Drug Induced Neurological disorder

  1. - black out, lapse in memory, sudden alter of conscious
    - falling, shaking, convulsion of all limbs
    - jerks, shoulder shrugs
    - sterotypical sensation of authomatic uncontrolled movement.

    A) seizure
  2. what monitor do you use to r/o seizure?
    EEG monitor
  3. 5 different categories of meds that can induce sz. (I)
    • analgesic
    • antibiotic
    • antidepressant
    • antipsychotic
    • anti-neoplastic
  4. ALL analgesics cause sz. T or F
  5. list analgesics that cause seizure
    • meperidine (Demerol)
    • tramadol (Ultram)
  6. what to monitor closely with meperidine for seizure?
    • renal fxn!!!
    • if renal dysfx, must d/c meperidine b/c metabolite accumulate and sz risk increases 7 folds
  7. which abx cause sz? (mechanism behind it?)
    • carbapenem
    • FQ (cipro, levo, moxi)
    • penicillin
    • due to GABA antagonism issue
  8. all carbapenem cause sz. so if sz, what to do?
    switch med
  9. what to check before FQ to minimize sz? what else can you use instead?
    • check hx of sz and other epileptic drugs
    • can use pcn or cephalo
  10. which antidepressant can cause sz?
    • TCA (imipramine)
    • SSRI (bupropion)
    • maprotiline, amoxapine
  11. what does anti-depressant induced sz depend on?
    dose dependent
  12. which 3 anti-depressant has lowest sz risk?
    • Prozac (fluoxetine)
    • Luvox (fluvoxamine)
    • Desyrel (trazodone)
  13. all anti-depressant induced sz are dose dependent. T or F
  14. what anti-psychotics induce seizure? (I)
    • chlorpromazine (greatest risk)
    • clozapine
    • haloperidol
    • * dose dependent
  15. which anti-neoplastic meds induce sz? (I)
    • 5-fluorouracil
    • cisplatin
    • methotrexate
  16. risk factors for drug induced sz (I).
    • 1) hx of epilepsy or sz
    • 2) cancer
    • 3) concomitant CNS stimulant drug
    • 4) compromised BBB (i.e. trauma)
    • 5) hepatic/renal dysfx
  17. how to prevent drug induced sz?
    • 1) appropriate dose adjust
    • 2) monitor lab (electrolyte (precipitate sz), glucose, sCr, LFT (b/c metab))
    • 3) avoid concomitant CNS stimulants
    • 4) avoid abrupt d/c of drugs with CNS activity
  18. drug induced sz produces epilepsy. T or F
    • false
    • no evidence!
    • usually acute. not chronic
  19. what is the focus of tx for drug induced sz? (I)
    prevent additional acute sz
  20. how to tx acute drug induced sz? (I)
  21. if drug-induced sz is sustained (not acute anymore; multiple sz), what to use?
  22. what does acute onset mean?
    • acute: hrs - days from exposure
    • subacute: wks
    • tardive: months - yrs
  23. EPS (extrapyramidal sympt) does NOT include:

    D) akathisia
  24. which neuroleptic is better for movement disorder?
    conventional vs. atypical?
    • atypical!
    • so if pt is on conventional, switch to atypical!
  25. which 2 antipsychotics have high risk/dose dependent EPS?
    • Invega (paliperidone)
    • Risperdal (risperidone)
  26. which 2 antipsychotics have mod risk/dose dependent EPS?
    • Zyprexa (olanzapine)
    • Geodon (ziprasidone)
  27. which 1 antipsychotic have mod risk/NON-dose dependent EPS?
    Abilify (aripiprazole)
  28. which 2 antipsychotics have low risk/NON-dose dependent EPS?
    • Seroquel (quetiapine)
    • clozapine
  29. which has EPS independent of dose?

    D) clozapine
  30. which has EPS dependent of dose?

    A) Risperdal (risperidone)
  31. which has high risk of EPS? (this is also dose-dependent)

    C) Risperdal
  32. which has moderate risk and NON dose dependent EPS?

    A) Abilify
  33. Which has low risk (non-dose dep) EPS?

    A) Seroquel
  34. subjective: feeling restlessness, need to move
    objective: pacing, walking in place, foot/toe tapping, rocking while seated.
    distress if unable to move. symptoms during sleep.
    what movement disorder is this?
  35. does akathisia subside voluntarily?
    yes maam!
  36. which meds cause durg-induced akathisia?
    • conventional neuroleptic
    • antiemetics (droperidol, metoclopramide, prochlorperazine)
    • promethazine, atypical antipsychotic, SSRI, TCA, CBZ, lithium, reserpine
  37. risk factors for drug induced akathisia.
    • adv age
    • affective disorder
    • cognitive impairment
    • female
    • high dose/potency neuroleptic
    • hx of akathisia
    • iron deficiency (no need to supple empirically btw)
    • mental retardation
    • presence of negative sympt of schizo
    • rapid neuroleptic dose escalation
  38. how to manage drug induced akathisia?
    • d/c or lower dose of drug
    • consider switch to atypical antipsychotic
    • try antimuscarinic agent or b-blocker (propranolol) - last line
  39. abnormal involuntary delayed onset of choreoathetoid sterotypic movements.
    non painful, embarrassing
    difficulty chewing, swallowing, talking
    lipsmacking, chewing movement, tongue protrusion.
    which movement disorder is this?
    tardive dyskinesia
  40. which body parts does tardive dyskinesia affect?
    • orofacial region
    • tongue
    • upper/lower extremities
    • trunk
  41. which meds cause tardive dyskinesia?
    • Antiemetic (metoclopramide, prochlorperazine) Conventional neuroleptic
    • Atypical antipsychotic
  42. are the drugs that cause akathisia similar to those that cause tardive dyskinesia? how about incidence-wise?
    yes (similar incidence too)
  43. are the drugs that cause akathisia similar to those that cause dystonia? how about incidence-wise?
    yes but incidence % is higher for akathisia and tardive dyskinesia
  44. risk factors for drug induced TD?
    • adv age
    • affective symptomatology
    • alcoholism, substance abuse
    • anticholinergic use
    • daily neuroleptic dose
    • diabetes
    • duratino of neuroleptic treatment
    • female
    • h/o electroconvulsive tx
    • h/o EPS
    • intermittent neuroleptic tx
    • iron deficiency
    • mental retardation
    • organic brain disorder
  45. how to manage drug induced TD?
    • d/c or reduce dose of drug
    • d/c concurrent anti-muscarinic agent
    • blah blah (slide 19)
  46. sustained involuntary muscle contractions or spasms resulting in abnormal postures or twisting and repetitive movements.
    what movement disorder is this?
  47. difficulty walking, breathing, head turning, speech, swallowing.
    what movement disorder is this?
  48. associated with pain, distress, disability.

    C) dystonia
  49. agents in drug induced dystonia.
    • conventional neuroleptic
    • atypical antipsychotic
    • anti-emetic (metoclopramide, prochlorperizine)
  50. Drugs that cause dystonia are (same/different) as for akathisia and tardive dyskinesia.
  51. Drugs that cause dystonia have (high/low) incidence as for akathisia and tardive dyskinesia.
  52. risk factors are male and young age.

    A) dystonia
  53. how to manage acute dystonia?
    • d/c med
    • administer antimuscarinic agent
  54. how to manage chronic dystonia?
    • d/c or reduce dose of med
    • if due to neuroleptic, switch to atypical antipsychotic
    • trial antimuscarinic
    • tertrabenazine
    • trial muscle relaxant (baclofen)
    • amantadine, clonidine, keppra, lyrica
  55. which body region does dystonia affect?
    • neck, upper and lower extremities
    • jaw, larynx, trunk
  56. tremor rigiditiy, slowness of movement affecting bilateral upper and lower extremities and truncal regions.
    what movement disorder?
  57. masked facies, micrographia, slow shuffling gait, stooped posture.
    what movement disorder?
  58. agents in drug induced parkinsonism?
    • methyldopa, reserpine, tetrabenazine
    • valproic acid
    • atypical antipsychotic
  59. tetrabenazine is NOT used in this condition b/c it actually induces this.

    D) parkinsonism
  60. methyldopa, reserpine, valproate cause this.

    A) parkinsonism
  61. if you have peripheral neuropathy, waht should you r/o first?
  62. if underlying condition is treated, peripheral neuropathy symptoms can improve. t or f
  63. drugs that induce peripheral neuropathy?
    • anti-neoplastic: carboplatin, docetaxel, oxaliplatin, bortezomib, paclitaxel, procarbazine, vincristine
    • thalidomide
    • HIV meds: Videx (didanosin), Zerit (stavudine)
    • isoniazid *
    • linezolid *
    • statins *
    • leflunomide
  64. risk factors for drug induced peripheral neuropathy
    • high dose, prolonged admin
    • HIV, DM, hypothyroidism
    • alcohol abuse
    • pre-exist neuropathy
    • possible genetic
    • rapid infusion of anti-tumor agents
    • hepatic/renal impairment
  65. how to prevent drug induced peripheral neuropathy?
    • limit/monitor risk factor
    • monitor liver/renal fxn
    • monitor s&s
  66. isoniazid causes peripheral neuropathy. why does it cause PN and what can you give?
    • b/c induce vitamin B6 deficiency
    • give pyridoxine empirically
    • (thus if long term isoniazid tx, like TB, need to give vitamin B6)
  67. disturbance in consciousness and change in cognition that occurs over a brief period of time.
    what condition is this?
  68. what is a lab test for delirium?
    • no lab test!
    • purely clinical
  69. mechanisms of drug induced delirium?
    • decreased ACh fxn
    • excess dopamine and glucocorticoid fxn
    • dysfx of GABA and serotonin
  70. what agents can you give to manage drug induced delirium?
    • haloperidol
    • benzo
    • atypical antipsychotic (Seroquel)
  71. agents that cause drug induced depression
    • anti-convulsant (Keppra, phenobarb, primadone, topiramate)
    • GnRH agonist
    • interferon alpha and beta
    • tripans
    • reserpine
    • methyldopa
    • isotretinoin
    • Venlafexin
    • clonidine
    • tamoxifen
    • oral contraceptive
  72. risk factor for corticosteroid induced depression.
    • >80mg/d prednisone equivalent
    • (inc dose --> inc depression)
  73. risk factor for efavirenz induced depression
    plasma conc >2.74mcg/L (during long term tx)
  74. risk factor for topiramate induced depression.
    • starting dose 50mg/d, titration of 50mg/d q2wk
    • temporal lobe epilepsy w/ hippocampal sclerosis
    • cognitive se
    • h/o family epilepsy or febrile sz.
  75. risk factor of interteron alfa induced depression
    • genetic
    • increased immune activation.
  76. risk factor for oral contraceptive induced dpression
    • h/o premenstrual dpn or pregnancy related dpn
    • h/o dysmenorrhea
    • family hx of dpn while on po contracept
    • predisposition to vit B6 deficiency
    • age < 20yo
    • high estrogen/progesterone content (use less potent agent or other method of contracept)
  77. how to prevent drug induced depression when using interferon?
    pretreat with SSRI
  78. how to prevent drug induced depression when using gonadotropin-releasing hormone agonist?
    pretreat with SSRI
  79. drugs that cause anxiety.
    • amphetamine, methylphenidate, stimulant, bupropion, ziprasidone (inhibit NE/DA reupdate and stimulate DA receptor)
    • benzo (dec GABA)
    • caffeine, guarana, theophylline
    • dopamine agonist and antagonist
    • opioids
    • SSRI, venlafaxine, TCA
  80. how to manage drug induced anxiety
    • benzo, beta blocker (propranolol)
    • mild analgesic
    • nicotine supplementation
    • thyroid supple decrease
  81. drug induced psychosis is commonly associated with the alteration of ___ concentration.
  82. onset is slow.

    A) dementia
  83. pattern is stable.

    B) psychosis
  84. patient is oriented.

    B) dementia
  85. attention is normal.

    C) dementia
  86. cognition is selectively impaired.

    B) psychosis
  87. cognition and attention are disordered.

    C) delirium
  88. speech is incoherent.

    B) delirium
  89. speech is rapidly pressured.

    A) psychosis
  90. risk for drug induced psychosis.
    • >40yo
    • infants/children
    • altered hepatic, renal fxn
    • substance abuse
    • concomitant meds
    • underlying dz state
  91. what are underlying dz states that worsen drug induced psychosis.
    • lupus
    • parkinson
    • psychiatric illness
    • HIV
    • head injury
  92. can you use anticholinergic to manage psychosis?
  93. does psychosis go away after d/c drug?
    yes self limit and within several hrs or days
  94. antidote for anticholinergic when psychosis
    • physostigmine 0.5 - 2mg im/iv/sq
    • may repeat q 20 min until response or ADE
  95. antidote for opioids when psychosis
    • naloxone 0.1 - 0.2 mg iv q 2-3min
    • may repeat q 20-60min
  96. antidote for benzo when psychosis
    • flumazenil 0.01 mg/kg over 15 min (max 0.2 mg)
    • repeat with 0.005-0.01mg/kg prn (do not exceed 3mg)
Card Set
Drug Induced Neurological disorder
Drug Induced Neurological disorder