustment or change in medications if this concerns the patient.

Management of social anxiety disorder (SAD) 1. Studies indicate that What medications can be used On a routine basis versus on an as needed basis 2. SSRIs are considered first-line drugs for most patients who 3. Initial effects of SSRIs take about 4. Which drugs can provide rapid relief and are well suited for pts who face performance anxiety

1. psychotherapy—both cognitive and behavioral—can be as effective as drugs 2. fear multiple situations and are obliged to face those regularly; two SSRIs—paroxetine (Paxil) and sertraline (Zoloft) are approved for SAD 3. Four weeks to develop; optimal effects are seen in 8 to 12 weeks; educated pt about delayed onset 4. 1-3 mg/day of clonazepam and 1-4 mg/day for alprazolam; Propranolol (Inderal) can be taken 1-2 hours before a scheduled performance, & can reduce sx assoc with autonomic hyperactivity (tremors, sweating, tachycardia, palpitations)

Physiologic and Pharmacologic Effects of Testosterone 1. testosterone promotes the transformations that signal 2. In males Androgens are also necessary for

1. puberty in males: testes enlarge, scrotum/penis enlarge. Pubic and axillary hair appears, and hair on the trunk, arms, and legs assumes adult male patterns. growth of bone and skeletal muscle, causes height and weight to increase rapidly. Testosterone accelerates epiphyseal closure, causing bone growth to cease within a few years. The larynx enlarges, Sebaceous glands increase (skin to becomes oily; acne results) The final pubertal change is beard development. 2. Spermatogenesis

OC Use in pregnancy and lactation 1. Combination OCs enter breast milk and. 2. In contrast, progestin-only OCs have Stroke in women with migraine. 3. When used by women who experience migraine headaches 4. B/c of the low risk of stroke, contraindications for women with migraines are

1. reduce milk production, especially in the early stages of lactation (so they're contraindicated) 2. little or no effect on milk production and hence are preferred for contraception during lactation 3. OCs may increase the risk for thrombotic stroke 4. >35 years, smokers, and those with HA that are preceded by a visual change known as an aura

Tyramine & Drug Interactions with (MAOIs) 1. MAOIs must not be dispensed to patients considered incapable of 2. Before an MAOI is dispensed, the patient must be fully informed 3. The patient must be given 4. The patient should be instructed to avoid all drugs not specifically .

1. rigid adherence to dietary restrictions. 2. about the hazard of ingesting tyramine-rich foods. 3. a detailed list of foods and beverages to avoid. 4. approved by the prescriber

IMINOSTILBENES Examples Carbazepine (Tegretol), Oxcarbazepine, Valproic acid (Depakote) 1. MOA 2. Drug-drug interactions 3. Carbamazepine is effective against 4. Valproic acid is used widely to treat all 5. Monitoring-Baseline labs: 6. Patient education: Teach symptoms of

1. same as that of phenytoin; selective inhibition of Na channels; Valproic acid enhances GABA inhibition 2. Watch out for grapefruit juice! erythromycin, clarithromycin, verapamil, Decreases plasma levels of beta blockers, warfarin, OCs, doxycycline 3. tonic-clonic, simple partial, and complex partial seizures 4. major seizure types; bipolar disorder & migraines 5. CBC, chemical panel, hepatic panel, TSH level 6. bone marrow depression, CAREFUL use of medications, therapeutic dosing, KINDLING

Baseline Data Needed to prescribe and strategies to minimize adverse effects for the following: (use each option only once) 1. SSRI/SNRI 2. Tricyclic Antidepressants 3. MAOIs

1. serum sodium esp in pts with impaired renal fxn and on diuretics, SSRIs cause wt gain/SNRIs cause wt loss 2. ECG; esp in pts with dysrhythmias or <40 3. BP to monitor for HTN episodes & tyramine food indications as well as drug interaction education

Nonmotor Symptoms of PD and Their Management 1. Erectile function can be managed with 2. Orthostatic hypotension can be improved by increasing one's 3. Urinary incontinence may improve with 4. Constipation can be managed by 5. Sleep Disturbances ie daytime sleepiness & periodic limb movement (PLMS) can be managed by 6. Depression can be managed by 7. Dementia can be managed by 8. Psychosis s usually caused by the

1. sildenafil (Viagra) and PD5E-Inhibitors 2. intake of salt and fluid and possibly by taking fludrocortisone, a mineralocorticoid 3. oxybutynin and other peripherally acting anticholinergic drugs 4. getting regular exercise and maintaining adequate intake of fluid and fiber. 5. modafinil or for PLMS DA agonists pramipexole and ropinirole 6. amitriptyline but has other SE ie dementia & orthostatic hypotension 7. donepezil and rivastigmine used for AD 8. drugs taken to control motor symptoms, if this occurs DA agonists, amantadine, and anticholinergic drugs should be withdrawn, and the dosage of levodopa should be reduced to the lowest effective amount.

Valerian 1. used for 2. drug interactions 3. adverse effects 4. should be used with caution by people with

1. sleep and anxiety assoc restlessness 2. can potentiate effects of CNS depressants, ETOH, barbiturates, opioids, & muscle relaxants 3. daytime drowsiness, depression, dyspepsia, pruritus, HA, nervousness, cardiac abnormalities 4. psychiatric illnesses (e.g., depression and dementia) do NOT use in pregnancy/breastfeeding

1. Tx goals for AD 2. No single drug is more effective than the others, so 3. The current gold standard of treatment for cognitive symptoms

1. slow loss of memory and cognition and prolong independent function (delay symptom progression) 2. selection should be based on tolerability, ease of use, and cost 3. includes pharmacologic management with a cholinesterase (ChE) inhibitor and an NMDA antagonist.

Echinacea how they interact with conventional drugs and common problems that can happen with each one 1. It is used to stimulate immune function, 2. Interactions: Echinacea can oppose the effects of 3. Adverse effects 4. To avoid allergic reactions 5. Echinacea should be avoided in patients with 6. Long-term use can cause or lead to

1. suppress inflammation, treat viral infections, influenza, and common cold. Topical is used to treat wounds, burns, eczema, psoriasis, and HSV infections. 2. immunosuppressants meds that are used to treat TB, cancer and HIV 3. Unpleasant taste is most common; fever, N/V. Can rarely cause . 4. Do NOT use if a pt is allergic to daisies, ragweed, asters, chamomile, chrysanthemums 5. SLE or RA. 6. suppressed immune systems due to blocked CD28 signaling pathways and t-cells creating an immunosuppressive effect.

Summary of Key Prescribing Considerations-MAOIs 1. Therapeutic Goal: Alleviation of 2. Baseline Data: 3. Monitoring: 4. Identifying High-Risk Patients: Monoamine oxidase inhibitors are contraindicated in 5. Evaluating Therapeutic Effects: Assess patients for improvement in 6. Minimizing Adverse Effects: Educate patients

1. sx of major depression, especially atypical depression. 2. Baseline blood pressure should be obtained. 3. Blood pressures can be obtained periodically. 4. patients taking SSRIs, patients with HF, severe renal impairment, HTN, and CV disease. Also use with caution in patients taking serotonergic drugs. 5. symptoms, especially depressed mood and loss of interest or pleasure in usual activities. 6. on foods containing tyramine and to report sx of hypertensive crisis (N/V, profuse sweating, severe headache) immediately

What to Do If Doses Are Missed for products that use a 28-day cycle 1. If one or more pills are missed in the first week, 2. If one or two pills are missed during the second or third week, 3. If three or more pills are missed during the second or third week What to Do If Doses Are Missed for extended cycle products 5. For combination OCs that use an extended or continuous cycle, up to 7 days can be missed with little or no increased risk for pregnancy provided that

1. take one pill as soon as possible and then continue with the pack. Use an additional form of contraception for 7 days. 2. take one pill as soon as possible and then continue with the active pills in the pack but skip the placebo pills and go straight to a new pack once all the active pills have been taken. 3. follow the same instructions given for missing one or two pills but use an additional form of contraception for 7 days. 4. the pills had been taken continuously for the prior 3 weeks.

Patient Education Estrogens From textbook 1. Inform the patient that nausea can be reduced by 2. Remind patients that estrogens present a small risk of 3. To minimize risk of undetected breast cancer, remind patients of the need to receive 4. To reduce cardiovascular risk, advise women to avoid smoking, perform regular exercise,

1. taking estrogens with food and by dosing at night. Explain that nausea diminishes over time. 2. breast cancer and endometrial cancer. 3. periodic mammograms. Instruct the patient to report any persistent or recurrent vaginal bleeding, to r/o endometrial carcinoma 4. decrease intake of saturated fats, and take appropriate drugs for HTN, DM, and high cholesterol

Patient Education Antiseizure Drugs 1. Explain that finding the optimal dose takes time and 2. Inform patients about the dangers of abrupt 3. Advise patients who are planning a trip to 4. Explain the need to obtain refills on time so 5. Teach the patient (or a family member) to maintain

1. that the medication regimen may require tweaking over the next several appointments. 2. drug withdrawal and instruct them never to discontinue drug use without consulting the prescriber. 3. carry extra medication to ensure an uninterrupted supply in the event they become stranded 4. that they do not run out of drugs. 5. a seizure frequency chart, indicating the date, time, and nature of all seizure events. They should bring this with them to all clinic appointments.

Testosterone is the prototype of the androgen hormones. Biosynthesis and Secretion 1. Testosterone synthesis in males is promoted by two hormones of 2. In women, preandrogens (precursors of testosterone) are secreted 3. preandrogens by the adrenal glands is regulated by

1. the anterior pituitary: follicle-stimulating hormone (FSH) and luteinizing hormone (LH) 2. by the adrenal cortex and ovaries 3. adrenocorticotropic hormone, whereas synthesis of preandrogens by the ovaries is regulated by LH

Minimizing Adverse Effects for all antiseizure drugs 1. Signs of CNS depression (sedation, drowsiness, lethargy) are most prominent during 2. Abrupt discontinuation of antiseizure drugs can lead to 3. Usage in Pregnancy: the risk from uncontrolled seizures exceeds 4. Screen for depression and

1. the initial phase of treatment and decline with continued drug use. Until then have pts avoid driving and other hazardous activities & give the largest portion of the daily dose at bedtime. 2. status epilepticus. Therefore meds should be withdrawn slowly (over 6 weeks to several months). Pts will need to ensure they DON'T run out of medications. 3. the risk from medication, Valproic is highly teratogenic and can decrease the IQ of children exposed to it in utero. 4. suicidality before starting treatment and assess for these at clinic appoints.

Partial Seizures 1. (no loss of consciousness (LOC) Simple Partial Seizures-These seizures manifest with discrete symptoms that are determined by the brain region involved. Hence 2. (LOC)Complex Partial Seizures-These szs are characterized by 3. Secondarily Generalized Seizures-These szs begin as simple

1. the pat may experience discrete motor sx (e.g., twitching thumb), sensory sx (e.g., local numbness; auditory, visual, or olfactory hallucinations) autonomic sx (e.g., nausea, flushing, salivation, urinary incontinence), or psychoillusory sx (e.g., feelings of unreality, fear, or depression). 2. impaired consciousness and lack of responsiveness. At sz onset, the pat becomes motionless and stares with a fixed gaze. This state is followed by a period of automatism, in which the patient performs repetitive, purposeless movements: lip smacking or hand wringing 3. or complex partial seizures and then evolve into generalized tonic-clonic seizures

SE of OCs-Glucose intolerance. 1. OCs can elevate blood glucose levels. This diabetogenic effect is caused by 2. Glucose intolerance is most likely in patients who are

1. the progestin in OCs. 2. already diabetic or have experienced gestational diabetes

How does this impact prescribing of OCs? Drugs whose effects are increased by oral contraceptives. 1. OCs can impair the hepatic metabolism of several agents, including 2. Because of reduced clearance, these drugs may accumulate to toxic levels. If signs of toxicity appear,

1. theophylline, TCAs, diazepam, and chlordiazepoxide (Librium) 2. the dosages of these drugs should be reduced

Monitoring Lithium 1. Lithium has a low 2. Generally levels should be between 3. Blood for lithium determinations should be drawn in 4. BLACK BOX WARNING:

1. therapeutic index. Accordingly, the monitoring of lithium levels is mandatory & an essential component of treatment. 2. 0.6-0.8 mEq/L as these levels are effective for most 3. the am; 12 hours after the evening dose. Lithium levels should be measured every 2-3 days during initial therapy & every 3-6 months during maintenance. 4. Lithium toxicity can occur at doses close to therapeutic levels. Facilities for prompt & accurate serum lithium determinations should be available before initiating therapy

Patient-Centered Care Across the Life Span Drugs for BPH 1. Pregnant women-Finasteride and dutasteride are teratogens; 2. Breast-feeding women-It is not known if 5-α-reductase inhibitors are 3. Older adults-Beers Criteria includes the

1. they cause feminization of the male fetus. Because these drugs can be absorbed through the skin, pregnant women should not handle finasteride or dutasteride tablets that have been broken or crushed. Men taking finasteride or dutasteride should not donate blood to avoid the risk of exposing a pregnant recipient. 2. excreted in breast milk. Women taking these drugs for off-label uses (e.g., hirsutism) should not breastfeed. 3. peripheral α-1 blockers doxazosin and terazosin among its listing of potentially inappropriate medications for patients age 65 and older.

Therapeutic Goal of Drugs for PD 1. Drugs can only provide symptomatic relief; 2. Furthermore, there is no convincing proof that any current drug 3. Given the neurochemical basis of parkinsonism—too little striatal dopamine and too much acetylcholine—the approach to treatment is 4. two types of drugs are used:

1. they do not cure PD 2. can delay disease progression 3. give drugs that can restore the functional balance between dopamine and acetylcholine. 4. (1) dopaminergic agents (i.e., drugs that directly or indirectly activate dopamine receptors) and (2) anticholinergic agents ie, Benztropine (rarely used)

Patient Education-Cholinesterase Inhibitors/Memantine 1. Explain that this drug is prescribed to improve 2. Explain that lightheadedness may occur and that this increases the 3. Encourage patient and family to ensure adequate. 4. Have the patient keep a list of new

1. thinking and function in patients with Alzheimer disease. It does not work on everyone. 2. risk for falls. If this occurs, sit or lie down until it passes. Move slowly when changing to a standing position; sudden movement may increase dizziness. 3. intake with supplemental meals and snacks to maintain optimal weight 4. symptoms and problems so that these can be discussed at each patient encounter.

Benefits and drawbacks of progestin-only contraception Pros 1. Because they lack estrogen, minipills do not cause 2. progestin-only OCs have little or no effect on breastmilk Cons 3. progestin-only preparations are less effective and 4. Irregular bleeding is the major drawback of these products and

1. thromboembolic disorders, HAs, nausea, or most of the other adverse effects associated with combination OCs, making it an alternative for women with high risk of thromboembolic disorders 2. and can be used during lactation 3. are more likely to cause irregular bleeding 4. the principal reason that women discontinue them.

Black Box Warning Estrogen and Progestin Therapy 1. Estrogen plus progestin may increase the risk for 2. Estrogen plus progestin is not indicated for 3. Estrogen plus progestin may increase the risk for

1. thromboembolic events such as DVT, stroke, myocardial infarction, and pulmonary embolism. 2. CV disease or dementia and may increase the risk for dementia in women aged 65 years and older. 3. breast cancer

Overview of Treatment 1. Drugs for migraine are employed in two ways: 2. Drugs used to abort an attack fall into two groups: 3. Drugs employed for prophylaxis include

1. to abort an ongoing attack and to prevent attacks from occurring. 2. nonspecific analgesics (aspirin-like drugs and opioid analgesics) and migraine-specific drugs (serotonin1 B/1D receptor agonists [triptans] and ergot alkaloids). 3. β blockers (propranolol), TCAs (amitriptyline), CGRP receptor antagonists, and antiepileptic drugs (divalproex)

Summary of Key Prescribing Considerations Levodopa Combinations 1. Therapeutic Goal: To maintain or improve the patient's ability 2. Baseline Data: HR & BP and general cardiovascular (especially if apomorphine or cabergoline are being considered) and neuro/motor assessment. ie: 3. Monitoring: Orthostatic VS must be assessed at each 4. Identifying High-Risk Patients: Caution must be exercised in dealing with patients who have

1. to carry out activities of daily living. 2. bradykinesia, akinesia, postural instability, tremor, rigidity—should be assessed as well as the extent to which these interfere with ADLs (e.g., ability to work, dress, bathe, walk). Some studies suggest that levodopa can activate malignant melanoma, so a careful skin assessment should also be performed. 3. clinic visit. If the patient reports palpitations or if dysrhythmias are suspected, an ECG may be indicated. Motor function must be evaluated and compared with baseline. 4. cardiac disease or psychiatric disorders and in those taking selective MAO-B inhibitors.

What should be done if suicidal thoughts emerge during drug therapy, or if depression is persistently worse while taking drugs? 1. One option is 2. Another option is to

1. to switch to another antidepressant. 2. stop antidepressants entirely. If the risk for suicide appears high, temporary hospitalization may be the best protection

Administration Considerations-Rivastigmine 1. Rivastigmine is administered orally or 2. Blood levels are lower with 3. Rivastigmine has no significant 4. Common SE​ 5. Precautions​

1. topically (transdermal patch) 2. transdermal dosing than with oral dosing, hence the intensity of SE is lower as well. 3. drug interactions, probably because it does not interact with hepatic drug-metabolizing enzymes. 4. GI sx (anorexia, N/V, or diarrhea)​, weakness​ dizziness​, tremor​ 5. asthma/COPD​, sick sinus syndrome​, GI Bleeding​ & weight < 50 kg​

Posttraumatic Stress Disorder 1. develops after a 2. PTSD has three core symptoms: Treatment 3. Two basic types of psychotherapy are recommended: 4. Regarding drugs, evidence of efficacy is strongest for

1. traumatic event that elicited an immediate reaction of fear, helplessness, or horror 2. re-experiencing the event, avoiding reminders of the event (coupled with generalized emotional numbing), and a persistent state of hyperarousal 3. trauma-focused therapy and stress inoculation training 4. three SSRIs (fluoxetine, paroxetine, and sertraline) and one SNRI (venlafaxine); only paroxetine (Paxil) and sertraline (Zoloft)—are FDA approved for PTSD.

Atypical Antidepressants example: Bupropion 1. MOA 2. therapeutic use 3. Patient education 4. Adverse effects 5. Drug interactions

1. unclear but may be related to blockade of dopamine or NE reuptake. The drug does not affect serotonergic, cholinergic, or histaminergic transmission, and does not inhibit MAO 2. is a good alternative to SSRIs for 1) major depressive disorder and (2) prevention of seasonal affective disorder 3. effects begin in 1 to 3 weeks; unlike SSRIs does not cause weight gain or sexual dysfunction 4. most common- agitation, headache, dry mouth, constipation, weight loss, GI upset, dizziness, tremor, insomnia, blurred vision, and tachycardia. Most serious is Seizures occurring in doses above 450 mg/day 5. drugs that inhibit CYP2B6 (sertraline, fluoxetine, paroxetine) can increase risk for szs; MAOIs can increase risk for toxicity

Black Box Warning for Estrogen Therapy 1. Endometrial cancer risk is increased in women with a 2. Estrogen may increase the risk for 3. Estrogen is not indicated for

1. uterus who take unopposed estrogen. 2. deep vein thrombosis and stroke. 3. cardiovascular disease or dementia and may increase the risk for dementia in women aged 65 years and older.

Ginger root how they interact with conventional drugs and common problems that can happen with each one 1. used primarily to treat 2. Interactions: Ginger can suppress platelet aggregation. Accordingly, ginger can increase 3. Very few adverse effects but excessive doses (above 5g/d) have the potential to cause

1. vertigo and to suppress N/V assoc with motion sickness, morning sickness, seasickness, and anesthesia. Ginger has antiinflammatoryanalgesic properties used to tx arthritis & other chronic inflammatory conditions 2. the risk for bleeding with antiplatelet drugs (ASA) or anticoagulants (warfarin/heparin) or other drugs that inhibit clotting via thrombin & factor XA inhibitors. Ginger may potentiate the hypoglycemic effects of insulin and other drugs for diabetes 3. CNS depression and cardiac dysrhythmias, & GI disturbances.

Patient Education-Levodopa/Carbidopa 1. So that expectations may be realistic, inform patients that benefits of levodopa may be delayed for 2. Forewarn patients about possible abrupt loss of therapeutic effects during 3. Inform patients that N/V can be reduced by taking levodopa with 4. Counsel patients about possible levodopa-induced movement disorders ie

1. weeks to months. This will facilitate adherence. 2. off times and instruct them to notify you if this occurs. Avoiding high-protein meals may help. 3. low-fat, low-protein foods such as fruits and vegetables. In addition high fat meals can reduce absorption reducing therapeutic effects. Instr pts to notify you if N/V persist or becomes severe. 4. (tremor, dystonic movements, twitching) and instruct them to make an appointment for follow-up if these develop.

Summary of Key Prescribing Considerations -Estrogens 1. Therapeutic Goal: Management of symptoms and structural changes associated 2. Baseline Data: Heart rate, blood pressure, weight. Pregnancy test, thyroid-stimulating hormone (TSH), & 3. Monitoring: Blood pressure, weight. Serum triglycerides, TSH if thyroid replacement required, & 4. Identifying High-Risk Patients: Estrogen therapy should not be prescribed for patients with: 5. Evaluating Therapeutic Effects: Therapeutic effects depend on the reason prescribed.

1. with decreased endogenous estrogen. (Other uses include palliation of metastatic breast cancer in selected cases.) 2. serum triglyceride (or full lipid panel). Screening for breast CA and CV disease. Gynecologic exam, if indicated. 3. Regular breast and pelvic exams as recommended for age. Schedule endometrial biopsy for unscheduled bleeding that continues for 6 months. 4. Abnormal vaginal bleeding of unknown cause • Estrogen-dependent cancer or breast cancer (except when used as treatment for certain metastatic cancers) • History of DVT or pulmonary embolism • Stroke, MI, or other arterial thromboembolism occurring within the past year • Abnormal liver function or disease • Pregnancy 5. For menopausal HT, patients report relief of symptoms and the vagina is pink and moist on gynecologic exam.

Clinical Practice Guidelines for menopause Not all women who experience distressing symptoms of menopause should be treated with oral estrogen or combination estrogen/progestin therapy. Key points include: 1. intravaginal preparations are most useful for treating sx associated 2. transdermal estrogen preparations have fewer adverse effects, use lower doses of estrogen, and have 3. progesterone is contraindicated in women who have undergone a

1. with local estrogen deficiency such as vaginal and vulvar atrophy; these preparations are assoc with a lower risk of systemic effects 2. less fluctuation of estrogen levels than do oral preparations 3. hysterectomy but required in women with an intact uterus who undergone hormone replacement therapy

Summary of Key Prescribing Considerations-Memantine 1. Therapeutic Goal: Slow cognitive and functional decline of patients 2. Baseline Data: Cognitive and functional neurological status. R/O 3. Monitoring: At each visit, assess cognition, functional status & 4. Identifying High-Risk Patients: Use caution with prescribing to 5. Evaluating Therapeutic Effects: Evaluate for improvement of 6. Minimizing Adverse Effects: 6a. Dizziness can increase the risk for 6b. Advise patients to take acetaminophen or NSAIDS for 6c. Have the patient notify you if they have changes in

1. with moderate to severe AD 2. out corneal conditions and hepatic conditions check renal fxn 3. scheduling ophthalmic exams while taking this drug. 4. patients with a hx of CV disease, hepatic or renal impairment, or ophthalmic disease. 5. cognitive and functional status. 6a. falls. Institute fall risks if hospitalized. 6b. headaches. 6c. vision, develop a rash, or have chest pain or other new symptoms

Treatment of STIs/STDs-Syphilis 1. Primary, secondary, & early latent syphilis 1a. Children 1b. Adults 2. Late latent syphilis or latent syphilis of unk duration, or Tertiary 2a. children 2b. adults 3. Neurosyphilis 4. Congenital syphilis

1a. (Rx on exam) Benzathine PCN G, 50,000 units/kg IM once 1b. Benzathine PCN G, 2.4 million units IM once 2a. Benzathine PCN G, 50,000 units/kg IM once/week for 3 weeks 2b. Benzathine PCN G, 2.4 million units IM once/week for 3 weeks 3. Aqueous crystalline PCN G, 18-24 million units IV daily for 10-14 days 4. Aqueous crystalline PCN G, 50,000 units/kg IV every 12 h for the first 7 days of life, followed by 50,000 units/kg every 8 h for the next 3 days OR Procaine PCN G, 50,000 units/kg IM once daily for 10 days

Know Examples for the major drug classes for Insomnia Melatonin Receptor Agonist 1a. Examples 1b. MOA 1c. Therapeutic Use 1d. Adverse Effects 1e. Rx considerations

1a. Ramelteon 1b. activates receptors for melatonin which are key mediators of the normal sleep-wake cycle 1c. good for inducing sleep but NOT maintaining it. 1d. common: somnolence, dizziness, and fatigue, sleep driving, can increase levels of prolactin and reduce levels of testosterone; causing amenorrhea, galactorrhea, reduced libido, and fertility problems 1e. avoid use during pregnancy/nursing mothers

Know Examples for the major drug classes for Insomnia Benzodiazepines 1a. Examples include 1b. MOA 1c. High risk pts 1d. Adverse effects 1e. Rx considerations

1a. Triazolam [Halcion], Flurazepam, Estazolam, Quazepam, Temazepam 1b. They are NOT GABA agonists; they simply intensify the effects of GABA to produce CNS depression 1c. This is contraindicated for pregnancy; use extreme caution in pts with resp illness COPD/OSA & in pts with a hx of substance abuse 1d. CNS depression-daytime drowsiness, Anterograde Amnesia ((impaired recall after dosing), sleep-driving, paradoxical effects, tolerance/dependence & abuse 1e. warn pts abrupt cessation can cause withdrawal/rebound insomnia even after short term use

Traditional Antiseizure Drugs Phenytoin Adverse Effects 1a. Blackbox warning: Cardiovascular effects. 1b. Others Significant Drug Interactions 2a. Induction of hepatic drug-metabolizing enzymes 2b. Drugs that increase plasma levels (causing toxicity sx) 2c. Drugs that decrease plasma levels (causing breakthrough szs) 2d CNS depressants effects will add to 2e. Enteral tube feedings

1a. When admin by IV injection (to treat SE), cardiac dysrhythmias and hypotension may result. Can be minimized by injecting no faster than 50 mg/min 1b. Hirsutism; Interference with vit D metabolism causing rickets and osteomalacia (softening of bones). Interference with vit K metabolism can cause bleeding esp in newborns. Rare, liver damage from drug allergy. Oral preparations may cause gastric discomfort 2a. can decrease the effects of OCs, warfarin, & glucocorticoids 2b. Drugs known to elevate phenytoin levels include diazepam, isoniazid, cimetidine (for gastric ulcers), & alcohol (when taken acutely) 2c. Carbamazepine, phenobarbital, and alcohol (when used chronically) can accelerate the metabolism 2d. those of phenytoin: alcohol, barbiturates, & others 2e. TFing decreases phenytoin absorption and can lead to subtherapeutic serum levels. Don't admin with TFs. For continuous TFs, hold the feeding for 1 to 2 hours before and after phenytoin administration

Know Examples for the major drug classes for Insomnia Benzodiazepine-like Drug 1a. examples 1b. Therapeutic use/MOA 1c. SE

1a. Zolpidem (Ambien IR/ER), Zaleplon (Sonata) Eszopiclone (Lunesta) 1b. except for Sonata all are used for DFA/DMS; MOA: binds to GABA receptor-chloride channel complex & enhances the depressant actions of endogenous GABA 1c. headache, nausea, drowsiness, dizziness, sleep driving, less of risk for dependance/rebound insomnia than benzos, (only sched IV)

Summary of Key Prescribing Considerations-Progestins 1. Therapeutic Goal: Goals for noncontraceptive uses are to counteract 2. Baseline Data: Heart rate, blood pressure, and weight. 3. Monitoring: Blood pressure. Assessment for fluid retention, including weight. Consider referral for 4. Identifying High-Risk Patients: Progestins are contraindicated in the presence of 5. Minimizing Adverse Effects: Progestins can cause breakthrough bleeding, spotting, and amenorrhea. Warn patients that

1a. endometrial hyperplasia caused by unopposed estrogen during HR 1b. management of dysfunctional uterine bleeding, amenorrhea, and endometriosis 1c. support of pregnancy in women with corpus luteum deficiency & also used in in vitro fertilization cycles and to prevent risk for preterm birth. 2. Pregnancy test. Screening for breast and cardiovascular disease. Pelvic exam as indicated for age. 3. transvaginal ultrasound or hysteroscopy for occurrence of undx'ed bleeding for >6 months. 4. undx'ed vaginal bleeding, active thrombophlebitis or a hx of thromboembolic disorders, active liver disease, breast CA & women who've had a hysterectomy 5. this may occur, and instruct them to report any abnormal or prolonged vaginal bleeding.

What behaviors would make one birth control method more effective over another? 1. personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. 2. If family planning goals have already been met 3. For women who engage in coitus frequently, 4. Conversely, when sexual activity is limited, 5. Because barrier methods combined with spermicides can offer some protection against STDs 6. If adherence is a problem (as it can be with OCs, condoms, and diaphragms),

1a. even the best form of contraception will be less effective if improperly practiced, 1b. Practitioners should take pains to educate patients about the contraceptive methods available so that selection and use can be based on understanding 2. sterilization of either the male or female partner may be desirable. 3. OCs or a long-term method (e.g., Nexplanon, Depo-Provera, IUD) are reasonable choices 4. use of a spermicide, condom, or diaphragm may be more appropriate. 5. these combinations may be of special benefit to individuals who have multiple partners. 6. use of a long-term method (e.g., vaginal contraceptive ring, IUD, Nexplanon, Depo-Provera) can confer more reliable protection.

Summary of Key Prescribing Considerations Phosphodiesterase-5 Inhibitors 2a. Minimizing Adverse Effects: Variability in response can be a problem if diet and timing are not considered. High-fat meals will delay 2b. Stress the importance of having an examination for development of

2a. absorption of avanafil, sildenafil, or vardenafil (but not tadalafil). Avanafil should be taken approximately 15-30 min before sexual activity. All other PDE-5 inhibitors should be taken about 1 h before sexual activity. Only tadalafil is approved for daily dosing. 2b. vision or hearing changes. Explain that prolonged priapism lasting longer than 4 h is a surgical emergency; go to the ED right away if this occurs.

Levodopa Adverse Effects 3a. N/V 3b. Dyskinesias 3c. Cardiovascular effects. 3d. Psychosis. 3e. Central nervous system effects

3a. Dopamine triggers the CTZ of the medulla; N/V can be reduced by admin low initial doses or with food: low fat/protein meals 3b. 80% dev dyskinesias ranging from annoying (head bobbing, tics, grimacing), to disabling (ballismus, a rapid jerking or flinging of proximal muscle groups, or choreoathetosis, a slow involuntary writhing) can be tx'ed with amantadine 3c. Postural hypotension which can lead to falls, is common early in treatment; increasing salt/water intake may help or an α-adrenergic agonist 3c. Dopamine can induce visual hallucinations, vivid dreams or nightmares, and paranoia. Two sec-gen antipsychotics—clozapine and quetiapine—have been can manage levodopa-induced psychosis. 3e. Can range from anxiety and agitation to memory and cognitive impairment. Insomnia and nightmares are common. Some experience impulse control problems, ie promiscuity, gambling, binge eating, or alcohol abuse

Patient Education-Levodopa/Carbidopa 5. Patients may require assistive devices for opening medication containers. Ask the pharmacist to avoid 6. Inform patients about signs of excessive 7. Explain that hypotension with associated dizziness and lightheadedness may occur. Advise patients to 8. Inform patients about possible levodopa-induced psychosis ie; 9. Patients should be educated on dopamine dysregulation syndrome (DDS) which can manifest as: 10. Levodopa may darken

5. using childproof containers, which can be challenging to open. If appropriate, involve family members in medicating the patient. 6. cardiac stimulation (palpitations, tachycardia, irregular heartbeat) and instruct them to notify you if these occur. 7. move slowly when sitting up or standing up. Also instruct them to sit or lie down if these symptoms occur when standing. 8. (visual hallucinations, vivid dreams, paranoia) and instruct them to seek medical attention if these develop. 9. Impulse control disorder 10. sweat and urine; patients should be informed about this is a harmless effect

Summary of Key Prescribing Considerations ChE Inhibitors Minimizing Adverse Effects: 5a. Most adverse effects 5b. Falls are more likely to occur as a result of 5c. To prevent weight loss, encourage

5a. (e.g., nausea, diarrhea, insomnia) are dose related and can be decreased by starting with lower doses and increasing gradually. These sx usually abate in 2-3 wks. 5b. bradycardia and cardiac changes. Initiate fall precautions if hospitalized and teach patient and family how to prevent falls at home. 5c. nutritional supplements (e.g., Boost) and snacks between meals. Schedule an appointment with a registered dietician.

Summary of Key Prescribing Considerations Dopamine Agonists 5. Minimizing Adverse Effects: 5a. Multiple adverse effects—To minimize adverse effects, dosage should be 5b. Avoid serotonin receptor antagonists and dopamine receptor antagonists for 5c. medication adjustments may be necessary for 5d. Fetal injury—avoid 5e. Impulse-control disorders—Pramipexole and ropinirole may induce

5a. low initially and then gradually increased. 5b. the management of N/V b/c the former can worsen orthostatic hypotension and the later can decrease the effectiveness of drugs prescribed for PD. 5c. dyskinesias, hallucinations, or sleep attacks, 5d. ropinirole if pregnancy occurs 5e. compulsive, self-rewarding behaviors, including compulsive gambling, eating, and shopping as well as hypersexuality; Before prescribing screen pts for a history of compulsive behaviors.

Patient Education Antiseizure Drugs 6. Advise patients to avoid potentially hazardous activities 7. B/c seizures may recur after 8. Forewarn pts about CNS depression that can 9. To reduce the risk for neural tube defects, advise women 10. Educate patients, families, and caregivers about signs

6. (driving, operating dangerous machinery) until seizure control is achieved; explain laws concerning this 7. they are largely under control, advise patients to carry some form of ID (Medic Alert bracelet) to aid in dx/tx if a seizure occurs. 8. occur as a drug SE. Advise them to avoid driving and other hazardous activities if CNS depression is significant; warn patients against using alcohol and other CNS depressants. 9. to take folic acid supplements before and throughout pregnancy. 10. that may precede suicidal behavior (increased anxiety, agitation, mania, or hostility) and advise them to report these immediately.

6. Minimizing Adverse Effects of Estrogen: • Nausea is common early in treatment. Advise patients that this adverse effect

6. diminishes with time. In the meantime, avoidance of cooking odors and warm, stuffy environments may help. Dry foods and raw fruits and vegetables help as well as Guided imagery with muscle relaxation, yoga, and music therapy • Menopausal HT with estrogen alone increases the risk for endometrial carcinoma. Adding a progestin lowers this risk to the pretreatment level. • Adverse effects similar to those caused by OCs (abnormal vaginal bleeding, hypertension, benign hepatic adenoma, reduced glucose tolerance)

Summary of Key Prescribing Considerations Androgens 6. Minimizing Adverse Effects: 6a. (blank) may occur in women who want to avoid this affect. . 6b. Accelerated bone maturation in children can decrease 6c. The 17-α-alkylated androgens can cause 6d. (blank & blank) may result in edema. 6e. Androgens can cause masculinization of the female fetus.

6a. Virilization; Assess for deepening voice, chest and facial hair, acne, and menstrual irregularities at each clinical encounter. Irreversible changes may be avoided if androgens are withdrawn early 6b. attainable adult height. Monitor effects on epiphyses with radiographs of the hand and wrist twice yearly. 6c. cholestatic hepatitis, jaundice. Rarely, liver CA develops. Monitor for sx of liver dysfunction such as jaundice, fatigue, and malaise. Obtain periodic AST/ALT. Liver function normalizes after the cessation of drug use. Avoid long-term use of 17-α-alkylated preparations. 6d. Salt and water retention; Assess for edema and weight gain at each clinical encounter. Consider androgen withdrawal or use of a diuretic. 6e. R/O pregnancy before androgen use. Ensure that female patients of child-bearing age are using adequate contraception

Summary of Key Prescribing Considerations Levodopa Combinations 6. Minimizing Adverse Effects 6a. N/V—Medications are best taken with 6b. If Dyskinesias develop 6c. Orthostatic hypotension—Patients should be advised to change 6d. Psychosis—(blank&blank) may be beneficial. 6e. Acute loss of effect—Off times can be reduced by combining

6a. a nonfat, nonprotein snack (e.g., fruit) for N/V 6b. A reduction in dosage may be needed. Amantadine may help with dyskinesias. 6c. from supine or sitting to standing slowly. Fall precautions must be implemented if a patient is hospitalized. 6d. Clozapine or quetiapine 6e. levodopa/carbidopa with a dopamine agonist- pramipexole, a COMT inhibitor-entacapone, or a MAO-B inhibitor-rasagiline.

Foods With Little or No Tyramine

Most vegetables Most fruits Meats that are known to be fresh (exercise caution in restaurants; meat may not be fresh sausages: Nonfermented varieties Fish that is known to be fresh; vacuum-packed fish, if eaten promptly or refrigerated Milk, yogurt, cottage cheese, cream cheese Baked goods that contain yeast Major domestic brands of beer, most wines

Which of the following is the most appropriate treatment for Mimi? a. donepezil monotherapy b. memantine monotherapy c. donepezil and galantamine d. treatment is not indicated

a. donepezil monotherapy; For pts dx with mod AD, the DOC is a ChE inhibitor plus consideration of memantine. It is not recommended to combine 2 cholinesterase inhibitors.

A patient diagnosed with Alzheimer's disease has decided to stop treatment. The NP has educated the client that medication discontinuation will result in the return of cognitive symptoms and the medication may not work as well if restarted. The client would still like to stop the medication due to the gastrointestinal side effects. Which of the following medications requires tapering? ​ a. donepezil ​ b. rivastigmine ​ c. galantamine ​

a. donepezil req tapering the others DO NOT

Cleo is a 65-year-old male diagnosed with mild cognitive changes related to Alzheimer's disease. He also has anxiety, COPD, and smokes cigarettes. Which of the following medications is appropriate for Cleo? ​ a. donepezil ​ b. rivastigmine ​ c. galantamine ​

a. donepezil ​is appropriate for Cleo. It is approved by the FDA for the treatment of mild dementia and is not affected by nicotine

Which of the following is a relevant risk factor for Mimi for Alzheimer's Disease? a. male gender b. female gender c. history of diabetes d. she is a current smoker

b. female gender; only other risk factor is advanced age

Mimi is a 67-year-old Hispanic woman presenting for a walk-in appointment. In the exam room, she states she is not feeling well and that "something is not right." She has difficulty completing her thoughts which worsened during the visit. she stopped going to church groups because of "too many new people." She also became agitated and wanted to leave. The Neuro Exam revealed: Alert, difficulty with questions of orientation, misses day and date. Could not recall the name of the physician and unable to name the objects shown Which of the following stages best describes the severity of Mimi's disease process? a. mild b. moderate c. intermittent d. severe

b. moderate; Mimi is presenting with anxiety, agitation, and difficulty recognizing family and familiar people (e.g., church friends). These symptoms are indicative of moderate stage

When on medications for AD and symptoms increase, it is better to increase the AD medication than to add things like

herbal medications, vitamins, or NSAIDs

There is convincing evidence that neuropsychiatric symptoms can be reduced with two atypical antipsychotics:

risperidone (Risperdal) and olanzapine (Zyprexa). However, benefits are modest, and these drugs slightly increase mortality, mainly from cardiovascular events and infection -avoid use of conventional antipsychotics ie: haloperidol, chlorpromazine