Pharmacology: Exam 4 Study Session - w/ Dr. Krause, Dr. Baradwa, & Dr.

P. (2016)
Neuro:
Labs to check before starting on anti-seizure meds: These meds metabolized by liver
Check baseline liver function test and monitor periodically at least once a year
18 months seizure free? DO NOTHING. Never d/c these meds
Neurologist will usually d/c seizure meds after 2 years with no seizures
Monitoring LFT: what is liver enzymes are high while patient taking seizure meds for 6 months
to 1 year? Stop meds and refer to Neurologist immediately!
Anti Psychotic meds: start low go slow!
Recognize adverse effects: what kind of labs before starting on anti-psych? LFT, CMP, CBC,
EKG! Make sure kidneys working well: urine analysis.
Depression: know for peds patients with depression (Fluoxetine usually 1st line) Usually age
19 and under considered a child: at risk for suicide
Know appropriate agent for elderly (Celexa=1st line treatment for depression)
Know what to use for anxiety, OCD (most we start with SSRI)
Someone with depression and chronic pain? Duloxetine (Cymbalta)
Depression and chronic migraine headaches=tricyclic antidepressants (not beta blocker bc they
also have the depression!!) Less pills the better
Alzheimers: no cure meds, will just delay progression. Meds taken forever
ADHD: know what labs to order. Sometimes misdiagnosed with ADHD when they actually
have manic disorder. Symptoms of meds not doing what theyre supposed to do. If the Ritalin
makes them 10x more hyper? Immediately stop the meds! Refer to psych.
Which drug is known to have interactions with other drugs? Valproic acid can increase
metabolism of drug (Dilantin, Coumadin, theophylline, Digoxin, etc). Measure levels of these
drugs immediately
Chronic use of phenytoin can= hirsutism hair growth
General questions about headaches. Chronic mgmt for headaches: BB
Thyroid Disorders:
Hypothyroidism=lazy thyroid, TSH is HIGH. Weight gain, hair loss, constipation, cold,
lethargic
Levothyroxine/Synthroid is 1st line treatment
 Prescribe 3 months at a time to make sure pt is getting the same chemical compound in the med
Monitor in 6 weeks, titrate up slowly. Start low go slow.
If elderly may be overdosed, check TSH and decrease meds
Hyperthyroid= TSH is low. 1st line therapy is beta blocker whether in office or ER! Protect the
heart! Propranolol 1st, then radioactive iodine
Women had SOB, CP, and tachy in ER. Ran out of Methimazole. TSH shows less than 0.01.
Thyroid storm diagnosis. Still, PROPRANOLOL is first!!
Chronic overdose with levothyroxine s/s: tachycardia, weight loss, extreme energy
Levothyroxine in elderly: can have an overstimulation of heart
Diabetes:
Type 1: 1st line= INSULIN
Gestational diabetes (even if shes type 2 before pregnancy)= INSULIN
Type 1 Dm= 1 oral agent, SYMLIN. Can be used in uncontrolled glycemic swings
Type 2 Dm= Metformin monitor renal function
HGB A1C: less than 6.9 130/80 is goal for LDL: less than 100. Microalbumin: less than 130.
Triglycerides: less than 150
Child as Type 2 DM: being overweight, diet changes and lifestyle Important. Metformin ok for
peds T2DM
T1DM can develop at any time of life
Hypoglycemia with Metformin? Not usually seen, very safe! Used as weight loss drug in
Europe
Metformin: GI symptoms, bloating, diarrhea. Take with food!
Glipizide can cause hypoglycemia (eat every 3 hours!)
Acarbose used in very obese patients. Pt. excretes (poop) carbs, instead of carbs being
absorbed
GI:
Compazine 1st line for nausea
Zofran more expensive: good for preg and chemo patients
Will not stop vomiting? Admit preg, eldery, and children to hospital
GERD: lifestyle mods: lose weight, exercise, no chocolate, avoid acidic foods,
Acute treatment of heartburn: H2 blockers and antacids
 PPI: Prilosec takes 10-14 days
PPI takes 2 weeks. Then consider decreasing after another 2 wks. (4 wks. total). Expect to
have relief of heart burn symptoms: 4 weeks
Decrease absorption:
H Pylori:
IBS associated with lifestyles: stress,
IB disease is an inflammatory disease with autoimmune component
Chronic mgmt. of IBS: tricyclic antidepressant, or SSRI low dose
Acute treatment of irritable bowel syndrome: Cramping? BENTYL
Motion sickness: OTC meds: 30-60 mins before exposure on the boat or car
Scopolamine: patch behind ear. Can keep on for 3 days. Shouldnt apply another one! Can get
rebound dizziness
Diarrhea: just hydrate self!! Dont eat anything.
Pt needs to let diarrhea out: sepsis could occur
Imodium
Constipation: 1st line treatment occasionally: increase fiber and water. Bulk laxative
occasionally
Peptic Ulcer disease H Pylori: amoxicillin with clarithromycin and PPI. Hardly need to use
quadruple therapy (Flagyl)
Probiotics diarrhea
Loperamide related to Demerol
Clarithromycin
Chemo patient for nausea: Zofran
 PHARMACOLOGY: Q/A 4TH EXAM (previous to 2016, from senior
students)

1. What medication is used for Prophylaxis of Headaches?

Case study: Acute or too many HA/ mo.; select Chronic HA 3 + HA month BB,
TCA Amitriptyline, Topamax (topiramate): wt. loss, anti-seizure, & TX of
ETOH withdrawal SXs: higher doses

4. Seizures in Pregnancy: refer to specialist Neuro; Only D/C after 2 yrs.

Without Seizure Activity; EEG confirmed no seizures, no need to send to
neurologist due to sufficient time seizure free
5. Depression: population children < 18 y/o, (21 in literature): Best Agent:
Prozac (fluoxetine); If using any agent for younger population: Risk for
Suicide: Lexapro**: 2 wks after initial dose: jumped off bridge in Calif.
6. Elderly Population for depression: Celexa, inexpensive $4 program, daily
dose, easy to ingest.
7. Monitor Labs: regular basis: Annually, prior to starting TX; know SEs.
8. Depression: Second Line TX: increase dosage of 1st Line; if no positive
results: double up RXs: add SSRI; if no improvement in 2 wks: add another
SSRI; 2 wks later: again change TX, but stay with SSRIs due to their safety.
9. Anxiety & Insomnia: Acute Attack: Benzodiazepines know all
10. Sleeping Agents: natural products: do not require Rx; or Benadryl

(OTC); if no positive results: then RX, i.e. Zolpidem/ Ambien;

2nd line is Zolpidem: prescribe a slow release (SR) form for 2ND Line

11. Dizziness and Vertigo: Meclizine only Rx for lowest possible dose; work-up
slowly

12. Recognize most commonly prescribed for Seizures: SEs; D/C; ADE
13. Alzheimer Disease: 1ST Line Agent: Namenda, KNOW: Do not Cure the
Disease, but Delay the Progression; explain to pt. & families

14. 1ST Line Agent for ADHD: Adderall, what to monitor

15. All Psych Diseases, OCD, Anxiety, Restless Leg, AZH, Depression:
all of them
16. Endocrinology System: 1ST Line for DM2: Metformin; DM1: Insulin -
also for pregnant women. Metformin: start double, then increase before using 2ND
Agent. Use HgA1C as a guideline; for DM1 use fasting in A.M., or before meal
in A.M. for rapid insulin dose; POOR for Renal Pts.
15. Hyperthyroidism GOLD TX: Radioactive Iodine; some decline; Treat
symptoms HTN w/ BB; refer to Endocrinology to give PTU, or metimazole,
Pregnant women recommend PTU.
Hypothyroidism: Levothyroxine/ Synthroid: different preparation form generic
& brand names; give 90 day supply from same pharm. co.; if Cardiac: BB
16. GI system: constipation medications, bulking agent at first, how they work;
Never give to Peds or Elderly; Stimulants: never to PEDS, i.e. Dulcolax;
severe dehydration: avoid in Elderly

17. H2 Tagamet what they used for when to double up,

18. PPI delay absorption of other medicines, if you dont see SXs: its
working; for other meds: check Levels & D/C PPI; give 2 hrs apart;
PPI taken in A.M. before eating
19. When to D/C PPI: do not take for prolonged time due to decreasing nutrient
absorption; monthly follow-up.
20. H. Pylori: causes PUD; ABX RX: triple & quadruple TX; at least 10 days
to avoid resistance (book 7-14 days)
21. N/V: someone is Emesing Severely, or Pregnant: send to ER
22. Stopping Diarrhea: only time to recommend for chronic or Crohns, IBS
or no infection; **NOT FOR ACUTE Diarrhea**
23. Zofran: was created for N/V for chemo TX prior to admin. of chemo;
to decrease or avoid N/V SXs, pregnancy
24. IBS: TREAT the PAIN: some Diarrhea, some constipation, but Treat pain:
Bentyl dicyclomine $4 program; or Amitiza or Linzess expensive
25. TX of Chronic IBS: Amitriptyline, TCAs: chronic pain, migraine HA,
Fibromyalgia, Multiple Uses as Sleeping Aids
26. Reglan off label use with triptants (e.g. sumatriptan) for headaches
27. Narcolepsy: Amphetamines
28. Restless Leg Syndrome: chronic treatment: Methyldopa-Levodopa
29. Insomnia OTC: 1st line Benadryl, 2nd line: Zolpidem ER

PHARM: EXAM 4 Review Dr. Pramedass-Blom - Summer 2016

1) After recommending diet and exercise for your patient, know the 1st line tx for diabetes.
Metformin
2) Know the drug of choice for anti-depression for elderly & PEDS:
Elderly = Celexa (citalopram)
Peds = Prozac (fluoxetine)
3) Know the prescribing recommendations for your patients who are taking seizure
medications and the lab tests that are needed.
Labs = -hepatic enzymes as baseline and as appropriate (at least 1x a year);
-trough of med annually, when seizures increase or compliance an issue or
toxicity (random)
-Elderly: monitor renal & hepatic
-Peds: neuro cons before any meds; phenobarbital is effective for prevention
of febrile seizures in children
-Preg & Lact: Cat. X***; neurologist consulted before preg to see if meds
needed
simple partial (focal or Jacksonian) seizure: no alteration of consciouness; one
hemisphere
complex partial seizure: impaired consciousness; one hemisphere
generalized: both hemispheres
-absence seizures: petit mal - sudden onset, brief, and interrupt activities; usually children
 -subtype of absence: atypical - alteration of consciousness may not be complete
tonic-clonic:(grand mal): abrupt loss of consciousness; both hemispheres; depressed
consciousness may last several hours
clonic seizures: repetitive bilateral jerking of extremities & face muscles; loss of
consciousness
atonic seizures: drop attacks of muscle tone, but don't lose consciousness.
myclonic: sudden, brief, shock-like; can occur regularly or sporadic; may accompany
metabolic or toxic states as well as epilepsy.
tonic seizures: brief, generalized tonic contractions with associated head extension,
possible stiffening of the back, and stiffening of all four extremities.
Generalized Seizures Symptoms
(Produced by the entire brain)
Unconsciousness, convulsions, muscle
1. "Grand Mal" or Generalized tonic-clonic
rigidity
2. Absence Brief loss of consciousness
3. Myoclonic Sporadic (isolated), jerking movements
Repetitive, jerking movements;
4. Clonic
unconsciousness
5. Tonic Muscle stiffness, rigidity
6. Atonic Loss of muscle tone

***First line for all types of seizures = valproic acid (Depakote or depakene)
***If unconsciousness part of it, then phenytoin (Dilantin) or carbamazepine will be
on board
-Valproic acid: 30-60 mg/kg/d in 2-3 doses; reduce in hepatic impaired. Take with
food/milk and not with carbonated drinks. ADE = lethargy, GI upset; weight gain,
alopecia, and hepatitis. Therapeutic range 50-100 mg/mL and toxic if greater than 200
ug/mL. Preg. Cat. D
-phenytoin (Dilantin): loading does 15-20 mg/kg in 3 divided doses Q2-Q4 to decrease
GI effects. Main dose 300 mg/d or 5-6 mg/kg/d in 3 divided doses or QD - BID using
extended release. ADE = nystagmus, ataxia, cognitive impairment, lethargy, gingival
hyperplasia, increase in body hair, coarsening of facial features, acne, folate
deficiency, & skin rash. Contraindicated: heart block or SB; Preg. Cat. D
-Carbamazepine (Tegretol): 6 -12 y/o = 20-30 mg/kg/d in 2-4 divided doses (usual does
if 400-800 max day); 12y/o - Adult = usual dose 800-1200 mg/d in 3-4 divided doses
ADE: hematologic abnormalities, drowsiness, fatigue, ataxia, SIADH, rash
(SJS-Asian), GI upset, confusion, nystagmus, and seizures. Contraindicated:
TCAs, bone marrow supp & recent use of MAO. Preg. Cat. D. If GI upset, take w/
 food and divide doses. Therapeutic range 6-12 ug/mL 4-8 if used with other AEDs;
toxicity at 15 ug/ML.
Know all the uses of Topamax (topiramate): Used as monotherapy or adjunctive therapy
for partial-onset seizures and primary generalized tonic-clonic seizures. It is also used as
adjunctive therapy for seizures associated with Lennox-Gastaut syndrome (severe form of
epilepsy).
-Used for: seizures; headaches (prophylaxis)
-Dose: 50mg/d; titrate by 50 mg/d at 1 wk intervals to target does of 200 mg/d. Adjust dose
if Cr Cl <70 ml/min (administer 50% of dose & titrate slower). ADE: cognitive difficulties,
tremor, dizziness, ataxia, H/A, fatigue, GI upset, Renal calculi. Preg. Cat. C. Special
considerations: maintain adequate fluid intake.
-Know what to do if ADEs occur in your patients taking stimulant medications: nausea, H/A,
anxiety, nervousness
-Know the mechanism of actions for Aricept and Namenda, and the patient education facts
-Know the SSRIs and their multiple uses, also the first line drugs in the class
-Know the TCAs and their multiple uses as well
-Avoid changing brands on thyroid medications
-Educate your pts. that Tums may be taken w/ PPIs to reduce SXs: can take antacids on
PRN basis to control acid, but doesn't help much.
-Know ***all you can about PPIs***
-Remember what I said about Digoxin & PPIs: obtain serum digoxin level prior to
prescribing the PPI lansoprazole (Prevacid)
-Chronic constipation in kids: cannot use bisacodyl (dulcolax)
-Directions of Scopolamine: transdermal patch Q3 days; for motion sickness. Vertigo is
different: you take 1st line meclizine (antivert) [Dramamine does not tx vertigo and neither does
Scopolamine].
-Mechanism of action and uses for bentyl: Used for IBS (nervous innervation) and it is an
antispasmodic. Helps with cramping and diarrhea. If tx is not effective, can add TCAs.