NR566 / NR 566 Final Exam (Latest 2024 / 2025): Advanced Pharmacology for Care of the Family – Chamberlain
NR-566 Advanced Pharmacology for
Care of the Family
Final Exam
Which anticonvulsant would be given for someone with epilepsy needing
adjunctive therapy for partial seizures with or without secondary
generalization?
Correct Answer:
Lamotrigine
Preventive therapy for migraines headache
Correct Answer:
Metoprolol/propranolol (Beta-blockers) are often used as preventive therapy
What is abortive therapy for migraines headache and when is it used?
Correct Answer:
Abortive medications stop a migraine when pt feels one coming or once it
has begun.
NSAIDS and opioid and migraine-specific meds (Triptans and Ergot
alkaloids)
used at 1st sign of attack
1st line treatment for acute, mild to moderate migraine without nausea or
vomiting
Correct Answer:
NASID: Naproxen and ASP
How to know someone would be appropriate for preventative therapy for
migraine headache
Correct Answer:
Patients who have frequent attacks 3 or more, severe attacks, or attacks
that do not respond adequately to abortive therapy
Examples of opioid analgesics reserved for severe migraines that don’t
respond to first-line medications
Correct Answer:
Butorphanol nasal spray
use one spray each nostril every 60 minutes PRN
the mechanism of action for sumatriptan
Correct Answer:
Suppresses the release of CGRP from trigeminal neurons, which leads to
vasoconstriction and decreased perivascular inflammation to relieve migraine
pain
Triptans contraindications
Correct Answer:
History of ischemic heart disease, uncontrolled hypertension,
cerebrovascular disease, pregnancy, basilar or hemiplegic migraine; use
within 24 hours of an ergot derivative
The first dose of triptan should be
Correct Answer:
under direct supervision case of any unknown underlying cardiac disease
Rivastigmine (Exelon) patient teaching
Correct Answer:
can cause bradycardia, fainting, fall, and fall-related fractures.
family teaching how to prevent fall at home
Donepezil (Aricept)
when would it be appropriate to increase the dose?
Correct Answer:
patient are stabilized on the initial dosage for 1 to 3 months before an
increased in dosage
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What is Alzheimer’s disease?
Progressive memory loss and decreasing brain function.
What causes Alzheimer’s disease?
Genetic and environmental factors leading to abnormal protein deposits in the brain.
What happens to neurons in Alzheimer’s disease?
They lose connections with other brain cells and die.
What is Parkinson’s disease?
Degenerative disorder characterized by involuntary muscle movements and tremors.
What happens to dopamine-producing neurons in Parkinson’s disease?
They are damaged, leading to decreased dopamine levels and neurotransmitter imbalance.
What is the substantia nigra?
A region in the midbrain where dopamine-producing neurons are located.
What is a seizure?
An episode of abnormal, hyperactive brain activity.
What happens to neurons during a seizure?
Their excitatory signals are hyperactive, without a normal rest period.
What are the symptoms of a seizure?
Staring blankly, loss of consciousness, loss of sensation, twitching and jerking.
What is a migraine?
A neurological disorder characterized by recurring, episodic headaches.
What is the most common symptom of a migraine?
Unilateral, pulsating head pain.
What are some accompanying symptoms of a migraine?
Nausea, vomiting, irritability, attention deficits, increased sensitivity to light and sound.
What is peripheral sensitization in migraines?
Increased sensitivity to non-painful stimuli.
What is the cause of migraines?
The mechanisms are not well understood.
What is dementia?
A general term for a decline in mental ability.
What is the most common form of dementia?
Alzheimer’s disease.
What are the characteristics of Alzheimer’s disease?
Progressive memory loss and decreasing brain function.
What is the role of dopamine in the brain?
It is a neurotransmitter involved in movement and reward.
What is the role of the substantia nigra?
It is a brain region involved in movement and Parkinson’s disease.
What is peripheral sensitization?
Increased sensitivity of peripheral nerves to pain stimuli.
What is the role of the trigeminal nerve in peripheral sensitization?
Trigeminal nerve branches are stimulated, contributing to pain.
Where does the stimulation typically occur in peripheral sensitization?
Near the forehead, paranasal sinuses, and temporomandibular joint.
What is abortive therapy and when is it used?
Abortive therapy is used to eliminate headache pain and suppress associated symptoms. It should be started at the earliest sign of an attack.
What are the two types of drugs used in abortive therapy?
Nonspecific analgesics and migraine-specific agents.
What is the first-line treatment for migraine prevention?
β blockers, with propranolol being the most commonly used.
What is the first-line treatment for acute, mild to moderate migraine without nausea or vomiting?
Sumatriptan.
When is preventive therapy indicated?
Preventive therapy is indicated for patients with frequent, severe, or inadequately responsive attacks.
What is the recommended opioid analgesic for severe migraines that don’t respond to first-line medications?
Butorphanol nasal spray.
What is the mechanism of action for sumatriptan?
Sumatriptan binds to 5-HT1B/1D receptors, causing vasoconstriction and suppressing the release of CGRP, reducing inflammation and relieving migraine pain.
What are triptans?
Triptans are a class of drugs used to treat migraines.
What is the mechanism of action for sumatriptan?
Sumatriptan binds to 5-HT1B/1D receptors, causing vasoconstriction and suppressing the release of CGRP, reducing inflammation and relieving migraine pain.
What are the contraindications for triptans?
Ischemic heart disease, prior MI, uncontrolled hypertension.
What precautions should be taken for the first dose of any triptan?
Under direct supervision in case of unknown underlying cardiac disease.
What is the purpose of prescribing Rivastigmine for Alzheimer’s disease?
To improve thinking and function in patients with Alzheimer’s disease.
What should be done if lightheadedness occurs while taking Rivastigmine?
Sit or lie down until it passes, move slowly when changing positions.
How can optimal weight be maintained while taking Rivastigmine?
Ensure adequate intake with supplemental meals and snacks.
What should the patient do to keep track of new symptoms and problems while taking Rivastigmine?
Keep a list to discuss at each patient encounter.
When is it appropriate to increase the dose of Donepezil?
After stabilizing on the initial dosage for 1 to 3 months.
How can the side effects of cholinesterase inhibitors be minimized?
Start with lower doses and increase gradually.
What precautions should be taken to prevent falls while on cholinesterase inhibitors?
Initiate fall precautions if hospitalized, teach patient and family fall prevention at home.
How can weight loss be prevented while on cholinesterase inhibitors?
Encourage nutritional supplements and snacks between meals.
What should be done if symptoms increase while on medications for Alzheimer’s Disease?
Increase the AD medication rather than adding herbal medications, vitamins, or NSAIDs.
What disease is associated with Parkinson’s Disease?
Alzheimer’s Disease.
What are the most common adverse effects of pramipexole?
Nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, hallucinations.
What adverse effects are seen when pramipexole is combined with levodopa?
Orthostatic hypotension and dyskinesias.
When is pramipexole best used in treating Parkinson’s disease?
As monotherapy in early PD.
When should entacapone be prescribed?
For patients who experience a wearing off of the effects of levodopa/carbidopa.
What can cause sleep attacks in PD treatment?
Pramipexole, ropinirole, rotigotine, and apomorphine.
How should sleep attacks be managed?
Patients should avoid potentially hazardous activities until attacks are managed.
What side effects are associated with bromocriptine?
Nausea, vomiting, orthostatic hypotension.
How can nausea and vomiting be managed with bromocriptine?
Avoid serotonin receptor antagonists and dopamine receptor antagonists.
What is the use of levodopa/carbidopa in treatment/diagnosis?
Seizure disorders.
What are the common side effects of phenytoin?
Nystagmus, sedation, ataxia, diplopia, cognitive impairment.
What are the eight antiseizure drugs that decrease the effectiveness of oral contraceptives?
Carbamazepine, eslicarbazepine, lamotrigine, oxcarbazepine, phenytoin, phenobarbital, rufinamide, and topiramate.
What should be advised to the patient if any of these drugs are prescribed?
Advise the patient of the risks and the need for additional contraceptives if pregnancy is not desired.
How should antiepileptic drugs be monitored for effectiveness?
Teach the patient (or a family member) to maintain a seizure frequency chart, indicating the date, time, and nature of all seizure events.
What is the purpose of maintaining a seizure frequency chart?
To evaluate treatment, make dosage adjustments, and alter drug selections.
Which anticonvulsant would be given for someone with epilepsy needing adjunctive therapy for partial seizures with or without secondary generalization?
Gabapentin.
10 early warning signs and symptoms of Alzheimer’s
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, changes in mood.
Treatment for AD includes cholinesterase inhibitors (ChEIs) and memantine.
ChEIs increase levels of the neurotransmitter acetylcholine. Recent comparative studies of ChEIs conclude that these medications do not change the progression of AD Selecting the appropriate ChEIs requires consideration of the agent’s mechanism of action, side effects, potential medication interactions, and patient/caregiver preference.
ChEIs agents inlcude
Donepezil (Aricept)
Revastigmine (Exelon)
Galantamine (Razadyne, Razadyne ER)
N-methyl-D-aspartate (NMDA) Receptor Antagonist
What is the mechanism of action of Donepezil (Aricept)?
Inhibits centrally active acetylcholinesterase
What are the common side effects of Donepezil (Aricept)?
Gastrointestinal symptoms, headache, dizziness, muscle weakness
What precautions should be taken with Donepezil (Aricept)?
Sick sinus syndrome, seizure disorder
What is the approved dose of Donepezil (Aricept) for treating moderate to severe AD?
23 mg/day
What is the cognitive functioning improvement difference between a 23 mg/day dose and a 10 mg/day dose of Donepezil (Aricept)?
Minimal improvement at higher dose
What is the higher dose of Donepezil (Aricept) associated with?
Higher incidence of adverse effects
What is the possibility of peripheral side effects when Donepezil (Aricept) is added to CYP2D6 or CYP3A4?
Possible peripheral side effects
What effect do inducers of CYP2D6 and CYP3A4 have on the elimination rate of Donepezil (Aricept)?
May increase the rate of elimination
What is the mechanism of action of Rivastigmine (Exelon)?
Acts centrally for both acetylcholinesterase and butyrylcholinesterase
What are the common side effects of Rivastigmine (Exelon)?
Gastrointestinal symptoms, weakness, dizziness, tremor
What precautions should be taken with Rivastigmine (Exelon)?
Asthma or COPD, sick sinus syndrome, GI bleeding, weight < 50 kg
How is Rivastigmine (Exelon) administered?
Orally or topically (transdermal patch)
What is the transdermal patch of Rivastigmine (Exelon) used for?
Dementia associated with Parkinson’s disease
Will medications that induce or inhibit CYP450 metabolism modify Rivastigmine (Exelon) metabolism?
No
What is the mechanism of action of Galantamine (Razadyne, Razadyne ER)?
Elevates acetylcholine in the cerebral cortex, modulates nicotinic Ach receptors
What are the common side effects of Galantamine (Razadyne, Razadyne ER)?
Gastrointestinal symptoms, headache, dizziness, fatigue
What precautions should be taken with Galantamine (Razadyne, Razadyne ER)?
NSAID use, GI bleed, asthma or COPD
What does Galantamine (Razadyne, Razadyne ER) increase besides acetylcholine?
Glutamate and serotonin levels
What is the unknown benefit of Galantamine (Razadyne, Razadyne ER)’s action?
Increase in glutamate and serotonin levels
What is the term for concurrent use with medications that slow or decrease heart rate?
Contraindications
What is the term for severe impairment of the liver?
Severe hepatic impairment
What is the term for severe impairment of the kidneys?
Severe renal impairment
What are the two major metabolizing enzymes that can affect galantamine concentrations?
CYP3A4 and CYP2D6
What is the mechanism of action of N-methyl-D-aspartate (NMDA) receptor antagonist?
Prevents glutamate from binding at the receptor site
What is the only NMDA receptor antagonist approved to manage moderate to severe Alzheimer’s disease?
Memantine (Namenda)
What are the common side effects of memantine?
Gastrointestinal symptoms, urinary frequency, confusion, dizziness, headache, cough
What precautions should be taken when using memantine?
Concurrent use with specific medications, severe hepatic impairment, severe renal impairment
Can memantine be used as monotherapy or in conjunction with ChEIs?
Yes, it can be used as monotherapy or in conjunction with ChEIs
What are the fall precautions required when memantine is given with ChEIs?
Fall precautions are required and driving is forbidden due to delayed reactions
Does memantine have significant interactions with CYP450 enzymes?
No, it has minimal inhibition of CYP450 enzymes
Which CYP450 enzymes are minimally inhibited by memantine?
CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, and CYP3A4
What is the association between memantine and donepezil?
Memantine is associated with increased life expectancy compared to donepezil.
What should be done if treatment failure occurs?
Try another agent as 50% of individuals respond to a different agent.
What should clients and families be educated about regarding these medications?
These medications cannot halt or reverse the progression of Alzheimer’s disease.
What should be considered before initiating treatment?
Consider goals of care and associated risks and benefits.
What is the effect of a higher dose of donepezil?
Higher dose has a higher incidence of adverse effects without increased cognitive benefit.
In what forms is rivastigmine available?
Rivastigmine is available in oral form or transdermal patch.
For what condition is the transdermal patch of rivastigmine used?
The transdermal patch is used for dementia associated with Parkinson’s disease.
How are medications that induce or inhibit CYP450 metabolism related to rivastigmine?
They will not modify rivastigmine metabolism.
Are antipsychotics recommended for treatment of dementia related to agitation and behavioral symptoms?
No, they are not recommended.
Cleo is a 65-year-old male diagnosed with mild cognitive changes related to Alzheimer’s disease (AD). He also has anxiety, chronic obstructive pulmonary disease (COPD), and smokes cigarettes. Which of the following medications is appropriate for Cleo?
Donepezil is appropriate for Cleo. It is approved by the FDA for the treatment of mild dementia and is not affected by nicotine. Donepezil also treats psychological symptoms of AD such as anxiety, depression, apathy, delusions, and pacing
A client diagnosed with Alzheimer’s disease has decided to stop treatment. The family nurse practitioner (FNP) 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?
Donepezil requires tapering
Which of the following is a relevant risk factor for Mimi for Alzheimer’s Disease?
Risk factors for Alzheimer’s disease (AD) include female gender, previous family history, onset at 65 years or older, lower education, sedentary lifestyle, and smoking. The relevant risk factor for Mimi is her gender. She is not male and does not have a history of diabetes or is a smoker.
Which of Mimi’s symptoms support a diagnosis of Alzheimer’s disease?
Symptoms of Alzheimer’s disease include confusion, memory loss, disorientation, feeling lost in a familiar situation, impaired judgment, anxiety, insomnia, and other personality changes. Mimi’s symptoms that support a diagnosis include her inability to name familiar objects, anxiety, and difficulty sleeping.
What is the treatment goal for memory loss associated with Alzheimer’s disease
Current pharmacologic agents are unable to stop or restore memory or cognitive function. Drugs cannot reverse the pathophysiologic disease process. Therefore, the goal of therapy is to slow Mimi’s memory and cognitive decline.
Moderate stage of Alzheimer’s
anxiety, agitation, and difficulty recognizing family and familiar people (e.g., church friends). These symptoms are indicative of moderate stage Alzheimer’s disease.
For patients diagnosed with moderate AD, the drug of choice is
donepezil monotherapy
Which of the following is the appropriate starting dose for oral rivastigmine (Exelon)?
The recommended start dose for rivastigmine is 1.5 mg twice a day PO.
Which of the following conditions or diseases raise concern if acetylcholinesterase inhibitors were used to treat Mimi’s AD?
Acetylcholine inhibitors can lead to an increase in acetylcholine at the synapses in the lungs leading to bronchoconstriction. Therefore, caution is warranted in patients with concomitant asthma or COPD.
Which of the following agents has not demonstrated symptom improvement in mild AD?
Memantine is not indicated for mild AD as studies have not demonstrated symptom improvement. It is indicated in patients with mild-moderate AD.
Which of the following agents is not metabolized by CYP-450 enzymes?
Rivastigmine is metabolized by AChE in the brain. The other agents are metabolized by CYP-450 enzymes.
Which of the following clinical and/or laboratory parameters are necessary to evaluate therapeutic effects?
the patient’s cognitive function the level of disease severity activities of daily living patient’s level of behavioral disturbances or quality-of-life The patient’s ability to sleep 8 hours during the night is not an indication of efficacy.
Which of the following antipsychotics has demonstrated a reduction in neuropsychiatric symptoms with their use?
risperidone (Risperdal) and olanzapine (Zyprexa).
What is Parkinson’s disease?
A slow, progressive neurodegenerative disease affecting motor control.
Which neurons are primarily affected in Parkinson’s disease?
Dopamine neurons in the substantia nigra.
What are the hallmark features of Parkinson’s disease?
Resting tremors, rigidity, akinesia/bradykinesia, and postural instability.
Is there a cure for Parkinson’s disease?
No, there is no cure. Treatment focuses on symptom control and maintaining quality of life.
What are the symptoms of Alzheimer’s disease?
Memory loss, confusion, disorientation, impaired judgment, personality changes.
At what age do symptoms of Alzheimer’s typically begin?
After age 65, but can appear as young as 40.
What are some early symptoms of Alzheimer’s?
Memory loss, confusion, disorientation.
What are some behavior problems that may develop in Alzheimer’s patients?
Wandering, pacing, agitation, screaming.
What is sundowning?
Intensified symptoms in the evening.
What happens in the final stages of Alzheimer’s disease?
Inability to recognize family members or communicate.
What is the average time from symptom onset to death in Alzheimer’s?
Four to eight years.
What percentage of Alzheimer’s patients develop behavior problems?
Between 70% and 90%.
What happens to an individual’s sense of identity in the final stages of Alzheimer’s?
It is completely lost.
What is levodopa?
Dopamine precursor, most effective medication for PD.
What is the improvement in motor function with levodopa?
Approximately 50% improvement.
What is the improvement in motor function with dopamine agonists?
Approximately 30% improvement.
What is the mechanism of action of dopamine agonists?
They bind to postsynaptic dopamine receptors.
When are dopamine agonists practical for PD initial therapy?
They are practical for PD initial therapy.
When are dopamine agonists most effective?
They are most effective in the advanced stages of the disease.
What are the advantages of dopamine agonists?
They can minimize variations in response, improve wearing-off symptoms, decrease levodopa dose, and improve overall functioning.
What are MAO-B inhibitors recommended for?
They are recommended for treatment of PD in conjunction with levodopa.
What is the function of MAO-B inhibitors?
They inhibit the breakdown of dopamine and levodopa in the brain.
What is the effect of MAO-B inhibitors on levodopa in the brain?
They increase levodopa in the brain and enhance its effect.
What is the selective blockade of dopamine metabolism through MAO-B?
It is the mechanism of action of MAOIs.
When are MAO-B inhibitors particularly useful?
They are particularly useful for patients who choose to delay dopaminergic medications and use MAO-B inhibitors as initial therapy.
What is the additional benefit of using MAOIs when medication therapy is initiated early?
Neuroprotection is an additional benefit.
What is the function of COMT inhibitors?
They catalyze levodopa to 3-o-methyldopa, increase levodopa concentrations, extend its half-life, and decrease wearing off time.
What is the effect of COMT inhibitors on daily levodopa dose?
They allow for a decrease in daily levodopa dose.
What is the mechanism of action of amantadine?
It is an N-methyl-D-aspartate (NMDA)-receptor antagonist that blocks glutamate transmission, promotes dopamine release, and blocks acetylcholine.
What is the effectiveness of amantadine?
It is likely effective as monotherapy and adjunct therapy for off time and dyskinesia.
What is the function of anticholinergics?
They block acetylcholine.
What is the mechanism of action of Ach medications?
Block acetylcholine and decrease acetylcholine to dopamine ratio.
What are the effects of Ach medications?
Minimize resting tremor and drooling.
How effective are Ach medications in treating rigidity?
Not as efficacious as other medications.
How effective are Ach medications in treating bradykinesia?
Not as efficacious as other medications.
How effective are Ach medications in treating problems with gait?
Not as efficacious as other medications.
T/F:
Dopamine agonists are the most effective medications for Parkinson’s Disease.
False
Levodopa, a dopamine precursor, is the most effective medication for PD. Initiating pharmacotherapy for PD remains controversial. Patients experience approximately 50% improvement in motor function with levodopa compared to 30% with dopamine agonists.
Patients should be educated on dopamine dysregulation syndrome (DDS) which can manifest as
Impulse control disorder
Combining _ medications with levodopa in early treatment may delay motor complications.
MAO-B Inhibitors
What is the therapeutic goal for Helen and others with Parkinson’s Disease (PD)?
symptom management
Helen’s family asks why marked symptom improvement is not seen since she was started on three medications for PD at the time of diagnosis. Which of the following education points will help Helen’s family understand the pharmacological approach to symptom management in PD?
Medications increase the level of dopamine and decrease the level of acetylcholine in CNS responses can take several months to occur.
Helen’s family asks why she is receiving the combination drug, levodopa/carbidopa, and not just levodopa. Which of the following education points will help Helen’s family understand the desired effects of carbidopa in the combined levodopa/carbidopa therapy?
carbidopa reduces cardiovascular responses to levodopa
Helen and her family have heard of other medications that are used to treat PD and inquire if they may help control Helen’s symptoms. Which of the following medications may be used for symptom management in PD?
Donepezil may be used for symptom management in PD. Dementia occurs in 40% of PD patients.
Which of the following statements best describes the mechanism of action of rasagiline?
Both rasagiline and selegiline are MAO-B inhibitors and work by inhibiting the breakdown of dopamine by MAO-B.
Which of the following is needed to monitor the effects of carbidopa/levodopa therapy? Select all that apply.
Orthostatic vital signs: reports of palpitations, and motor function assessments are needed to monitor the effects of carbidopa/levodopa therapy.
Which of the following education points is required to help preserve the therapeutic effects of carbidopa/levodopa therapy?
take the medication with low protein food
Which of Helen’s medications is contraindicated with selegiline?
Sertraline 75mg PO daily is contraindicated with selegiline. Selegiline should not be combined with selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac). The combination of an MAO-B inhibitor plus an SSRI can cause fatal serotonin syndrome. Accordingly, SSRIs should be withdrawn at least 5 weeks before giving selegiline
What is levodopa carbidopa?
A familiar drug used to maintain or improve daily activities.
What is the therapeutic goal of levodopa carbidopa?
To maintain or improve the patient’s ability to carry out activities of daily living.
What are the baseline data that should be assessed?
Heart rate, blood pressure, cardiovascular and neurologic assessment.
What motor symptoms should be assessed?
Bradykinesia, akinesia, postural instability, tremor, and rigidity.
How should the interference of motor symptoms with daily activities be assessed?
Assess the extent to which they interfere with work, dressing, walking, etc.
Why should a skin assessment be performed?
Levodopa may activate malignant melanoma.
What are the common adverse effects of levodopa carbidopa?
Nausea and vomiting.
How should medications be taken with levodopa carbidopa?
With a non-fat, non-protein snack like a piece of fruit.
What symptoms may indicate a need to reduce the dose of bromocriptine?
Agitation and frequent nightmares.
What should be done to minimize the side effects of bromocriptine?
Reduce the dose of bromocriptine, not levodopa.
What is the purpose of reducing the dose of bromocriptine?
To minimize the side effects of agitation and nightmares.
What is Pramipexole?
A drug used in Parkinson’s disease.
How is Pramipexole used in early stage Parkinson’s disease?
Used alone.
How is Pramipexole used in advanced stage Parkinson’s disease?
Combined with levodopa.
What are the common side effects of Pramipexole?
Nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, hallucinations.
What is a sleep attack?
An overwhelming and irresistible sleepiness that comes on without warning.
What are the side effects of all dopamine agonists?
Dizziness, hallucinations, dyskinesia.
Is Pramipexole less likely to cause side effects compared to other dopamine agonists?
Yes.
What are the two categories of seizures?
Focal and generalized.
What are seizures typically a result of?
Dysfunction of the central nervous system, treatable systemic process, or underlying brain pathology.
Name some examples of underlying brain pathology that can cause seizures.
Brain lesions or disorders, migraines, TIAs, metabolic derangement, encephalitis, head injury, drug/alcohol withdrawal, syncope, infections, fever.
According to the American Epilepsy Society clinical practice guidelines
acute seizures are typically treated with IV or rectal benzodiazepine and supportive care. IV lorazepam or rectal diazepam are common choices.
What are anticonvulsants?
Medications used to treat seizures.
What are hydantoins?
A class of anticonvulsant medications.
What is the example of a hydantoin medication?
Ethotoin (Peganone).
What is the availability of Ethotoin?
Only available in 250 mg.
What is the example of a non-primary care hydantoin medication?
Fosphenytoin (Cerebyx).
What is the availability of Fosphenytoin?
Available only in intramuscular (IM) or intravenous (IV) dosing.
How long is Fosphenytoin given for?
Given only for about 5 days.
What is the example of a hydantoin medication available in different forms?
Phenytoin (Dilantin).
What are the available forms of Phenytoin?
Chewable, suspension, IV, and extended-release caps.
What is Phenytoin used as a first-line treatment for?
Tonic-clonic and partial complex seizures.
What is the mechanism of action of anticonvulsants?
Stabilizing neuronal membranes and decreasing seizure activity by altering sodium ion movement.
What is the pharmacokinetics of anticonvulsants?
Metabolized in the liver, affected by various drug interactions.
What are some drug interactions with anticonvulsants?
Cimetidine, diazepam, acute alcohol intake, valproic acid, allopurinol increase levels. Barbiturates, antacids, calcium, chronic alcohol use decrease effects.
What is the role of a nurse practitioner in rational drug selection for anticonvulsants?
Working with a neurologist who has made the diagnosis.
What are anticonvulsants used for?
Treating grand mal and psychomotor seizures.
What should be monitored when taking anticonvulsants?
Baseline labs, plasma levels, and thyroid stimulating hormone (TSH).
What OTC drugs should be assessed when taking anticonvulsants?
Ibuprofen and antacids.
What should be included in patient education for anticonvulsants?
Discussing risk factors for seizures, reporting adverse drug reactions, and avoiding driving if not seizure-free for more than 1 year.
What are iminostilbenes?
Another class of anticonvulsant medications.
What are some examples of iminostilbene medications?
Carbamazepine (Tegretol, Tegretol XR, Carbatrol), Oxcarbazepine (Trileptal), Valproic acid (Depakote, Depakene).
What is the mechanism of action of iminostilbenes?
Depressing neuron transmission in the nucleus ventralis anterior of the thalamus.
What is the Black Box warning for iminostilbenes?
Causing blood dyscrasias.
What should be considered when prescribing iminostilbenes to Asians?
Genetic testing.
What drugs increase drug levels when used concurrently with propoxyphene?
Cimetidine, erythromycin, clarithromycin, verapamil, hydantoins
What drugs decrease plasma levels of several drugs?
Beta blockers, warfarin, doxycycline, succinimides, haloperidol
What are some adverse drug reactions of these medications?
Depression of bone marrow, liver damage, impaired thyroid function, drowsiness, dizziness, blurred vision, nausea/vomiting, dry mouth, diplopia, headache
What labs should be monitored before starting these medications?
Complete blood count, chemical panel, hepatic panel, TSH level
What should be taught to the patient regarding these medications?
Symptoms of bone marrow depression, careful use of medications, therapeutic dosing, kindling
What are succinimides used for?
Treatment of absence seizures in children and adults
What are some examples of succinimides?
Ethosuzimide (Zarontin), Methsuximide (Celontin)
How do succinimides work?
They suppress seizures by delaying calcium influx into neurons and decreasing nerve impulses and transmission in the motor cortex
How are succinimides metabolized?
In the liver
What are some adverse drug reactions of succinimides?
Most common: GI (nausea), CNS (somnolence, fatigue, ataxia), Hematological (agranulocytosis, aplastic anemia, granulocytopenia)
What is lamotrigine used for?
Adjunctive treatment of primary generalized tonic-clonic seizures and partial seizures in adults and children older than 2 years, also used for bipolar disorder
What is an example of lamotrigine?
Lamotrigine (Lamictal)
What drugs decrease the levels of lamotrigine?
Barbiturates, estrogens, phenytoin, mefloquine
What drugs increase the levels of lamotrigine?
Alcohol, carbamazepine, CNS depressants, valproic acid
How are lamotrigines metabolized?
In the liver and the kidneys
What are some adverse drug reactions of lamotrigine?
GI (nausea/vomiting, constipation), cardiovascular (chest pain, peripheral edema), CNS (somnolence, fatigue, dizziness, anxiety, insomnia, headache, amblyopia, nystagmus)
What does dermatological refer to?
Rashes
What is patient education?
Providing information to the patient
What are the adherence measures for seizure management?
Avoid alcohol, avoid OTC meds, adequate hydration, report any new drugs, report ADRs
What is discussed regarding risk factors for seizures?
Contributing factors to seizures
What is the topic of discussion related to driving?
Driving restrictions for patients with seizures
What is the controversy regarding discontinuing medications?
Discontinuation of medications after being seizure-free for a few years
After having an EEG. Amaya is diagnosed with partial complex seizure. What is the first line of treatment for this diagnosis?
Valproic acid (Depakene, Depakote, Depakote ER, Depakote Sprinkles, Depacon) is the first line of treatment for partial complex seizures and is used widely to treat all major seizure types
Which of the following baseline data are recommended before starting Amaya on valproic acid? Select all that apply.
Pregnancy tests, liver function tests, seizure frequency assessment, and depression screening are recommended before starting valproic acid.
Amy is of child-bearing age; therefore, which nutritional supplement should be encouraged with valproic acid therapy?
First-trimester exposure to valproic acid has been associated with an increased risk of neural tube defects and other structural abnormalities. This finding led to the recommendation that women on valproic acid should take an increased daily dose of folic acid.
Amy and her parents ask how antiseizure drugs work. Which of the following describes the mechanisms of action of antiseizure medications? Select all that apply.
The mechanisms of action of antiseizure medications include suppression of sodium influx, suppression of calcium influx, promotion of potassium efflux, blockade of glutamate receptors, and an increase of gamma-aminobutyric acid (GABA).
Amaya is Asian. When considering a change in antiseizure medications, which of the following medications carry a higher risk for Amaya?
Carbamazepine and phenytoin both carry a higher risk for Steven Johnson’s Syndrome (SJS) or toxic epidermal necrolysis (TEN) for Asians.
Amaya shares her concern about running out of medication due to a busy life, forgetting to refill her prescription, and not liking the idea of having to take medicine every day for the rest of her life. Which of the following education points will help encourage Amaya to take her medication as prescribed?
Abrupt discontinuation of antiseizure drugs can lead to status epilepticus; medication should be withdrawn slowly (over 6 weeks to several months). Precautions must be taken to have a sufficient supply of medications. Follow-up care visits scheduled before medication refills may be helpful
What are absence seizures?
Brief periods of unconsciousness with or without movements.
What should be done if seizures continue despite medication?
Increase the dosage or try a different drug.
How can knowledge of plasma drug levels be useful?
Guide dosage adjustment, monitor patient adherence, identify causes of loss of seizure control or toxicity.
Which anti-seizure drugs decrease the effectiveness of oral contraceptives?
Carbamazepine, eslicarbazepine, lamotrigine, oxcarbazepine, phenytoin, phenobarbital, rufinamide, topiramate.
What should be advised to patients taking anti-seizure drugs and oral contraceptives?
Inform them of the decreased effectiveness and the need for additional contraceptives if pregnancy is not desired.
What are the risks of anti-seizure drugs on a fetus?
Congenital anomalies
Why is it important for pregnant women with seizures to take anti-seizure drugs?
Risk of uncontrolled seizures is greater than drug risks
What percentage of women who take anti-seizure drugs have normal pregnancies?
More than 90%
What is the first guideline to decrease fetal risk?
Avoid valproic acid unless necessary
What should be done if valproic acid is necessary?
Use lowest effective dosage
What is the second guideline to decrease fetal risk?
Use just one drug whenever possible
What should pregnant patients take to reduce the risk of neural tube defects?
Supplemental folic acid
When should pregnant patients start taking supplemental folic acid?
Before conception and throughout pregnancy
What is a concern regarding maternal and fetal bleeding risk?
Decreased synthesis of vitamin K dependent clotting factors
Which anti-seizure drugs can decrease synthesis of vitamin K dependent clotting factors?
Phenytoin, phenobarbital, carbamazepine, primidone
What is one method to address the bleeding risk?
Administering vitamin K to the mother before and during delivery
What should be done if someone taking phenytoin requests oral contraceptives?
Advise to increase dose or use alternative method of birth control.
Why can phenytoin reduce the effects of oral contraceptive pills?
Because it is an anti-seizure medication.
Why is avoiding pregnancy desirable when taking phenytoin?
Because phenytoin can have negative effects on pregnancy.
Is it necessary to increase the patient’s dosing of phenytoin?
No, it is not necessary.
What are migraine headaches?
Headaches with moderate to severe pain, worsened by light, noise, and motion.
What are the symptoms of migraine headaches?
Nausea, vomiting, and sensitivity to light, noise, and motion.
How long can migraine headaches last?
A few hours to up to three days.
Who is more affected by migraines, men or women?
Women are more affected.
When can migraines start?
During puberty or childbearing years.
location of symptoms for sinus headaches
above and below the eyes/around the nose
location of symptoms for cluster headaches
around one eye
location of symptoms for neck headaches
on top of head and back of the head
location of symptoms for tension headaches
forehead area
location of symptoms for migraine headaches
one whole side of face or the other
location of symptoms for TMJ
around one temple or the other
What are the agents for Analgesics?
Acetaminophen, Acetaminophen + aspirin + caffeine (Excedrin Migraine)
What are the agents for Serotonin 1B/1D Receptor Agonists?
Almotriptan (Axert), Eletriptan (Relpax), Frovatriptan (Frova), Naratriptan (Amerge), Rizatriptan (Maxalt), Sumatriptan (Imitrex, Sumavel DosePro, Onzetra Xsail), Zolmitriptan (Zomig)
What are the agents for Ergot Alkaloid?
Dihydroergotamine intranasal spray (Migranal), Ergotamine sublingual (Ergomar)
What are the agents for Preventive Therapy?
Beta blockers, Antiseizure drugs, Tricyclic antidepressants, Estrogens and triptans for menstrually associated migraine, Erenumab, Botulinum toxin
What is the mechanism of action of Sumatriptan?
Decreases release of inflammatory neuropeptides and relieves migraine pain.
What is the mechanism of action of Ergotamine?
Exact mechanism unknown, but it has agonist activity at serotonin receptors and blocks inflammation.
What is the therapeutic goal of Triptans?
Termination of migraine headache.
What is the therapeutic goal of Ergot Alkaloids?
Termination of migraine or cluster headache.
What are the contraindications for Triptans?
Ischemic heart disease, prior MI, uncontrolled hypertension.
What are the contraindications for Ergot Alkaloids?
Hepatic or renal impairment, CAD, PVD.
What precautions should be taken with Triptans?
Avoid use during pregnancy due to birth defects. Overdose may cause muscle pain, paresthesia, and cold extremities. Interactions with ergot alkaloids, SSRIs, SNRIs, MAOIs may occur.
What precautions should be taken with Ergot Alkaloids?
Avoid use during pregnancy due to toxicity. Overdose may cause muscle pain, paresthesia, and cold extremities. Interactions with triptans, SSRIs, SNRIs, MAOIs may occur.