NSG 6320 AGNP BOARD EXAM QUESTIONS and ANSWERS Neurology Prescribing GRADED A 2020/2021

AGNP BOARD EXAM QUESTIONS Neurology Assessment (102 Questions) Question: Which of the following medications is NOT a serotonin 5-HT1 receptor agonist? Axert. Fioricet. Correct Maxalt. Zomig. Explanation: Fioricet is a combination of butalbital, acetaminophen and caffeine. Axert (almotriptan), Maxalt (rizatriptan), Zomig (zolmitriptan) are all classified as serotonin 5-HT1 receptor agonists, or triptans. Question: A patient presenting with a transient ischemic attack (TIA) is taking nifedipine (Adalat CC) for hypertension. Pharmacokinetics of nifedipine may be altered in patients with: renal insufficiency. hepatic impairment. Correct irritable bowel disease. G6PD deficiency. Explanation: Since hepatic biotransformation is the predominant route for the disposition of nifedipine, the pharmacokinetics may be altered in patients with chronic liver disease. Patients with hepatic impairment have a longer disposition half-life and higher bioavailability of nifedipine than healthy volunteers. Question: Oxcarbazepine (Trileptal) is structurally similar to: carbamazepine (Tegretol). Correct divalproex sodium (Depakote). lamotrigine (Lamictal). topiramate (Topamax). Explanation: As the name suggests, oxcarbazepine (Trileptal) is related to carbamazepine (Tegretol, Carbatrol) and appears to be similarly effective for controlling complex partial seizures and primary and secondary generalized tonic-clonic seizures. It seems to cause fewer unwanted side effects in many (but not all) patients. Oxcarbazepine is not effective against absence or myoclonic seizures. Question: Patients who experience greater than 7 to 9 tension-type headaches per month may be considered for maintenance therapy including: anticonvulsants and tricyclic antidepressants. antidepressants and onvulsants and muscle relaxants. muscle relaxants and tricyclic antidepressants. Correct Explanation: Patients who experience greater than 7 to 9 tension-type headaches per month may be considered for maintenance therapy including muscle relaxants (i.e., tizanidine) and tricyclic antidepressants (i.e., amitriptyline). Muscle relaxants are considered secondline therapy to be added to TCAs if inadequate in reducing headache episodes. Antiepileptics and beta-blockers may be indicated for the prophylactic treatment of migraines. There is more evidence of effectiveness with amitriptyline than doxepin, or with other antidepressants such as venlafaxine and mirtazapine. Doses used are generally low and not in the range used to treat depression. The need for continued chronic treatment of tension-type headaches should be reviewed at least every 6 months. Question: Beta-blockers, used for the prophylactic treatment of migraines, would NOT be contraindicated in a patient with a history of: ventricular arrhythmias. 2nd degree heart block. pulmonary congestion. acute coronary syndrome. Correct Explanation: Beta-blockers are contraindicated in patients who have a history of ventricular arrhythmias, sick sinus syndrome, 2nd or 3rd degree heart block, cardiogenic shock, and pulmonary congestion. Beta-blockers are indicated in acute coronary syndrome in order to prevent recurrent ischemia and life-threatening ventricular arrhythmias. Question: Patients who are taking carbidopa/levodopa (Sinemet) for Parkinson's disease should be advised to avoid a diet high in: carbohydrates. fat. protein. Correct sodium. Explanation: Since levodopa competes with certain amino acids for transport across the gut wall, the absorption of levodopa may be impaired in some patients on a high-protein diet. The patient should be advised that a change in diet to foods that are high in protein may delay the absorption of levodopa and may reduce the amount taken up in the circulation. Excessive acidity also delays stomach emptying, thus delaying the absorption of levodopa. Iron salts (such as in multivitamin tablets) may also reduce the amount of levodopa available to the body. The above factors may reduce the clinical effectiveness of the levodopa or carbidopa levodopa therapy. Question: Which of the following statements is NOT true about antiepileptic drugs (AEDs)? Antiepileptics should be withdrawn gradually.Antiepileptics may increase the risk of suicidal thoughts. Dosing of antiepileptics should be based on therapeutic drug levels. Correct The pharmacokinetics of antiepileptics are influenced by age, especially during childhood. Explanation: Due to individual variation, many patients may require concentrations outside the reference ranges. Dosing of antiepileptic drugs (AEDs) is best defined as the concentration at which a person achieves the best compromise between improvement in seizure control and concentration-related adverse effects. All antiepileptic drugs should be withdrawn gradually to minimize the potential for increased seizure frequency. AEDs may increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. The pharmacokinetics of AEDs are markedly influenced by age, especially during infancy and childhood. For most AEDs studied in infants and young children, pharmacokinetic characteristics include shorter elimination half-lives and, at times, larger volume distribution values compared with adults. Question: Patients who are taking divalproex sodium (Depakote) and lamotrigine (Lamictal) are at higher risk for developing: central nervous system depression. false-positive drug screens for tetrahydrocannabinol. hormone-related side effects. rash, including Stevens-Johnson syndrome. Correct Explanation: Serious rashes (including Stevens-Johnson syndrome and toxic epidermal necrolysis) requiring hospitalization and discontinuation of treatment have occurred in pediatric and adult patients who have received the drug as adjunctive therapy with valproic acid for the treatment of epilepsy. When Lamictal is given in conjunction with estrogen plus oral contraceptives, the dose of Lamictal will need to be adjusted, especially if hormone therapy is discontinued. Lamictal may interfere with the assay used in some rapid urine drug screens, which can result in false-positive readings, particularly for phencyclidine (PCP). Use a more specific analytical method to confirm a positive result. Question: Children who are receiving gabapentin (Neurontin) should be monitored for: emotional lability. Correct hypoesthesia. symptoms of tardive dyskinesia. weight loss. Explanation: Use in pediatric patients with epilepsy has been associated with CNS adverse effects of mild to moderate intensity. The most significant include emotional lability, hostility (e.g., aggressive behaviors), changes in behavior and thinking (e.g., concentration problems and changes in school performance), and hyperkinesia (primarily restlessness and hyperactivity). Monitor all patients for notable changes in behavior that might indicatesuicidal thoughts or depression. Other side effects include hyperesthesia (sensitive skin), weight gain, nystagmus, dizziness and drowsiness. Question: During initiation of treatment and escalation of doses, pramipexole (Mirapex) and other dopamine agonists are known to cause: akathisia. gastrointestinal bleeding. orthostatic hypotension. Correct thrombocytopenia. Explanation: In clinical studies and clinical experience, dopamine agonists appear to impair the systemic regulation of blood pressure, resulting in orthostatic hypotension. This occurs at initiation and during dose escalation. In addition, Parkinson's disease patients appear to have an impaired capacity to respond to an orthostatic challenge. For these reasons, both Parkinson's disease patients and restless leg syndrome (RLS) patients being treated with dopaminergic agonists ordinarily require careful monitoring for signs and symptoms of orthostatic hypotension, especially during dose escalation. They should be informed of this risk. Question: Sumatriptan (Imitrex), a serotonin (5-HT1) receptor agonist, is: contraindicated in patients with peripheral vascular disease. Correct first-line therapy for mild to moderate migraine symptoms. the most effective of all the triptans. considered only if butalbital is ineffective. Explanation: Sumatriptan (Imitrex) is contraindicated in peripheral vascular disease; ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia); coronary artery vasospasm, including Prinzmetal’s angina; Wolff-Parkinson-White syndrome; history of stroke or transient ischemic attack (TIA); and ischemic bowel disease. It is considered first-line therapy for severe migraine symptoms in non-pregnant adults. All triptans have similar efficacy. Triptans are recommended over the use of potentially sedating or habit-forming medications, such as opioids or butalbital-containing combination drugs. Question: Patients who require oral corticosteroids for the treatment of Bell's Palsy should be instructed to take the medication: at bedtime. with citrus juice. with food. Correct at least 2 hours after consuming alcohol. Explanation: Patients who receive prescriptions for oral corticosteroids should be instructed to take the medication with food to help prevent stomach upset. Alcohol should be avoidedwhile taking corticosteroids because these medications potentiate the side effects of alcohol. Question: To be of greatest benefit, corticosteroids in the treatment of Bell's palsy should be initiated within: 24 hours of symptom onset. 48 hours of symptom onset. 72 hours of symptom onset. Correct 5 days of symptom onset. Explanation: Corticosteroids should be initiated within 3 days of symptom onset. Bell's palsy may be caused by edema and inflammation of cranial nerve VII. Corticosteroids are potent antiinflammatories. Question: Beta-blockers are contraindicated in patients with: essential tremor. hyperthyroidism. a history of migraine. second-degree heart block. Correct Explanation: Beta-blockers are contraindicated in patients with second-degree heart block. They may be beneficial for migraine prophylaxis in patients who exhibit signs and symptoms of essential tremor or hypothyroidism. Question: Ropinirole (Requip), used in the treatment of restless legs syndrome (RLS), is metabolized primarily in the: liver. Correct lungs. kidneys. intestines. Explanation: Ropinirole (Requip), a dopamine agonist, is metabolized extensively in the liver by the CYP450: 1A2 substrate and excreted in the urine with 10% of the drug unchanged. Question: Which of the following medications is an N-methyl-D-aspartate receptor antagonist for the treatment of dementia of the Alzheimer's type? Donepezil (Aricept) Galantamine (Razadyne) Memantine (Namenda) Correct Rivastigmine (Exelon) Explanation:Memantine (Namenda) is an N-methyl-D-aspartate receptor antagonist (NMDA). NMDA receptor antagonists binds preferentially to the NMDA receptor-operated cation channels, creating a blockade of current flow through channels of N-methyl-d-aspartate (NMDA) receptors, which is a glutamate receptor subfamily broadly involved in brain function. The other choices are cholinesterase inhibitors, which are thought to prevent the breakdown of acetylcholine to acetylcholinesterase, thereby increasing the availability of acetylcholine at cholinergic synapses. Question: The most common short-term adverse effects of ropinirole (Requip) used in restless leg syndrome (RLS) include: arthralgia, peripheral edema and muscle cramps. cough, hyperhidrosis and nasal congestion. nausea, vomiting, and fatigue. Correct somnolence, dizziness, and paresthesia. Explanation: Ropinirole (Requip) is classified as a dopamine agonist. The most common short-term adverse events related to the administration of ropinirole (Requip) include nausea, vomiting and fatigue. The other symptoms may be present when Requip is used in conjunction with levodopa for the treatment of parkinsonism. Question: Carbidopa/levodopa (Sinemet) for the treatment of Parkinson's disease is contraindicated in patients with: diabetes. history of peptic ulcer disease. narrow-angle glaucoma. Correct wide-angle glaucoma. Explanation: Sinemet is contraindicated in patients with narrow-angle glaucoma. Patients with chronic wide-angle glaucoma may be treated cautiously with Sinemet provided the intraocular pressure is well-controlled and the patient is monitored carefully for changes in intraocular pressure during therapy. As with levodopa, treatment with Sinemet may increase the possibility of upper gastrointestinal hemorrhage in patients with a history of peptic ulcer. Question: Pramipexole (Mirapex), a dopamine agonist, is indicated in the treatment of: insomnia and parasomnia disorders. Parkinson disease and sleep-related eating disorders. REM sleep behavior disorder and multiple sclerosis. restless leg syndrome and Parkinson disease. Correct Explanation: Pramipexole (Mirapex) is a dopamine agonist (DA) that works by directly stimulating dopamine receptors in the brain. It is indicated in the treatment of restless leg syndrome and Parkinson disease. It does have an off-label indication for the treatmentof sleep-related eating disorder, but it is not indicated in insomnia, parasomnia disorders, REM sleep behavior disorder or multiple sclerosis. Question: Exercise caution before initiating pregabalin (Lyrica) in combination with: amitriptyline (Elavil). enalapril (Vasotec). Correct fluconazole (Diflucan). warfarin (Coumadin). Explanation: Exercise caution when prescribing pregabalin (Lyrica) to patients who have had a previous episode of angioedema. In addition, patients who are taking other drugs associated with angioedema (e.g., angiotensin-converting enzyme inhibitors) may be at increased risk of developing angioedema. Because Lyrica is predominantly excreted unchanged in the urine, undergoes negligible metabolism, and does not bind to plasma proteins, its pharmacokinetics are unlikely to be affected by other agents through metabolic interactions or protein binding displacement. Question: The first-line treatment in acute tension-type headache is: muscle relaxers. non-steroidal anti-inflammatory drugs. Correct triptans. tricyclic antidepressants. Explanation: The first-line treatment in acute tension-type headache is non-steroidal antiinflammatory drugs (NSAIDs). Episodic attacks generally respond well to NSAIDs such as ibuprofen. Treatment must be of adequate dose and at early onset of an attack. Question: Triptans, such as sumatriptan (Imitrex), should NOT be administered concomitantly with: beta-blockers. calcium channel blockers. selective serotonin reuptake inhibitors (SSRIs). Correct sulfonamides. Explanation: Triptans, serotonin (5-HT1) receptor agonists, contribute to agonist effects on serotonin 5-HT1B and 5-HT1D receptors in blood vessels (causing their constriction) and nerve endings in the brain, and subsequent inhibition of pro-inflammatory neuropeptide release, including calcitonin gene-related peptide (CGRP) and substance P. Serotonin syndrome may occur with any triptan, particularly during coadministration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors. Question: The brand name of oxcarbazepine is:Keppra. Lamictal. Tegretol. Trileptal. Correct Explanation: The brand name of oxcarbazepine is Trileptal. The generic name of Keppra is levetiracetam; Lamictal is lamotrigine; and Tegretol is carbamazepine. These are classified as anti-epileptic drugs (AEDs). Question: The first-line pharmacological option for the treatment of generalized tonic-clonic seizures is: carbamazepine (Tegretol). gabapentin (Neurontin). oxcarbazepine (Trileptal). valproic acid (Depakote). Correct Explanation: The first-line pharmacological option for the treatment of generalized tonic-clonic seizures is valproic acid (Depakote). Carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are second-line medications for generalized tonic-clinic seizures. Gabapentin (Neurontin) is not indicated for the treatment of generalized tonic-clonic seizures. Question: The most common side effects related to benztropine (Cogentin) and trihexyphenidyl, used in the treatment of parkinsonism, are: anorexia and bradycardia. blurred vision and urinary retention. Correct hypotension and headache. weight gain and edema. Explanation: Benztropine (Cogentin) and trihexyphenidyl have anticholinergic properties. The most common side effects of anticholinergics include dry mouth, blurred vision, constipation, nausea, difficulty emptying the bladder, impaired sweating, and rapid heart rate. Other side effects include memory problems, confusion, and hallucinations. These may be pronounced in older adults. Question: Education for patients who are taking amantadine should NOT include: Avoid abrupt discontinuation of the medication. Gradually increase physical activity as symptoms of Parkinson's improve. Additional doses may be taken for symptom exacerbation. Correct Report changes in mood, swelling of extremities, shortness of breath and difficulty urinating. Explanation:Amantadine should not be discontinued abruptly in patients with Parkinson's disease because patients may experience a parkinsonian crisis, i.e., a sudden marked clinical deterioration. Abrupt discontinuation may also precipitate delirium, agitation, delusions, hallucinations, paranoid reaction, stupor, anxiety, depression and slurred speech. Patients should be advised to gradually increase physical activity as the symptoms of Parkinson's disease improve. This medication should be taken exactly as prescribed. If symptoms do not improve, patients should NOT take additional doses because this is associated with overdose and increased morbidity. Patients should notify the prescriber if mood/mental changes, swelling of extremities, difficulty urinating and/or shortness of breath occur. Although amantadine is not an anticholinergic it does mimic anticholinergic activity. Question: The generic name for Depakote is: divalproex sodium. Correct lamotrigine. levetiracetam. pregabalin. Explanation: The generic name for Depakote is divalproex sodium. Valproic acid (Depakene) is a closely related drug and is interchangeable with Depakote. Depakene is available as elixir and capsule. Depakote is available as sprinkles, tablets and delayed-release tablets. The brand name for lamotrigine is Lamictal; levetiracetam is Keppra; and pregabalin is Gabapentin. Question: The primary beta-blocker indicated for the prophylactic treatment of migraine headaches is: atenolol (Tenormin). nadolol (Corgard). metoprolol tartrate (Lopressor). propranolol hydrochloride (Inderal). Correct Explanation: Propranolol (Inderal) and timolol have indications for the prophylactic treatment of migraines. Metoprolol (Lopressor), nadolol (Corgard), and atenolol (Tenormin) also have evidence of benefit, but their use is considered off label. Question: A patient who is receiving divalproex sodium (Depakote) reports acute abdominal pain accompanied by nausea and vomiting. This patient should be evaluated for: gastroesophageal reflux disease. peptic ulcer disease. pancreatitis. Correct renal calculi. Explanation: Cases of life-threatening pancreatitis have been reported in both children and adults receiving divalproex sodium (Depakote). Some of the cases have been described ashemorrhagic, with rapid progression from initial symptoms to death. Some cases have occurred shortly after initial use as well as after several years of use. Patients and guardians should be warned that abdominal pain, nausea, vomiting, and/or anorexia can indicate pancreatitis and requires prompt medical evaluation. If pancreatitis is diagnosed, valproate should be discontinued. Alternative treatment for the underlying medical condition should be initiated as clinically indicated. Question: At each follow-up visit for patients who are taking carbidopa/levodopa (Sinemet), the provider should specifically inquire about: abnormal eating patterns and abnormal dreams. delay in initiating movements and freezing of gait. snoring or vivid dreams. sudden sleep onset and gambling or sexual urges. Correct Explanation: Prescribers should directly question patients about drowsiness or sleepiness, including episodes of sudden sleep onset, during specific activities. Prescribers should also ask patients about the development of new or increased gambling urges, sexual urges or other urges while being treated with Sinemet. Consider discontinuing Sinemet in patients who report significant daytime sleepiness or episodes of falling asleep during activities that require active participation (e.g., conversations, eating, etc.) or experiencing aberrant behaviors. Patients may not acknowledge these problems unless directly questioned. Patients should be advised to exercise caution while driving or operating machines during treatment with Sinemet. Patients who have already experienced somnolence or an episode of sudden sleep onset should not participate in these activities during continued treatment with Sinemet. Use of concomitant sedating medications and the presence of sleep disorders increases the risk of drowsiness, sleepiness and sudden sleep onset. Question: A patient who is taking beta-blockers for the prophylactic treatment of migraine headache does NOT need to be monitored for: hypotension. bradycardia. heart failure. tachypnea. Correct Explanation: Due to beta-blockers' ability to depress sympathetic stimulation, patients should be routinely monitored for hypotension, bradycardia, and heart failure. Question: Macrolides, such as clarithromycin (Biaxin), are NOT generally used to treat: atypical pneumonia. meningitis. Correct pharyngitis. chlamydia. Explanation:Since macrolides do not penetrate the CNS they are not used to treat meningitis. Macrolides are indicated for the treatment of atypical pneumonia (Mycoplasma), chlamydia, and pharyngitis. Clarithromycin (Biaxin), azithromycin (Zithromax), and erythromycin (E.E.S.) are macrolides. Question: Amantadine, an antiviral agent and an N-methyl-D-aspartate (NMDA) receptor antagonist, is indicated in the treatment of: extrapyramidal symptoms. influenza A treatment. multiple sclerosis. parkinsonism. Correct Explanation: Amantadine is indicated in the treatment of drug-induced extrapyramidal reactions and parkinsonism. The exact mechanism of action of amantadine in the treatment of Parkinson’s disease and drug-induced extrapyramidal reactions is not known. However, it is thought to have direct and indirect effects on dopamine and has been identified as a weak non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. Question: A pediatric patient who is taking valproic acid (Depakene) may exhibit toxicity symptoms which would include: anasarca, abdominal pain, anuria. ataxia, irritability and somnolence. Correct bradycardia, edema and hallucinations. confusion, mydriasis and shortness of breath. Explanation: Toxic symptoms are symptoms experienced when the serum valproic acid (Depakene) level is too high. Toxic symptoms typically include ataxia, irritability and somnolence. Additional central nervous system symptoms may include confusion, dizziness, worsened seizure control, hallucinations, headache and cerebral edema. Physical examination findings may include hyper/hypothermia, tachycardia, hypotension (severe overdose) and respiratory depression necessitating intubation. Anorexia, nausea, and vomiting are the most common symptoms in acute toxicity. Alopecia may occur with severe and chronic overdose. Miosis (opposite of mydriasis) and nystagmus may be observed. Question: Phenobarbital, indicated for the treatment of epilepsy, is: a central nervous system stimulant. contraindicated in patients with hypersensitivity to barbiturates. Correct not a controlled substance. is contraindicated in pregnancy. Explanation: Phenobarbital, a long-acting barbiturate, is a central nervous system depressant. In ordinary doses, the drug acts as a sedative and anticonvulsant. Its onset of action occurs within 30 minutes, and the duration of action ranges from 5 to 6 hours. It ismetabolized in the liver. Phenobarbital is a Schedule IV drug. It should not be administered to persons with known previous addiction to the sedative/hypnotic group, since ordinary doses may be ineffectual and may contribute to further addiction. Phenobarbital is contraindicated in patients who are hypersensitive to barbiturates. Question: Divalproex sodium (Depakote) for the prophylactic treatment of migraines: can be used in the presence of hepatic insufficiency. has been associated with polycystic ovarian syndrome (PCOS). Correct is safe for use in pregnancy. is considered first-line treatment. Explanation: Divalproex sodium (Depakote) for the prophylactic treatment of migraines has been associated with polycystic ovarian syndrome (PCOS). It should be used with caution in women of childbearing age. It has been associated with developmental disorders and congenital malformations when used by pregnant mothers. Depakote has also been associated with hepatotoxicity and hepatic failure and should be used with caution. Due to potential serious side effects, it is recommended as a second-line option for the prevention of migraines. Question: The brand name for levetiracetam is: Keppra. Correct Lamictal. Lyrica. Mysoline. Explanation: The brand name for levetiracetam is Keppra. The generic name for Lamictal is lamotrigine; Lyrica is pregabalin; and Mysoline is primidone. These are anti-epileptic drugs. Question: Pregabalin (Lyrica) is NOT approved for the treatment of: fibromyalgia. migraines with aura. Correct partial seizures. postherpetic neuralgia. Explanation: Pregabalin (Lyrica) is NOT approved for the treatment of migraines with aura. It is indicated in the treatment of neuropathic pain related to diabetes and spinal cord injury, postherpetic neuralgia, partial seizures and fibromyalgia. Question: The mechanism of action of pramipexole (Mirapex) is to: decarboxylate dopamine in extracerebral tissues. inhibit the breakdown of dopamine in the ng and enhance the effect of levodopa. stimulate dopamine receptors in the striatum. Correct Explanation: Pramipexole (Mirapex) is a dopamine agonist (DA) that works by directly stimulating dopamine receptors in the brain. There are several DAs available in the United States, including bromocriptine (Parlodel), pramipexole (Mirapex), ropinirole (Requip), transdermal rotigotine (Neupro), and apomorphine given by injection (Apokyn). Question: Patients receiving non-cardioselective beta blockers for migraine treatment are much more likely to experience: bronchial constriction. Correct decreased exercise tolerance. decreased cardiac output. headaches. Explanation: Non-cardioselective beta-blockers can cause significant bronchial constriction due to blockage of both beta-1 and beta-2 receptors and could be harmful, especially in patients with respiratory conditions such as asthma or chronic obstructive pulmonary disease. Both cardioselective and non-cardioselective beta-blockers produce a desired decrease in cardiac output. Both cardioselective and non-cardioselective beta blockers can produce exercise intolerance. Question: Levetiracetam (Keppra), indicated in the adjunctive treatment of partial seizures, is: not bioequivalent to the oral solution. highly protein bound. primarily excreted renally unchanged. Correct cytochrome P450 dependent. Explanation: Levetiracetam (Keppra) is primarily excreted renally unchanged. Levetiracetam tablets and oral solution are bioequivalent. Levetiracetam is not significantly protein-bound (10% bound) and its volume of distribution is close to the volume of intracellular and extracellular water. The major metabolic pathway of levetiracetam (24% of dose) is an enzymatic hydrolysis of the acetamide group. It is not liver cytochrome P450 dependent. Question: Oral levetiracetam (Keppra) is indicated for use as: adjunct treatment of generalized tonic-clonic seizures and bipolar disorder. monotherapy treatment of generalized tonic-clonic and partial seizure activity. adjunctive treatment of partial onset seizures in adults and children. Correct monotherapy treatment of partial onset seizures and trigeminal neuralgia. Explanation:Oral levetiracetam (Keppra) is indicated for use as adjunct therapy in the treatment of partial onset seizures in adults and children 4 years and older with epilepsy; myoclonic seizures in adults and adolescents 12 years and older; and primary generalized tonicclonic seizures in adults and children 6 years and older with idiopathic generalized epilepsy. Question: Carbidopa/levodopa (Sinemet) for the treatment of Parkinson's disease is a(n): anticholinergic. dopaminergic agent. Correct dopamine agonist. MAO-B inhibitor. Explanation: Carbidopa/levodopa (Sinemet) is a dopaminergic agent. Levodopa is an aromatic amino acid that is the metabolic precursor to dopamine and is converted in the brain. However, when administered orally, levodopa is rapidly decarboxylated to dopamine in extracerebral tissues, leaving only a small portion of levodopa to cross the blood-brain barrier. Carbidopa is an inhibitor of aromatic amino acid decarboxylation, thereby slowing the conversion of levodopa to dopamine in the extracerebral tissues, making more levodopa available for transport to the brain. Carbidopa does not cross the bloodbrain barrier. Question: The most common reason patients discontinue use of pregabalin (Lyrica) is: dizziness. Correct flushing. salivary hypersecretion. sexual dysfunction. Explanation: Dizziness and somnolence may began shortly after the initiation of pregabalin (Lyrica) therapy. Dizziness and somnolence are the adverse reactions that most frequently lead to withdrawal of the medication by patients. Question: Ergotamine alkaloids, such as dihydroergotamine (Migranal), are indicated in the treatment of: basilar migraine headaches. cluster headaches. migraine headaches (acute). Correct tension headaches. Explanation: Ergotamine alkaloids, such as dihydroergotamine mesylate (Migranal) nasal spray, are indicated for the acute treatment of migraine headaches with or without aura. This class is not intended for the prophylactic therapy of migraine, tension headaches, cluster headaches, or for the management of hemiplegic or basilar migraine. Question:Patients taking topiramate (Topamax) are at high risk for developing: gastroesophageal reflux disease. hyperesthesia. metabolic alkalosis. nephrolithiasis. Correct Explanation: Patients receiving topiramate (Topamax) are at high risk for developing nephrolithiasis. An explanation for the association of topiramate and kidney stones may lie in the fact that topiramate is a carbonic anhydrase inhibitor. Carbonic anhydrase inhibitors (e.g., zonisamide, acetazolamide or dichlorphenamide) can promote stone formation by reducing urinary citrate excretion and by increasing urinary pH, hyperchloremic acidosis, non-anion gap, and metabolic acidosis. This metabolic acidosis is caused by renal bicarbonate loss due to the inhibitory effect of topiramate on carbonic anhydrase. Question: A patient was started on lamotrigine (Lamictal) 4 weeks ago, and today presents with a mild rash on the upper left thigh. The nurse practitioner should: treat the rash and continue lamotrigine. reduce the dose of lamotrigine until the rash is resolved. halt the escalating dose of lamotrigine until the rash is resolved. discontinue the lamotrigine immediately. Correct Explanation: Nearly all cases of life-threatening rashes caused by lamotrigine (Lamictal) have occurred within 2 to 8 weeks of treatment initiation. However, isolated cases have occurred after prolonged treatment (e.g., 6 months). The risk of rash may also be increased by (1) coadministration of Lamictal with valproate (includes valproic acid and divalproex sodium), (2) exceeding the recommended initial dose of Lamictal, or (3) exceeding the recommended dose escalation for Lamictal. Although benign rashes are also caused by Lamictal, it is not possible to reliably predict which rashes will be serious or life threatening. Accordingly, Lamictal should ordinarily be discontinued at the first sign of rash, unless the source of the rash is clearly identified (i.e. contact dermatitis). Discontinuation of treatment may not prevent a rash from becoming life threatening or permanently disabling or disfiguring. Question: Carbamazepine (Tegretol), used in the treatment of trigeminal neuralgia,: has no effect on hormonal contraceptives. may precipitate conduction disturbances on electrocardiograms (ECG). Correct is not metabolized by the liver and thus does not require monitoring of liver enzymes. is safe for use in pregnancy. Explanation: Carbamazepine (Tegretol) may cause ECG abnormalities and should be used with caution in patients with conduction abnormalities. Atrioventricular (AV) heart block, including second- and third-degree block, have been reported following the administration of carbamazepine. The effect occurred generally, but not solely, in patients with underlying ECG abnormalities or risk factors for conduction disturbances.Carbamazepine (Tegretol) is metabolized by the liver and may cause abnormalities in liver function tests, cholestatic and hepatocellular jaundice, hepatitis and, in rare cases, hepatic failure. Tegretol may render oral contraceptives ineffective. It is contraindicated in pregnancy (especially first trimester: risk of fetal carbamazepine syndrome). It should be used only in life-threatening emergencies when a safer drug is not available. Question: For treatment of Bell's palsy, combination therapy is considered to be more beneficial and includes corticosteroids plus: aspirin. acyclovir. Correct botulinum toxin. gabapentin. Explanation: Oral antiviral agents (acyclovir, famciclovir, valacyclovir) in conjunction with oral steroids are found to be more beneficial than steroid use alone in the treatment of Bell's palsy. Etiologies associated with Bell's palsy include: viral illnesses (i.e. herpes zoster, common cold, influenza), exposure to cold, and facial trauma. Question: The medication recommended for the rescue of refractory or cluster seizure activity is: oral diazepam (Valium). intravenous phenobarbital (Luminal). valproic acid sprinkles (Depakene). rectal diazepam (Diastat). Correct Explanation: Diazepam (Diastat) rectal gel is a gel formulation of diazepam intended for rectal administration in the management of select refractory patients with epilepsy. The intermittent use of Diastat is recommended to control bouts of increased seizure activity, refractory or cluster seizures that break through maintenance treatment regimens. Intravenous phenobarbital may be used in the acute care setting for refractory seizures or status epilepticus. Question: To prevent further events, patients with transient ischemic attacks (TIAs) should be treated with: aspirin (Ecotrin). Correct apixaban (Eliquis). warfarin (Coumadin). tirofiban (Aggrastat). Explanation: In the absence of a contraindication, patients with a history of transient ischemic attacks should be managed with aspirin. Dosages ranging from 75 to 325 mg daily are associated with the best risk/benefit ratio. Clopidogrel is an alternative in patients who are allergic to aspirin. Antiplatelet therapy rather than anticoagulation is recommended for secondary prevention.Question: A patient who is taking valproic acid (Depakote) should have routine laboratory monitoring which includes a: complete blood count, serum creatinine level and urine protein. complete blood count, serum folic acid and bicarbonate level. complete blood count, Depakote level and liver function tests. Correct complete blood count, antinuclear antibodies and thyroid function tests. Explanation: Scheduled monitoring of liver enzymes, blood cell counts and Depakote and Depakene levels has increased their safety and efficacy. The frequency of checking these values is variable and determined by several factors. A complete blood count (CBC) should be obtained prior to initiation of either medication and every 4-12 months thereafter. Liver function tests (AST or ALT) are usually obtained before starting the drug and then monthly for 3 months, then every 4-12 months. Question: Serotonin (5HT1) receptor agonists, or triptans: should be administered only if opioids are ineffective for migraine. are all the same. If treatment fails with one, there is no need to try another. may cause hypertensive crisis even in patients without a history of hypertension. Correct do not cause medication overuse headaches or reduced efficacy if used too frequently. Explanation: Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported with the use of triptans. These cases include patients without a history of hypertension. Blood pressure should be monitored. One triptan is believed to be as efficacious as others. However, several may have to be tried to individualize therapy. Triptans work best when they are taken as soon as the headache starts. Combining a triptan with a nonprescription medicine (such as acetaminophen or naproxen) may improve efficacy. Opioids are not recommended for the treatment of migraines. When used inappropriately or too frequently, medication overuse headache and tolerance may occur. Question: Primidone (Mysoline) is metabolized into two active metabolites, one of which is: pregabalin. phenobarbital. Correct tiagabine. vigabatrin. Explanation: Primidone (Mysoline) has anticonvulsant activity as do its two metabolites, phenobarbital and phenylethylmalonamide (PEMA). Mysoline, used alone or concomitantly with other anticonvulsants, is indicated in the control of grand mal, psychomotor, and focal epileptic seizures. It may control grand mal seizures refractory to other anticonvulsant therapy.Question: The brand name for carbamazepine is: Depakote. Mysoline. Trileptal. Tegretol. Correct Explanation: The brand name for carbamazepine is Tegretol. Carbamazepine is an antiepileptic drug (AED) used in the treatment of epilepsy and trigeminal neuralgia. The generic name of Depakote is valproic acid; Mysoline is primidone; Trileptal is oxcarbazepine. Question: A drug interaction may occur between carbamazepine (Tegretol) and: drospirenone/ethinyl estradiol (Yaz). Correct aspirin (Ecotrin). prednisolone (Prelone). sulfamethoxazole/trimethoprim (Bactrim). Explanation: Carbamazepine (Tegretol) should not be administered to patients who are also taking oral contraceptives such as drospirenone/ethinyl estradiol (Yaz). Carbamazepine increases metabolism of hormones in birth control pills and can reduce their effectiveness, potentially leading to unexpected pregnancies. Question: The brand name of phenytoin sodium is: Dilantin. Correct Mysoline. Phenobarbital. Topamax. Explanation: The brand name of phenytoin sodium is Dilantin. The generic name of Mysoline is primidone and Topamax is topiramate. Phenobarbital is the generic name and there are no brand names for oral dosing. Luminol is a parenteral brand for phenobarbital. Question: The patient who requires the LEAST cautionary measures when treated with carbidopa/levodopa (Sinemet) is: a 43-year-old woman with hypothyroidism. Correct a 45-year-old retired marine with secondary parkinsonism and a history of posttraumatic stress disorder. a 50-year-old woman with a history of obstructive sleep apnea. a 55-year-old man with history a of myocardial infarction with residual atrial arrhythmia.Explanation: The 43-year-old woman with hypothyroidism would require only routine monitoring for potential side effects of Sinemet. Patients should be observed carefully for the development of depression with concomitant suicidal tendencies, especially those in whom a condition is already present. Care should be exercised in administering Sinemet to patients with a history of myocardial infarction who have residual atrial, nodal, or ventricular arrhythmias. In such patients, cardiac function should be monitored with particular care during the period of initial dosage adjustment, in a facility with provisions for intensive cardiac care. Sinemet may cause drowsiness and sudden sleep onset, and may increase the risk for somnolence, especially in patients with concomitant use of sedating medications and the presence of sleep disorders. Question: Ergotamine alkaloids for the treatment of migraines are safe to administer with: clarithromycin (Biaxin). diltiazem (Cardizem). ketoconazole. topiramate (Topamax). Correct Explanation: Dihydroergotamine (DHT) in combination with CYP3A4 inhibitors can result in cerebral ischemia/peripheral ischemia secondary to vasospasm. Examples of 3A4 inhibitors are clarithromycin, ketoconazole, nelfinavir, ritonavir, saquinavir, and tipranavir. Topiramate is not extensively metabolized and is primarily eliminated unchanged in the urine. Question: Taking a triptan (5-HT1 agonist), such as sumatriptan (Imitrex), early in the headache cycle does NOT: improve the likelihood of complete pain relief. lower the chance of rebound headache. lower the overall treatment costs. decrease medication dependence and overuse syndrome. Correct Explanation: Medication dependence is more likely to occur with opioids or butalbital-containing products and has not been associated with triptans (5-HT1 agonists). Medication overuse syndrome is thought to occur when the medication is taken 10 or more days per month. Patients should be encouraged to record headache frequency and drug use (e.g., by keeping a headache diary). Taking triptans (5-HT1 agonists) early in the headache cycle improves the likelihood of complete pain relief, lowers the chance of rebound headaches, decreases the amount of medication needed to treat the entire attack, and lowers overall treatment costs. Question: Carbidopa and levodopa are the active ingredients in Sinemet used to treat Parkinson's disease. The addition of carbidopa: enhances the intrinsic efficacy of levodopa. decreases the plasma levels of levodopa. increases plasma dopamine ases plasma half-life of levodopa. Correct Explanation: The carbidopa component in Sinemet reduces the amount of levodopa required to produce a given response by about 75% and, when administered with levodopa, increases both plasma levels and the plasma half-life of levodopa. It also decreases plasma and urinary dopamine and homovanillic acid. The plasma half-life of levodopa is about 50 minutes without carbidopa. When carbidopa and levodopa are administered together, the half-life of levodopa is increased to about 1.5 hours. Question: Which medication may be beneficial in the treatment of restless legs syndrome (RLS)? Escitalopram (Lexapro) Hydroxyzine hydrochloride (Vistaril) Gabapentin (Neurontin) Correct Venlafaxine (Effexor) Explanation: Gabapentin enacarbil (Horizant), a prodrug of gabapentin with extended-release properties, may improve symptoms of restless legs syndrome (RLS). It is approved by the FDA for the treatment of RLS. Immediate-release gabapentin may be used if gabapentin enacarbil is unavailable. It may be a good option for painful RLS, or for RLS associated with comorbid neuropathic pain. Selective serotonin reuptake inhibitors (SSRI; e.g., Lexapro), serotonin-norepinephrine reuptake inhibitors (SNRI; e.g., Effexor) and antihistamines (e.g., Vistaril) may cause or worsen RLS. Question: Ticlopidine (Ticlid), a platelet aggregation inhibitor,: is preferred in the secondary prevention of strokes. does not require dose adjustment for hepatic dysfunction. is rarely used due to side effects and limited efficacy compared to other agents. Correct shows improved efficacy when combined with aspirin. Explanation: Ticlopidine (Ticlid) is rarely used due to side effect profile and limited trials showing superiority to other agents. Drug interactions occur with NSAIDs, aspirin, cimetidine, digoxin, theophylline and various foods. It is known to cause life threatening hematological adverse reactions and is contraindicated in the presence of active bleeding. Dosage adjustments are needed for renal and hepatic dysfunction. Bleeding times and other platelet function tests return to normal within 2 weeks of discontinuing the medication. Question: Butalbital, one of the components of Fioricet, a medication used to abort tension-type headaches: is habit forming and potentially abusable. does not impair mental and/or physical abilities. is a barbiturate that acts on the central nervous system. Correct can be purchased over the counter.Explanation: Butalbital belongs to the group of medicines called barbiturates. Barbiturates act in the central nervous system (CNS) to produce their effects. Evidence supporting the efficacy and safety of butalbital, acetaminophen, and caffeine tablets in the treatment of multiple recurrent headaches is unavailable. Caution is required because butalbital is habit-forming and potentially abusable. Butalbital, acetaminophen, and caffeine tablets may impair mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery. Such tasks should be avoided while taking this product. This medicine is available only with prescription. Question: Acetaminophen may be used to reduce fever in the presence of a febrile seizure. A severe complication of acetaminophen (Tylenol) is: hyperkalemia. hepatotoxicity. Correct migraine headaches. vomiting. Explanation: Acetaminophen (Tylenol) has an excellent safety profile when administered in proper therapeutic doses, but hepatotoxicity can occur after overdose. Additionally, the risk of hepatotoxicity is higher in alcoholics, chronic high doses, or use of more than one acetaminophen-containing product. Doses of acetaminophen should be calculated carefully in pediatric patients to prevent overdose. Question: Acute tension-type headaches refractory to simple analgesics may respond to a combination of analgesics and: butalbital. Correct corticosteroids. opioids. triptans. Explanation: Tension-type headaches refractory to simple analgesics may respond to combination analgesic preparations containing butalbital. This drug should be used moderately and with caution because of the increased risk of medication-overuse headaches. Opiates are rarely used because of their side effects and potential for dependency. If treatment is ineffective, the diagnosis of tension-type headache should be reconsidered. For the chronic treatment of tension-type headaches a tricyclic antidepressant may be considered. Question: Which medication does NOT have an indication for the treatment of Parkinson disease? pramipexole (Mirapex). primidone (Mysoline). Correct ropinirole (Requip). trihexyphenidyl (Artane).Explanation: Primidone (Mysoline) is an antiepileptic used in the treatment of seizures. It does have an off-label indication for essential tremor, but it does not have an indication for tremors associated with Parkinson disease (PD). Pramipexole (Mirapex) and ropinirole (Requip) are dopamine agonists. They directly activate dopamine receptors in the striatum and mimic dopamine without having to be converted. They are first-line therapy in PD. Trihexyphenidyl (Artane) is an anticholinergic useful in the treatment of tremors. Question: The medication class that does NOT lead to postural hypotension and possible syncope is: adrenergic agonists (Inotropes). Correct angiotensin-converting enzyme inhibitors. tricyclic antidepressants. vasodilators. Explanation: Adrenergic agonists (inotropes/pressors) are used in the treatment of orthostatic hypotension-related syncope. Alpha-adrenoceptor agonists (a-agonists) bind to areceptors on vascular smooth muscle and induce smooth contraction and vasoconstriction, thus mimicking the effects of sympathetic adrenergic nerve activation to the blood vessels. Possible causes of postural hypotension include hypovolemia, autonomic insufficiency, medications or toxins (tricyclic antidepressants, vasodilators, angiotensin-converting enzyme inhibitors, ganglionic blockers, alcohol), metabolic or endocrine causes (Addison’s disease, pheochromocytoma, systemic mastocytosis, carcinoid syndrome), or vascular insufficiency (varicose veins, arteriovenous malformations). Question: After initiation of 300 mg serum phenytoin (Dilantin), daily levels should be checked at approximately: 3 days. 7 days. Correct 14 days. 21 days. Explanation: When serum level determinations are necessary, they should be obtained at least 5 to 7 half-lives (7-10 days) after treatment initiation, dosage change, or addition or subtraction of another drug to the regimen. Trough levels provide information about clinically effective serum level range, confirm patient compliance, and are obtained just prior to the patient’s next scheduled dose. Peak levels indicate a patient’s threshold for emergence of dose-related side effects and are obtained at the time of expected peak concentration. For extended phenytoin sodium capsules, peak serum levels occur 4 to 12 hours after administration. Question: The generic name for Lyrica is: toin. pregabalin. Correct primidone. Explanation: The generic name of Lyrica is pregabalin. The brand name for lamotrigine is Lamictal; phenytoin is Dilantin; and primidone is Mysoline. These drugs are classified as antiepileptic drugs (AEDs). Question: Non-selective beta-blockers used in migraine prophylaxis actively compete for beta receptors, inhibiting the binding of: acetylcholine. serotonin. catecholamine. Correct adenosine. Explanation: The physiologic effects of catecholamines (norepinephrine and epinephrine) are mediated by activation of specific alpha and beta adrenergic receptors. Beta-blockers act by competitively inhibiting catecholamines from binding to these receptors. Nonselective beta-blockers block the action of epinephrine (adrenaline) and norepinephrine (noradrenaline) at both ß1- and ß2-adrenergic receptors. They have little intrinsic sympathomimetic activity and strong membrane stabilizing activity. Beta-blockers with intrinsic sympathomimetic activity are able to stimulate beta-adrenergic receptors (agonist effect) and to oppose the stimulating effects of catecholamines (antagonist effect) in a competitive way. Question: Benztropine (Cogentin), an anticholinergic, is NOT recommended for use in patients with: athetosis movements. Huntington's chorea. parkinsonism. tardive dyskinesia. Correct Explanation: Benztropine (Cogentin) is an anticholinergic drug indicated in the treatment of parkinsonism, as well as extrapyramidal and dystonic conditions. It helps relieve tremors and involuntary movements. Tardive dyskinesia may appear in some patients on long-term therapy with phenothiazines and related agents, or it may occur after these drugs have been discontinued. Antiparkinson agents do not alleviate the symptoms of tardive dyskinesia, and in some instances may aggravate them. Benztropine mesylate is not recommended for use in patients with tardive dyskinesia. Question: A patient who is taking carbamazepine (Tegretol) for trigeminal neuralgia presents with complaints of fatigue, muscle cramps and nausea. These are symptoms of: hypokalemia. atremia. Correct hypernatremia. Explanation: Hyponatremia can occur as a result of treatment with carbamazepine (Tegretol). Signs and symptoms of hyponatremia include headache, new or increased seizure frequency, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, all of which can lead to falls. In many cases, the hyponatremia appears to be caused by the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The risk of developing SIADH with Tegretol treatment appears to be dose-related. Older adults and patients treated with diuretics are at greater risk of developing hyponatremia. Question: Chronic use of phenytoin (Dilantin) has been associated with: hypercalcemia. hypoglycemia. osteopenia. Correct polycythemia vera. Explanation: The chronic use of phenytoin (Dilantin) in patients with epilepsy has been associated with decreased bone mineral density (osteopenia, osteoporosis, and osteomalacia) and bone fractures. Phenytoin induces hepatic metabolizing enzymes. This may enhance the metabolism of vitamin D and decrease vitamin D levels, which may lead to vitamin D deficiency, hypocalcemia, and hypophosphatemia. Consideration should be given to screening with bone-related laboratory and radiological tests as appropriate, and initiating treatment plans according to established guidelines. Hyperglycemia resulting from the drug's inhibitory effects on insulin release has been reported. Phenytoin may also raise the serum glucose level in diabetic patients. Question: Sumatriptan (Imitrex) is classified as a(n): ergot alkaloid. non-benzodiazepine receptor agonist. serotonin (5-HT1) receptor agonist. Correct serotonin (5-HT3) receptor antagonist. Explanation: Sumatriptan (Imitrex) is classified as a serotonin (5-HT1) receptor agonist or "triptan." These drugs contribute to agonist effects on serotonin 5-HT1B and 5-HT1D receptors in blood vessels (causing their constriction) and nerve endings in the brain, and subsequent inhibition of pro-inflammatory neuropeptide release, including CGRP and substance P. Serotonin (5-HT3) receptor antagonists block the vomiting reflex by inhibiting 5-HT3 receptors in the vomiting center, the chemoreceptor trigger zone and in the small intestine. Non-benzodiazepine receptor agonists are hypnotic agents used to treat insomnia. Ergot alkaloids are used in the treatment of migraine headaches and are thought to have a similar mechanism of action to triptans. Question:Due to increased cholinergic activity in patients treated with donepezil (Aricept), patients should be monitored for: ataxia. gastrointestinal bleeding. Correct tachycardia. weight gain. Explanation: Patients treated with donepezil (Aricept) should be monitored for gastrointestinal bleeding. Through their primary action, cholinesterase inhibitors may be expected to increase gastric acid secretion due to increased cholinergic activity. Bradycardia, AV blocks, syncope, seizures, hemolytic anemia, urinary obstruction, Stevens-Johnson syndrome and toxic epidermal necrolysis are other serious adverse events that may occur. Question: Patients who are taking rasagiline (Azilect) for the treatment of Parkinson's disease should avoid other CYP1A2 inhibitors such as: ciprofloxacin (Cipro). Correct clindamycin (Cleocin). erythromycin base (Ery-Tab) sulfamethoxazole/trimethoprim (Bactrim). Explanation: Ciprofloxacin (Cipro) is a strong inhibitor of CYP1A2 and should be avoided in conjunction with rasagiline (Azilect). Sulfamethoxazole/trimethoprim (Bactrim) is a CYP2C9 inhibitor. Clindamycin (Cleocin) and erythromycin base (Ery-Tab) are CYP3A4 inhibitors. Question: Patients receiving oxcarbazepine (Trileptal) should be routinely monitored for: hepatotoxicity. hyperammonemia. hyponatremia. Correct renal insufficiency. Explanation: Clinically significant hyponatremia (sodium 125 mmol/L) can develop during oxcarbazepine (Trileptal) use. Measurement of serum sodium levels should be considered for patients during maintenance treatment with oxcarbazepine, particularly if the patient is receiving other medications known to decrease serum sodium levels (for example, drugs associated with inappropriate ADH secretion). Also warranting serum sodium levels are symptoms indicating hyponatremia, such as nausea, malaise, headache, lethargy, confusion, obtundation, or increase in seizure frequency or severity. Other laboratory tests include those to evaluate for hematologic disorders including leukopenia, thrombocytopenia, pancytopenia, agranulocytosis and aplastic anemia. Question: Fioricet, indicated for the abortive treatment of tension-type headache, is a combination of acetaminophen,:butalbital and caffeine. Correct butalbital and pseudoephedrine. dihydroergotamine and pseudoephedrine. ergotamine and caffeine. Explanation: Fioricet is a combination of acetaminophen, butalbital and caffeine. It is used in the abortive treatment of tension-type headaches. Caution is required because butalbital is habit-forming and potentially abusable. Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death. Most of the cases of liver injury are associated with the use of acetaminophen at doses that exceed 4000 milligrams per day, and often involve more than one acetaminophen-containing product. Caffeine, like most xanthines, is rapidly absorbed and distributed in all body tissues and fluids, including the CNS, fetal tissues, and breast milk. It is considered a CNS stimulant. Question: Which of the following is a non-dihydropyridine calcium channel blocker? nebivolol (Bystolic). nifedipine (Procardia). verapamil (Calan). Correct amlodipine (Norvasc). Explanation: Non-dihydropyridine calcium channel blockers include verapamil (Calan) and diltiazem (Cardizem). Non-dihydropyridine calcium channel blockers have a negative chronotropic effect. Verapamil (Calan) may be used in the prophylactic treatment of cluster headaches. Question: Monitoring for side effects of topiramate (Topamax) includes: electrocardiogram. serum bicarbonate and chloride. Correct serum sodium. urinary protein and specific gravity. Explanation: Topiramate treatment causes non-anion gap, hyperchloremic metabolic acidosis manifested by a decrease in serum bicarbonate, and an increase in serum chloride. Measurement of baseline and periodic serum bicarbonate during topiramate treatment is recommended. Question: Patients with mild chronic obstructive pulmonary disease may receive a beta-blocker for migraine prophylaxis as long as they are not currently taking a(n): beta-2 adrenergic agonist. Correct anticholinergic. inhaled glucocorticoid. phosphodiesterase-4 inhibitor.Explanation: Bronchoconstriction due to beta-2 receptor blockade can be induced by nonselective agents and high doses of cardioselective agents. As a result, many clinicians have assumed that chronic obstructive pulmonary disease (COPD) or asthma is a contraindication to beta blocker therapy. However, beta blockers are safe and effective in patients with mild COPD/asthma who are not taking a beta-2 adrenergic agonist. Question: Propranolol hydrochloride (Inderal) for the treatment of migraines: does not interact with epinephrine. is contraindicated in patients with diabetes. should be tapered if discontinued. Correct should be administered at migraine onset. Explanation: If propranolol is ineffective for the prophylactic treatment of migraines at the optimal dose after 4-8 weeks of therapy, it should be withdrawn gradually over several weeks. Beta-blockers should never be stopped abruptly due to rebound tachycardia. Propranolol is not indicated for the treatment of acute migraine attacks. It should be used prophylactically. Beta-blockers given to a patient with diabetes may mask the symptoms of hypoglycemia, but they are not contraindicated. Patients who are receiving beta blockers may be unresponsive to usual doses of epinephrine used to treat allergic reactions. Question: A patient receiving lamotrigine (Lamictal) for the treatment of epilepsy would NOT need routine monitoring of: complete blood count. lamotrigine levels. Correct liver function tests. renal function. Explanation: The value of monitoring plasma concentrations of lamotrigine in patients treated with lamotrigine (Lamictal) has not been established. Because of the possible pharmacokinetic interactions between lamotrigine and other drugs, monitoring of the plasma levels of lamotrigine and concomitant drugs may be indicated, particularly during dosage adjustments. In general, clinical judgment should be exercised regarding monitoring of plasma levels of lamotrigine and other drugs and whether or not dosage adjustments are necessary. Question: In addition to the treatment of various forms of epilepsy, lamotrigine (Lamictal) is indicated in the treatment of: bipolar 1 disorder. Correct depression. fibromyalgia. trigeminal neuralgia.Explanation: In addition to the treatment of various forms of epilepsy, lamotrigine (Lamictal) is indicated in the treatment of bipolar I disorder. Carbamazepine (Tegretol) can be used for the treatment of trigeminal neuralgia. Question: Syncope related to vasovagal symptoms is best treated with: angiotensin-converting enzyme inhibitors. antihistamines. antidepressants. beta blockers. Correct Explanation: The rationale for beta-blocker therapy for the treatment of vasovagal related syncope is based on both physiologic and clinical observations. Sympathetic stimulation of betaadrenergic receptors is believed to be important in the pathophysiology of vasovagal syncope. Terminal levels of norepinephrine and epinephrine are significantly higher in syncope patients compared with control subjects immediately following head-up tilt testing. The time to reach a positive tilt test response is reduced in patients who receive a beta-blocker compared to those who do not. Question: Common side effects related to pregabalin (Lyrica) include: ataxia and abdominal pain. diarrhea and pruritus. edema and weight gain. Correct myoclonus and somnolence. Explanation: Common side effects of pregabalin (Lyrica) include peripheral edema and weight gain. Additional side effects include infection, ataxia, blurred vision, constipation, diplopia, dizziness, drowsiness, fatigue, headache, tremor, visual field loss, accidental injury, and xerostomia. Other side effects include: abnormal gait, abnormality in thinking, amnesia, arthralgia, asthenia, cognitive dysfunction, confusion, edema, neuropathy, sinusitis, speech disturbance, vertigo, visual disturbance, myasthenia, amblyopia, increased appetite, and twitching. Question: Clopidogrel (Plavix) is considered: a low molecular weight heparin medication. an anticoagulant medication. an antiplatelet medication. Correct first line for the treatment of deep vein thrombosis. Explanation:Clopidogrel (Plavix) is an antiplatelet medication. It is a thienopyridine-class antiplatelet agent used to inhibit blood clots in coronary artery disease, peripheral vascular disease, cerebrovascular disease, and to prevent heart attacks and strokes. Question: Clindamycin (Cleocin) is NOT indicated in the treatment of: skin and soft tissue infections. joint infections. respiratory infections. meningitis. Correct Explanation: Clindamycin (Cleocin), a lincosamide, does not penetrate the blood brain-barrier in therapeutically effective quantities and should not be used in the treatment of meningitis. Clindamycin (Cleocin) is indicated for the treatment of skin and soft tissue infections and infection of the joints, bones, and respiratory tract. Question: Which medication is approved for prophylactic treatment of migraine headaches? Amitriptyline (Elavil) Amlodipine (Candesartan) Topiramate (Topamax) Correct Quetiapine (Seroquel) Explanation: Topiramate (Topamax) is an anticonvulsant and is the only drug with moderate evidence for prophylactic treatment in patients with chronic migraine and medication overuse headache. Amitriptyline (Elavil) is a tricyclic antidepressant and is considered an offlabel use for the prophylactic treatment of migraine headache prophylaxis. Candesartan is an angiotensin receptor blocker that has been used for migraine prophylaxis. However, this is an off-label use. Quetiapine (Seroquel) is a second-generation antipsychotic used in the treatment of schizophrenia and bipolar 1 disorder. Question: Following an acute overdose of acetaminophen (Tylenol), patients who are at significant risk for hepatotoxicity should receive: activated charcoal. deferoxamine. acetylcysteine. Correct theophylline. Explanation: N-acetylcysteine (NAC), or acetylcysteine, is an extremely effective antidote for acetaminophen-induced hepatotoxicity due to an acute overdose, especially if administered within 8-10 hours after ingestion. Oral activated charcoal for known or suspected o