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2/26/2015
1
EFFECT OF MEDICATIONS ON SPEAKING, HEARING AND SWALLOWINGLinda Hughes, Pharm.D, BCPS, BCACP
Public Service Assistant
University of Georgia
Colleges of Pharmacy and Education
DISCLOSURE
I have no relevant financial or nonfinancial relationship(s) within the products or services described, reviewed, evaluated or compared in this presentation.
OBJECTIVES
Understand basic principles of pharmacology
Identify medications with negative side effects on hearing, swallowing, speech and cognition
Identify medications used to treat ototoxicity, vestibular toxicity and tinnitus
Use medication knowledge to positively impact a patient’s therapeutic plan
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METHYLPHENIDATE (CONCERTA)
Attention Deficit Hyperactivity Inattention
Hyperactivity and Impulsivity
Mixed
Central nervous system: Headache (adults 22%; children & adolescents 12%), insomnia (3% to 12%),
emotional lability (children 9%, adults 1%), anxiety (8%), dizziness (adults 7%; children & adolescents 2%), nervousness (3%), restlessness (3%), aggressive behavior (2%), agitation (2%), depression (2%), vertigo (2%), vocal tics (children 2%), confusion (1%), paresthesia (1%), tension (1%), cerebral arteritis, cerebral hemorrhage, drowsiness, fatigue, Gilles de la Tourette's syndrome (rare), hypertonia, hypervigilance, irritability, lethargy, neuroleptic malignant syndrome (rare), outbursts of anger, toxic psychosis
Lexicomp; Methylphenidate Monograph, accessed 2-23-2015
METHYLPHENIDATE (CONCERTA) Cardiovascular: Tachycardia (5%), palpitations (3%), angina pectoris, cardiac
arrhythmia, cerebrovascular accident, cerebrovascular occlusion, decreased pulse, heart murmur, hypertension, hypotension, increased pulse, myocardial infarction, necrotizing angitis, Raynaud’s phenomenon, vasculitis
Dermatologic: Hyperhidrosis (5%), excoriation (children 4%), skin rash (children 2%), alopecia, erythema multiforme, exfoliative dermatitis, urticaria
Endocrine & metabolic: Weight loss (7%), decreased libido (2%), growth suppression
Gastrointestinal: Decreased appetite (adults 25%; children 2%), xerostomia (14%), nausea (13%), anorexia (children & adolescents 9%; adults 2%), abdominal pain (children & adolescents 6% to 7%), vomiting (2% to 7%), bruxism (2%), dyspepsia (2%), motion sickness (children 2%), constipation (1%), diarrhea
Genitourinary: Dysmenorrhea, erectile dysfunction Hematologic & oncologic: Anemia, immune thrombocytopenia, leukopenia,
pancytopenia, thrombocytopenia
Lexicomp; Methylphenidate Monograph, accessed 2-23-2015
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Hepatic: Abnormal hepatic function tests, hepatic coma, increased serum bilirubin, increased serum transaminases
Hypersensitivity: Hypersensitivity reaction
Neuromuscular & skeletal: Tremor (3%), arthralgia, dyskinesia
Ophthalmic: Blurred vision (2%), eye pain (children 2%), accommodation disturbance, dry eye syndrome, mydriasis
Respiratory: Upper respiratory tract infection (2%), dyspnea, increased cough, pharyngitis, pharyngolaryngeal pain, rhinitis, sinusitis
Miscellaneous: Fever (children & adolescents 2%), accidental injury
Post marketing and/or case reports: Bradycardia, change in libido, chest pain, decreased visual acuity, diplopia, disorientation, erythema, extrasystoles, hallucination, increased serum alkaline phosphatase, mania, migraine, muscle twitching, myalgia, obsessive-compulsive disorder, peripheral vascular insufficiency, priapism, seizure, supraventricular tachycardia, talkativeness, ventricular premature contractions
Lexicomp; Methylphenidate Monograph, accessed 2-23-2015
GABAPENTIN (NEURONTIN)
Uses Seizures
Post – herpetic neuralgia (Shingles)
Neuropathic pain
Diabetic peripheral neuropathy
Fibromyalgia
Post-operative pain (adjunct)
Restless leg syndrome
Hot Flashes
Side Effects >10%: Central nervous system: Dizziness
(IR: 17% to 28%; children 3%; Gralise: 11%), drowsiness (IR: 19% to 21%; children 8%; Gralise: 5%), ataxia (1% to 13%), fatigue (11%; children 3%)
Infection: Viral infection (children 11%)
Lexicomp; Gabapentin Monograph, accessed 2-19-2015
1% to 10%: Cardiovascular: Peripheral edema (IR: 2% to 8%; Gralise: 4%), vasodilatation (1%) Central nervous system: Hostility (children 5% to 8%), tremor (7%), emotional lability
(children 4% to 6%), hyperkinesia (children 3% to 5%), headache (Gralise: 4%; IR: 3%), abnormality in thinking (2% to 3%; children 2%), abnormal gait (2%), amnesia (2%), depression (2%), nervousness (2%), pain (Gralise: 1% to 2%), hyperesthesia (1%), lethargy (Gralise: 1%), twitching (1%), vertigo (Gralise: 1%)
Dermatologic: Pruritus (1%), skin rash (1%) Endocrine & metabolic: Weight gain (IR: Adults and children 2% to 3%; Gralise: 2%),
hyperglycemia (1%) Gastrointestinal: Diarrhea (IR: 6%; Gralise: 3%), nausea and vomiting (3% to 4%; children
8%), xerostomia (IR: 2% to 5%; Gralise: 3%), constipation (IR: 1% to 4%; Gralise: 1%), abdominal pain (3%), dyspepsia (IR: 2%; Gralise: 1%), dry throat (2%), dental disease (2%), flatulence (2%), increased appetite (1%)
Genitourinary: Impotence (2%), urinary tract infection (Gralise: 2%) Hematologic & oncologic: Decreased white blood cell count (1%), leukopenia (1%) Infection: Infection (5%) Neuromuscular & skeletal: Weakness (6%), back pain (IR: 2%; Gralise: 2%), dysarthria (2%),
limb pain (Gralise: 2%), myalgia (2%), bone fracture (1%) Ophthalmic: Nystagmus (8%), diplopia (1% to 6%), blurred vision (3% to 4%), conjunctivitis
(1%) Otic: Otitis media (1%) Respiratory: Rhinitis (4%), bronchitis (children 3%), nasopharyngitis (Gralise: 3%),
respiratory tract infection (children 3%), pharyngitis (1% to 3%), cough (2%) Miscellaneous: Fever (children 10%)
Lexicomp; Gabapentin Monograph, accessed 2-19-2015
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Postmarketing and case reports: Acute renal failure, altered serum glucose, anemia, angina pectoris,
angioedema, aphasia, aspiration pneumonia, blindness, blood coagulation disorder, bradycardia, brain disease, breast hypertrophy, bronchospasm, cardiac arrhythmia (various), cardiac failure, cerebrovascular accident, CNS neoplasm, colitis, confusion, Cushingoid appearance, DRESS syndrome, drug abuse, drug dependence, dyspnea, erythema multiform, facial paralysis, fecal incontinence, gastroenteritis, glaucoma, glycosuria, hearing loss, heart block, hematemesis, hematuria, hemiplegia, hemorrhage, hepatitis, hepatomegaly, herpes zoster, hyperlipidemia, hypertension, hyperthyroidism, hyperventilation, hyponatremia, hypotension, hypothyroidism, hypoventilation, increased creatine phosphokinase, increased liver enzymes, increased serum creatinine, jaundice, joint swelling, leukocytosis, lymphadenopathy, lymphocytosis, memory impairment, meningism, migraine, movement disorder, myocardial infarction, myoclonus (local), nephrolithiasis, nephrosis, nerve palsy, non-Hodgkin's lymphoma, ovarian failure, palpitations, pancreatitis, paresthesia, peptic ulcer, pericardial effusion, pericardial rub, pericarditis, peripheral vascular disease, pneumonia, psychosis, pulmonary thromboembolism, purpura, retinopathy, rhabdomyolysis, seasonal allergy, skin necrosis, status epilepticus, Stevens-Johnson syndrome, subdural hematoma, suicidal ideation, suicidal tendencies, syncope, tachycardia, thrombocytopenia, thrombophlebitis, tumor growth, withdrawal syndrome
Lexicomp; Gabapentin Monograph, accessed 2-19-2015
CITALOPRAM (CELEXA)
Uses
Major Depressive Disorder Binge Eating Disorder Generalized Anxiety Disorder Panic Disorder Social Phobia Hot Flashes Obsessive Compulsive
Disorder Pathological Gambling
Alcohol Dependence
Premenstrual Dysphoric Disorder
Premature Ejaculation
Diabetic Neuropathy
Lexicomp; Citalopram Monograph, accessed 2-19-2015
Side Effects >10%: Central nervous system: Somnolence (18%; dose related), insomnia (15%; dose related)
Gastrointestinal: Nausea (21%), xerostomia (20%)
Miscellaneous: Diaphoresis (11%; dose related)
Side Effects 1-10%: Cardiovascular: QT prolongation (2%), hypotension (≥1%), orthostatic hypotension (≥1%),
tachycardia (≥1%), bradycardia (1%)
Central nervous system: Fatigue (5%; dose related), anxiety (4%), agitation (3%), fever (2%), yawning (2%; dose related), amnesia (≥1%), apathy (≥1%), concentration impaired (≥1%), confusion (≥1%), depression (≥1%), migraine (≥1%), suicide attempt (≥1%)
Dermatologic: Rash (≥1%), pruritus (≥1%)
Endocrine & metabolic: Libido decreased (1% to 4%), dysmenorrhea (3%), amenorrhea (≥1%)
Gastrointestinal: Diarrhea (8%), dyspepsia (5%), anorexia (4%), vomiting (4%), abdominal pain (3%), appetite increased (≥1%), flatulence (≥1%), salivation increased (≥1%), taste perversion (≥1%), weight gain/loss (≥1%)
Genitourinary: Ejaculation disorder (6%), impotence (3%; dose related), polyuria (≥1%)
Neuromuscular & skeletal: Tremor (8%), arthralgia (2%), myalgia (2%), paresthesia (≥1%)
Ocular: Abnormal accommodation (≥1%)
Respiratory: Rhinitis (5%), upper respiratory tract infection (5%), sinusitis (3%), cough (≥1%)
Lexicomp; Citalopram Monograph, accessed 2-19-2015
2/26/2015
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<1%, post marketing, and/or case reports: Acne, aggressiveness, akathisia, alkaline phosphatase increased, allergic reaction, allergic rhinitis, alopecia, anal itching, anaphylaxis, angioedema, anemia, angina pectoris, arthritis, asthma, ataxia, atrial fibrillation, bilirubinemia, bleeding gums, breast enlargement, breast pain, bronchitis, bronchospasm, bruising, bruxism, bundle branch block, bursitis, cardiac arrest, cardiac failure, cataracts, catatonia, cellulitis, cerebrovascular accident, cholecystitis, cholelithiasis, choreoathetosis, coagulation abnormalities, colitis, conjunctivitis, coordination abnormal, dehydration, delirium, delusions, dependence, depersonalization, dermatitis, diplopia, diverticulitis, dry eyes, dry skin, duodenal ulcer, dyskinesia,dysphagia, dyspnea, dystonia, dysuria, eczema, emotional lability, epidermal necrolysis, epistaxis, eructation, erythema multiforme, esophagitis, euphoria, extrapyramidal symptoms, extrasystoles, eye pain, facial edema, flu-like syndrome, flushing, gait instability, galactorrhea, gastric ulcer, gastritis, gastroenteritis, gastroesophageal reflux, gastrointestinal hemorrhage, gingivitis, glaucoma, glossitis, glucose tolerance abnormal, goiter, granulocytopenia, gynecomastia, hallucinations, hematuria, hemorrhoids, hemolytic anemia, hepatic necrosis, hepatitis, hiccups, hot flashes, hyper-/hypoesthesia, hyper-/hypokinesia, hyperpigmentation, hypertension, hypertonia, hypertrichosis, hypochromic anemia, hypoglycemia, hypokalemia, hyponatremia, hypothyroidism, involuntary muscle movement, jaundice, keratitis, lacrimation abnormal, laryngitis, leg cramps, libido increased, leukocytosis, leukopenia, liver enzymes increased, lymphadenopathy, lymphocytosis, lymphopenia, muscle weakness, myocardial infarction, myocardial ischemia, mydriasis, myoclonus, neuralgia, neuroleptic malignant syndrome, nightmares, nystagmus, obesity, oliguria, osteoporosis, panic attacks, paranoia, pancreatitis, peripheral edema, phlebitis, photophobia, photosensitivity, pneumonia, pneumonitis, priapism, prolactinemia, prothrombin decreased, psoriasis, psychosis, ptosis, pulmonary embolism, purpura, pyelonephritis, renal calculi, renal failure, renal pain, rhabdomyolysis, rigors, seizures, serotonin syndrome, SIADH, skeletal pain, skin discoloration, spontaneous abortion, stomatitis, stupor, sweating decreased, syncope, thirst, thrombocytopenia, thrombosis, tinnitus, torsade de pointes, transient ischemic attack, urinary incontinence, urinary retention, urticaria, vaginal bleeding, ventricular arrhythmia, vertigo, withdrawal syndrome
Lexicomp; Citalopram Monograph, accessed 2-19-2015
TOPIRAMATE
Epilepsy
Migraine prophylaxis
Alcohol dependence
Binge Eating Disorder
Bulimia Nervosa
Cluster HA prophylaxis
Infantile Spasms
Weight Loss
Neuropathic Pain
Uses
Lexicomp; Topiramate Monograph, accessed 2-19-2015
Side Effects > 10% : Central nervous system: Paresthesia (19% to 40%; dose dependent in migraine: 35% to
51%; adjunctive therapy in epilepsy: adults 11% to 19%, children 2 to 16 years 1%; monotherapy in epilepsy: children 10 to 16 years 2% to 16%; adjunctive therapy in partial-onset seizures: 7% to 9%), nervousness (9% to 19%; dose-related, adjunctive therapy in partial-onset seizures: adults 13% to 19%; monotherapy in epilepsy: children 10 to 16 years 4% to 5%; migraine: ≥2% to 4%), fatigue (7% to 16%; adjunctive therapy in epilepsy: adults 15% to 30%; dose-related, adjunctive therapy in partial-onset seizures: adults 11% to 30%; dose dependent in migraine: 14% to 19%; partial-onset seizures: 6% to 9%), ataxia (adjunctive therapy in epilepsy: adults 3% to 16%, children 6%; migraine: 1% to 4%), drowsiness (2% to 15%; adjunctive therapy in epilepsy: 26% to 29%, dose dependent in migraine: 7% to 10%), lack of concentration (2% to 15%; dose-related, adjunctive therapy in partial-onset seizures: adults 7% to 14%; dose dependent in migraine: 3% to 10%; adjunctive therapy in partial-onset seizures: adults 5%), language problems (1% to 15%; dose-related, adjunctive therapy in partial-onset seizures: adults 2% to 10%), dizziness (≤14%; adjunctive therapy in epilepsy: adults 25% to 32%, children 2 to 16 years 4%; dose dependent in migraine: 8% to 12%), memory impairment (≤14%; dose dependent in migraine: 7% to 11%; monotherapy in epilepsy: children 6 to <16 years 1% to 3%; adjunctive therapy in partial-onset seizures: adults 2%), confusion (adults: 9% to 14%; dose-related, adjunctive therapy in partial-onset seizures: adults 9% to 14%; monotherapy in epilepsy: adults 3% to 4%, children 6 to <16 years ≤3%; adjunctive therapy in epilepsy: children 2 to 16 years 4%; dose dependent in migraine: 2% to 4%), weight loss (6% to 13%; migraine: adolescents 12 to 17 years 4% to 31%; monotherapy in epilepsy: 6% to 21%; dose-related, adjunctive therapy in partial-onset seizures: adults 4% to 13%; dose dependent in migraine: 6% to 11%), depression (epilepsy: adults 5% to 13%; dose-related, adjunctive therapy in partial-onset seizures: adults 7% to 13%; dose dependent in migraine: 3% to 6%; monotherapy in epilepsy: children 6 to <16 years ≤3%), behavioral problems (adjunctive therapy in epilepsy: children 2 to 16 years 11%; monotherapy in epilepsy: children 6 to <16 years ≤3%), mood disorder (1% to 11%; dose-related, adjunctive therapy in partial-onset seizures: adults ≤9%; dose dependent in migraine: 3% to 6%
Lexicomp; Topiramate Monograph, accessed 2-19-2015
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Side Effects >10% Endocrine & metabolic: Decreased serum bicarbonate (migraine: adolescents 12 to
17 years 27% to 77%, adults 23% to 44%; children 2 to 16 years 9% to 67%; epilepsy: 14% to 32%; marked reductions [to <17 mEq/L] 1% to 11%), hyperammonemiawith/without encephalopathy, with/without valproate (migraine: adolescents 12 to 17 years 14% to 26%; migraine, markedly high [≥50% above ULN] adolescents 12 to 17 years ≤9%)
Gastrointestinal: Abdominal pain (6% to 15%; adjunctive therapy in partial-onset seizures: adults 5%), anorexia (4% to 15%; adjunctive therapy in epilepsy: children 2 to 16 years 24%; dose-related, adjunctive therapy in partial-onset seizures: adults 4% to 12%, dose-related in migraine: 9% to 15%; adjunctive therapy in partial-onset seizures: 2%), dysgeusia (migraine: 2% to 15%; epilepsy: adults 2% to 5%), nausea (≤12%; dose dependent in migraine: 9% to 14%), diarrhea (2% to 11%; dose dependent in migraine: 9% to 11%; adjunctive therapy in partial-onset seizures: adults 2%)
Infection: Viral infection (3% to 15%; migraine: 3% to 4%; adjunctive therapy in epilepsy: adults <1% to 2%)
Ophthalmic: Nystagmus (adjunctive therapy in epilepsy: adults 10% to 11%) Renal: Increased serum creatinine (children and adolescents 12 to 16 years 18% with
100 mg dose; epilepsy: <1%) Respiratory: Upper respiratory tract infection (12% to 26%), sinusitis (4% to 15%;
monotherapy in epilepsy: children 6 to 16 years 1% to 5%) Miscellaneous: Trauma (6% to 14%; migraine: adolescents 12 to 17 years ≥2%), fever
(children 6 to 17 years ≤12%; migraine: 1% to 2%)
Lexicomp; Topiramate Monograph, accessed 2-19-2015
Side Effects 1 – 10%
Cardiovascular: Flushing (monotherapy in epilepsy: children 6 to <16 years ≥5%; epilepsy: ≤1%), chest pain (adults: 1% to 4%; migraine: >1%), hypertension (1% to 3%), edema (adjunctive therapy in epilepsy: adults 1% to 2%), syncope (epilepsy: ≥1%), bradycardia (adjunctive therapy in epilepsy: children 2 to 16 years 1%), angina pectoris (epilepsy: ≤1%), atrioventricular block (epilepsy: ≤1%), deep vein thrombosis (epilepsy: ≤1%), facial edema (epilepsy: ≤1%), hypotension (epilepsy: ≤1%), orthostatic hypotension (epilepsy: ≤1%), phlebitis (epilepsy: ≤1%), pulmonary embolism (epilepsy: ≤1%), vasodilatation (epilepsy: ≤1%)
Central nervous system: Aggressive behavior (adjunctive therapy in epilepsy: children 2 to 16 years 9%; adults: 2% to 3%), insomnia (≤9%), abnormal gait (adjunctive therapy in epilepsy: children 2 to 16 years 8%, adults 2% to 3%), anxiety (≤8%; dose-related, adjunctive therapy in partial-onset seizures: adults 2% to 10%; dose dependent in migraine: 4% to 6%), cognitive dysfunction (epilepsy: ≤7%; migraine: <1% to 2%), psychomotor retardation (2% to 5%; adjunctive therapy in epilepsy: adults 13% to 21%; migraine: adolescents 12 to 17 years ≤8%), hypoesthesia (1% to 5%; dose dependent in migraine: 6% to 8%), speech disturbance (<1% to 4%; adjunctive therapy in epilepsy: adults 11% to 13%), emotional lability(adjunctive therapy in epilepsy: adults 3%), agitation (1% to 3%), apathy (adjunctive therapy in epilepsy: adults 1% to 3%), hypertonia (monotherapy in epilepsy: adults: ≤3%), vertigo (≤3%), pain (migraine: >1% to ≥2%), aphasia (adjunctive therapy in partial-onset seizures: 2%), dysarthria (adjunctive therapy in partial-onset seizures: 2%), hyporeflexia (adjunctive therapy in epilepsy: children 2 to 16 years 2%), irritability (adjunctive therapy in partial-onset seizures: 2%), depersonalization (adjunctive therapy in epilepsy: adults 1% to 2%), exacerbation of depression (migraine: 1% to 2%), stupor (adjunctive therapy in epilepsy: adults 1% to 2%), exacerbation of migraine headache (migraine: >1%), headache (migraine: >1%, adolescents 12 to 17 years 2% to 8%), sensory disturbance (migraine: >1%), hallucination(epilepsy: ≥1%), psychosis (epilepsy: ≥1%), psychoneurosis (adjunctive therapy in epilepsy: children 2 to 16 years 1%), tonic-clonic seizures (adjunctive therapy in epilepsy: children 2 to 16 years 1%), abnormal electroencephalogram (epilepsy: ≤1%), altered sense of smell (epilepsy: ≤1%), apraxia (epilepsy: ≤1%), brain disease (epilepsy: ≤1%), delirium (epilepsy: ≤1%), delusions (epilepsy: ≤1%), dystonia (epilepsy: ≤1%), euphoria (epilepsy: ≤1%), hyperesthesia (epilepsy: ≤1%), neuropathy (epilepsy: ≤1%), paranoia (epilepsy: ≤1%), rigors (adjunctive therapy in epilepsy: adults ≤1%), voice disorder (epilepsy: ≤1%)
Lexicomp; Topiramate Monograph, accessed 2-19-2015
Side Effects 1-10%
Dermatologic: Erythematous rash (migraine: adolescents 12 to 17 years ≤8%; adjunctive therapy in epilepsy: ≤1% to 2%), alopecia (1% to 5%; migraine: >1%), pruritus (1% to 4%), skin rash (1% to 4%), acne vulgaris (monotherapy in epilepsy: adults 2% to 3%), dermatological disease (adjunctive therapy in epilepsy: 1% to 3%), dermatitis (adjunctive therapy in epilepsy: children 2 to 16 years 2%), hypertrichosis (adjunctive therapy in epilepsy: children 2 to 16 years 2%), eczema (adjunctive therapy in epilepsy: children 2 to 16 years 1%), pallor (adjunctive therapy in epilepsy: children 2 to 16 years 1%), seborrhea (adjunctive therapy in epilepsy: children 2 to 16 years 1%), skin discoloration (adjunctive therapy in epilepsy: children 2 to 16 years 1%), abnormal hair texture (epilepsy: ≤1%), body odor (adjunctive therapy in epilepsy: adults ≤1%), diaphoresis (adjunctive therapy in epilepsy: adults: ≤1%), skin photosensitivity (epilepsy: ≤1%), urticaria (epilepsy: ≤1%)
Endocrine & metabolic: Hyperthyroidism (migraine: adolescents 12 to 17 years ≤8%), decreased serum phosphate (adjunctive therapy in partial-onset seizures: adults 6%), increased gamma-glutamyltransferase (monotherapy in epilepsy: adults 1% to 3%), menstrual disease (1% to 3%), decreased libido (≤3%), intermenstrual bleeding (≤3%), amenorrhea (adjunctive therapy in epilepsy: adults 2%), hot flash (adjunctive therapy in epilepsy: adults 1% to 2%), hypermenorrhea (adjunctive therapy in epilepsy: adults 1% to 2%), increased thirst (1% to 2%), hypoglycemia (adjunctive therapy in epilepsy: children 2 to 16 years 1%), weight gain (adjunctive therapy in epilepsy: children 2 to 16 years 1%), albuminuria (epilepsy: ≤1%), dehydration (epilepsy: ≤1%), diabetes mellitus (epilepsy: ≤1%), hyperglycemia (epilepsy: ≤1%), hyperlipidemia (epilepsy: ≤1%), hypocalcemia (epilepsy: ≤1%)
Gastrointestinal: Dyspepsia (3% to 7%; adjunctive therapy in partial-onset seizures: adults 2%), sialorrhea (adjunctive therapy in epilepsy: children 2 to 16 years 6%), xerostomia (dose dependent in migraine: 2% to 5%; adults: 1% to 4%), constipation (1% to 5%; migraine: >1%), decreased appetite (adjunctive therapy in partial-onset seizures: 4%), gastroenteritis (1% to 3%), vomiting (migraine: 1% to 3%), gastritis (≤3%), ageusia (≤2%), gastroesophageal reflux disease (1% to 2%), dysphagia (adjunctive therapy in epilepsy: children 2 to 16 years 1%), fecal incontinence (adjunctive therapy in epilepsy: children 2 to 16 years 1%), flatulence (adjunctive therapy in epilepsy: children 2 to 16 years 1%), gastrointestinal disease (adjunctive therapy in epilepsy: adults 1%), gingival hyperplasia (adjunctive therapy in epilepsy: children 2 to 16 years 1%), gingivitis (adjunctive therapy in epilepsy: adults 1%), glossitis (adjunctive therapy in epilepsy: children 2 to 16 years 1%), increased appetite (adjunctive therapy in epilepsy: children 2 to 16 years 1%), enlargement of abdomen (epilepsy: ≤1%), esophagitis(epilepsy: ≤1%), gingival hemorrhage (epilepsy: ≤1%), hemorrhoids (epilepsy: ≤1%), melena (epilepsy: ≤1%), stomatitis (epilepsy: ≤1%)
Lexicomp; Topiramate Monograph, accessed 2-19-2015
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Side Effects 1-10% Genitourinary: Mastalgia (adjunctive therapy in epilepsy: adults ≤4%), urinary incontinence
(1% to 4%), urinary tract infection (1% to 4%), premature ejaculation (migraine: ≤3%), urinary frequency (epilepsy: ≤3%), vaginal hemorrhage (monotherapy in epilepsy: adults ≤3%), cystitis (adults: 1% to 3%), hematuria (adjunctive therapy in epilepsy: adults <1% to 2%), leukorrhea (adjunctive therapy in epilepsy: children 2 to 16 years 2%), dysuria (monotherapy in epilepsy: adults ≤2%), prostatic disease (adjunctive therapy in epilepsy: adults ≤2%), genital candidiasis (migraine: >1%), impotence (epilepsy: ≥1%), nocturia(adjunctive therapy in epilepsy: children 2 to 16 years 1%), ejaculatory disorder (epilepsy: ≤1%), nipple discharge (epilepsy: males ≤1%), oliguria (epilepsy: ≤1%), urinary retention (epilepsy: ≤1%), urine abnormality (adjunctive therapy in epilepsy: adults ≤1%)
Hematologic & oncologic: Purpura (adjunctive therapy in epilepsy: children 2 to 16 years 8%), hemorrhage (4% to 5%), anemia (epilepsy: ≥1% to 3%), neoplasm (migraine: 2%), leukopenia (adjunctive therapy in epilepsy: 1% to 2%), hematoma (adjunctive therapy in epilepsy: children 2 to 16 years 1%), prolonged prothrombin time (adjunctive therapy in epilepsy: children 2 to 16 years 1%), thrombocytopenia (adjunctive therapy in epilepsy: children 2 to 16 years 1%), eosinophilia (epilepsy: ≤1%), granulocytopenia (epilepsy: ≤1%), lymphadenopathy (epilepsy: ≤1%), lymphocytopenia (epilepsy: ≤1%), thrombocythemia(epilepsy: ≤1%)
Hepatic: Increased serum alkaline phosphatase (adjunctive therapy in partial-onset seizures: adults 3%), increased serum ALT (epilepsy: ≤1%), increased serum AST (epilepsy: ≤1%)
Hypersensitivity: Hypersensitivity reaction (<1% to 3%; migraine: adolescents 12 to 17 years ≤8%)
Infection: Infection (>1% to ≥2%; monotherapy in epilepsy: 2% to 8%), candidiasis (adjunctive therapy in epilepsy: adults ≥1%)
Lexicomp; Topiramate Monograph, accessed 2-19-2015
Side Effects 1-10%
Neuromuscular & skeletal: Tremor (adjunctive therapy in epilepsy: adults 9%; adjunctive therapy in partial-onset seizures: adults 3%; migraine: >1%), muscle spasm (≤8%; dose dependent in migraine: 2% to 4%; adjunctive therapy in epilepsy: adults: 2%), leg pain (2% to 8%), arthralgia (migraine: 1% to 7%; epilepsy: ≥1%), weakness (epilepsy: ≤6%; adjunctive therapy in partial-onset seizures: 2%; migraine: <1% to 2%), hyperkinesia (adjunctive therapy in epilepsy: children 2 to 16 years 5%), back pain (≥2% to 5%; adjunctive therapy in epilepsy: children 2 to 16 years 1%), leg cramps (adjunctive therapy in partial-onset seizures: adults 2%), myalgia (>1% to ≥2%), arthropathy (epilepsy: ≤1%), dyskinesia (epilepsy: ≤1%), skeletal pain (adjunctive therapy in epilepsy: adults ≤1%)
Ophthalmic: Diplopia (adjunctive therapy in epilepsy: adults 10%, children 2 to 16 years 1%; adjunctive therapy in partial-onset seizures: adults 2%), blurred vision (migraine: 2% to 4%), visual disturbance (≥2%; adjunctive therapy in epilepsy: adults: 10% to 13%; dose dependent in migraine: 1% to 3%), eye pain (migraine: >1% to ≥2%), eye disease (adjunctive therapy in epilepsy: children 2 to 16 years 2%), conjunctivitis (1% to 2%; migraine: adolescents 12 to 15 years ≤7%), accommodation disturbance (migraine: ≥1%), abnormal lacrimation (adjunctive therapy in epilepsy: children 2 to 16 years 1%), myopia (adjunctive therapy in epilepsy: children 2 to 16 years 1%), blepharoptosis (epilepsy: ≤1%), photophobia (epilepsy: ≤1%), scotoma (epilepsy: ≤1%), strabismus (epilepsy: ≤1%), visual field defect (epilepsy: ≤1%), xerophthalmia (epilepsy: ≤1%)
Otic: Hearing loss (adjunctive therapy in epilepsy: adults 1% to 2%), otitis media (migraine: 1% to 2%, adolescents 12 to 17 years ≤8%), tinnitus (<1% to 2%)
Renal: Nephrolithiasis (1% to ≤3%; dose dependent in migraine: ≤2%), polyuria (epilepsy: ≤1%), renal pain (epilepsy: ≤1%)
Respiratory: Laryngitis (migraine: adolescents 12 to 17 years ≤8%), pharyngeal edema (migraine: adolescents 12 to 17 years ≤8%), epistaxis (2% to 8%; adjunctive therapy in epilepsy: adults 1% to 2%; migraine: >1%), rhinitis (adults: 2% to 8%; migraine: adults 1% to 2%), cough (migraine: 2% to 7%), bronchitis (monotherapy in epilepsy: 1% to 7%; migraine: ≥2% to 3%), pharyngitis (≥2% to 6%), pneumonia (adjunctive therapy in epilepsy: children 2 to 16 years 5%; migraine: >1%), flu-like symptoms (<1% to 4%), dyspnea (migraine: 1% to 3%), asthma (migraine: >1% to ≥2%), respiratory tract disease (adjunctive therapy in epilepsy: children 2 to 16 years 1%)
Lexicomp; Topiramate Monograph, accessed 2-19-2015
Side Effects <1%
Alcohol intolerance (epilepsy), bone marrow depression (epilepsy), bullous skin disease, cerebellar syndrome (epilepsy), chloasma (epilepsy), erythema multiform, hepatic failure (including fatalities), hepatitis, hypernatremia (epilepsy), hypocholesterolemia (epilepsy), hypokalemia (adjunctive therapy in adults with partial-onset seizures), hyponatremia (epilepsy), increased libido (epilepsy), iritis (epilepsy), lymphocytosis (epilepsy), maculopathy, manic reaction (epilepsy), mydriasis (epilepsy), pancreatitis, pancytopenia (epilepsy), pemphigus, polycythemia (epilepsy), Stevens-Johnson syndrome, suicidal ideation, tongue edema (epilepsy), tongue paralysis (epilepsy), toxic epidermal necrolysis, upper motor neuron lesion (epilepsy), vasospasm (epilepsy)
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Medications with Negative Side Effects
Medications used to Treat
Using knowledge to effect patient care
BASED ON YOUR PRACTICE SITE:(OR WHATEVER YOU MAY BE CURIOUS ABOUT)
Jot down
Question
Clinical dilemma
Case scenario
PHARMACO…..WHAT???
Pharmacology: study of drugs and interactions with living organisms
Pharmacotherapeutics: use of drugs to prevent, diagnosis and treat diseases
Pharmacodynamics: the biochemical and physical effects of drugs and MOA (mechanism of action)
Pharmacokinetics: how drugs move through body Absorption
Distribution
Metabolism
Excretion
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PHARMACO…..WHAT???
Pharmacogenetics: how genetic makeup of different people, ethnicities, gender affects response to certain drugs
Pharmacogenomics: use of genome technology to discover new drugs
DRUG NAMES
Chemical Formula C13-H18-O2
Chemical Name α-p-isobutylphenylpropionic acid
Generic: Ibuprofen
Brand Name: Advil®, Motrin®, Nurofen®
IT’S ALL IN THE NAME
Chemical Name
sodium [(9S,13S,14S)-13-methyl-17-oxo-9,11,12,14,15,16-hexahydro-6H-cyclopenta[a]phenanthren-3-yl] sulfate
Source: Pregnant Mare’s Urine
Generic Name: Conjugated Estrogens
Brand Name: Premarin
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WHERE DO DRUGS COME FROM
Plants Alkaloids – most active component of plants (atropine, caffeine, nicotine)
Glycosides – active component (digoxin)
Gums – interact and hold water
Resins - pine tree sap – irritant, laxative
Oils – volatile – peppermint, spearmint, juniper or fixed – castor oil, olive oil
YamsEstrogenHormone Replacement Therapy
Opium PoppyMorphineHeroin
Colchicum autumnaleColchicineGout
Rose HipsVitamin C
Willow BarkAspirin
Cinchona BarkQuinine
Black CohoshHot flashes
DaffodilsGalantamineAlzheimer's
Calcium
Zinc
Iron
Ferrous Sulfate
Potassium
Potassium Choloride
Iodine
Potassium Choloride
Povidone Iodine
Sodium Iodide,Potassium Iodide
Tums
Zinc Chloride
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Brazilian Arrowhead ViperCaptoprilHypertension
Pregnant Mare UrinePremarinHormone Replacement
Coho SalmonCalcitonin, MiacalcinOsteoporosis
Beef and PorkInsulinDiabetes
Gila Monster SpitByettaDiabetes
SheepLanolin
DRUG DEVELOPMENT Ancient sources
New Chemical from environment
Isomers
Recombinant DNA technology
Stem cell therapy
Gene therapy
HOW DRUGS ARE ADMINISTERED
Oral routes of administration Buccal, sublingual, translingual, gastric tube
Injections Subcutaneous, intradermal, intramuscular, intravenous, intrathecal, epidural,
intraplueral, intraosseous
Topically respiratory
skin
rectal
vaginal
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HOW DRUGS COME….
Solids Oral: Tablets, capsules, orally dispersible tablets, troches, lozenges
Topical: suppositories
Immediate vs Sustained Released tablets/capsules donotcrush(4).pdf
http://www.drugguide.com/ddo/ub/view/Davis-Drug-Guide/109642/all/
http://www.philly.com/philly/blogs/healthcare/Certain-medicines-should-never-be-crushed-or-chewed.html
HOW DRUGS COME….
Liquids Solutions, suspensions, emulsions
Topical Application Solutions, Creams, Ointments
Respiratory Inhalation of aerosolized liquids or powders
Sprays
Nebulization
TESTING NEW DRUGS
Animal testing Frequency distribution curve
Half-life
Median effective dose
Median toxic dose
Therapeutic index
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“This drug was tested on 2000 white mice, and they had a ball.”
David W. Harbaugh.
PROCESS FOR CLINICAL TRIALS
IND
Phase I Clinical Trial Healthy volunteers
Phase II 50 to 500 of people with disease
Phase III Several hundred – thousands people
PROCESS FOR CLINICAL TRIALS
New Drug Application to FDA 20% receive final approval
Phase IV Clinical testing Post Marketing Surveillance
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PHARMACOTHERAPEUTICS
Use of drugs to treat disease
Patient’s response to the drug Patient specific factors
Drug tolerance
Drug dependence
PHARMACODYNAMICS
Study of how the drug causes the changes in the body
On a cellular level, drugs alter target cell’s function by modiyfing the cells physical or chemical environment
interacting with a receptor on the cell
© The McGraw-Hill Companies, Inc, 2011
PHARMACODYNAMICS
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PHARMACOKINETICS
Distribution
Metabolism
Excretion
PHARMACOKINETICS
ABSORPTION
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FACTORS AFFECTING DRUG ABSORBTION
Drugs absorbed through the skin Thickness of skin
Open wounds
Age
Drugs absorbed in the GI Tract Vomiting
Diarrhea
Ostomy
Surgical removal of intestines
http://www.nursingbuddy.com/2011/02/10/drugs-and-the-body/
PHARMACOKINETICS
Distribution
Metabolism
Excretion
DISTRIBUTION
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PHARMACOKINETICS
Distribution
Metabolism
Excretion
METABOLISM
Biotransformation of the drug Active metabolites (pro-drugs)
Inactive metabolites
Liver, kidney, lungs, intestines, skin, brain, CNS
http://www.doctorfungus.org/thedrugs/antif_interaction.php
PHARMACOKINETICS
Distribution
Metabolism
Excretion
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EXCRETION-RENAL
EXCRETION
GI Excretion Unabsorbed drug
Metabolites
Respiratory General anesthetics
BLOOD LEVELS
Half- Life Steady State
Time it takes concentration of drug to decrease by 1/2 the original level
Consistent Blood level
http://www.rxkinetics.com/pktutorial/1_6.htmlhttp://apps.who.int/medicinedocs/en/d/Jwhozip23e/7.1.4.3.html
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THERAPEUTIC INDEX
PHARMACOKINETICS AFFECTS:
Onset of action SSRIs
Peak concentration
Duration of action
Medications with Negative Side Effects
Medications used to Treat
Using knowledge to effect patient care
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ADVERSE DRUG REACTIONS Undesirable, harmful response to a medication
Chemical Patient specific parameters
Side Effects Secondary effects – therapeutic response AND not intended therapeutic response
Morphine = Pain AND sedation, respiratory, distress, constipationBenadryl= Antihistamine OR sleep aid because of side effects
Enhanced action – caused by patient specific parameters effecting pharmacokinetics resulting in a higher blood concentration
Toxicity: Ototoxicity with aminoglycosides or lasix
Drug allergy (resulting from patient’s immune system) or idiosyncratic reaction (genetically specific)
DRUG INTERACTIONS
Drug-drug
Drug-food
Drug-herbal
Drug-labs
DRUGS THAT AFFECT
Swallowing (aphagia, dysphagia)
Balance
Hearing (ototoxicity, tinnitus)
Cognition
Movement
Speech (apraxia, aphasia,)
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DRUG INDUCED DYSPHAGIA
No apparent abnormality of esophageal transit
No prior esophageal disease
Al-Sheri A, Dysphagia as a Drug Side Effect, The Internet Journal of Otorhinolarngology; 2001, Vol 1 Number 2
DRUG INDUCED DYSPHAGIA
Consider: When is med taken? Bedtime?
Inadequate fluid to swallow medication
Decreased swallowing, saliva, peristalsis
Size and shape of tablets and capsules 2cm tablets more delayed than <1cm
Elderly patients More meds
More likely to have anatomic or motility abnormalities of esophagus
More likely to have cardiac enlargement with concomitant compression of mid-esophagus
Motility problems due to diabetes or autonomic neuropathy
Swallowing dysfunction due to stroke or connective tissue disease
Decreased saliva leading to decreased esophageal lubrication and increased likelihood of the drug to the esophageal mucosa
Al-Sheri A, Dysphagia as a Drug Side Effect, The Internet Journal of Otorhinolarngology; 2001, Vol 1 Number 2
DRUG INDUCED DYSPHAGIA
Alleviate problem Correctly formulated drug
Sublingual, buccal or dissolvable tablets
Liquid preparations
Timing of medication administration
Al-Sheri A, Dysphagia as a Drug Side Effect, The Internet Journal of Otorhinolarngology; 2001, Vol 1 Number 2
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DRUG INDUCED DYSPHAGIA
Drugs acting on CNS Sedatives
Narcotics
Drugs acting on striated muscle
Muscle relaxants (pancuronium, succinlycholine)
Local Anesthetics (benzonatate, Tessalon Perles)
Extrapyramidal motor movements Antipsychotics
Xerostomia
DRUG INDUCED DYSPHAGIA
Alcohol
Cytotoxic agents Predispose patient to viral and fungal infections
Esophagitis
Drug Induced Esophageal Injury Drugs with pH <3
Doxycycline, tetracycline, ascorbic acid, ferrous sulfate
Esophagitis or esophageal stricture formation
NSAIDs, low dose aspirin
WHEN TO SUSPECT MEDICATION IN HEARING LOSS
Patient has history of Cancer
Renal Disease
Infection
Love et al. Ototoxicity and Vestibulotoxicity Considerations in Primary Care; Clinician Review; April 2013
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OTOTOXICITY Aminoglycosides (8%)
gentamicin, tobramycin, streptomycin (vestibular toxicty)
May or may not have hearing loss
Usually noted with standing up. Sitting down, during head movement or when eyes are closed
Adaption often develops over 2 weeks to 2 months
amikacin, netilmycin, kanamycin (auditory toxicity)
Irreversible, occurs within 2-6 days of therapy initiation or discontinuation, may not be evident for several weeks
Genetic predisposition
Destruction of hair cells in the inner ear
Dependent on cumulative dose and duration of therapy
Love et al. Ototoxicity and Vestibulotoxicity Considerations in Primary Care; Clinician Review; April 2013
OTOTOXICITY Erythromycin/Macrolides (20-30%)
Erythromycin
“blowing sound” with vertigo
Begin 4 – 8 days into high dose therapy and resolve in days to weeks of discontinuation
Vancomycin
High frequency hearing loss with tinnitus
Minocycline
Dose dependent, reversible vestibulotoxicity
75mg twice daily – 50% patients
100mg twice daily – 100% patients develop vertigo
Incidence is 2-3 times in female > male
Resolves with 48 hours of drug discontinuation in 75% of patients
Love et al. Ototoxicity and Vestibulotoxicity Considerations in Primary Care; Clinician Review; April 2013
OTOTOXICITY NSAIDS
Aspirin Ototoxicity: 0.3% to 1.7% in patients > 2.7g/day Tinnitus: 50% of patients taking > 4g/day Hearing loss: 25% of patients taking > 4g/day
Loop Diuretics (furosemide, bumetanide) Dose dependent or rapid IV infusion
Drugs for Erectile Dysfunction (Viagra, Cialis) Sudden hearing loss Vertigo, dizziness, tinnitus
Chemotherapeutic Agents Platinum (cisplatin, carboplatin)
Tinnitus High-frequency hearing loss Children are more susceptible
Love et al. Ototoxicity and Vestibulotoxicity Considerations in Primary Care; Clinician Review; April 2013
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OTOTOXICITY
Risk Factors for Ototoxic Reactions Patient populations more vulnerable
Extremes in age (very young or very old)
Renal or Hepatic failure
Rapid IV infusion rates
High-dose regimens
Lengthy duration of treatment
Combination of ototoxic drugs
Love et al. Ototoxicity and Vestibulotoxicity Considerations in Primary Care; Clinician Review; April 2013
BALANCE AND VERTIGO
Balance Vision
Inner Ear
Cerebellum
Proprioceptive pathways
Vasovagal system
Vertigo Unbalanced input by central
vestibular apparatus
Unbalanced processing of vestibular visual and somatosensory inputs
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542
DRUGS THAT CAUSE DIZZINESS
Antibiotics Aminoglycosides
Tetracyclines
Antihypertensives Orthostatic Hypotension
Clonidine
Methyldopa
Phentolamine
Nifedipine
Ranolazine
Labetalol
Diuretics Furosemide, bumetanide
Hydrochlorothiazide
Antipsychotics Phenothiazines
Antidepressants SSRIs (SE and upon discontinuation)
TCAs (orthostatic hypotension)
SNRIs
Bupropion (Wellbutrin®)
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542
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DRUGS THAT CAUSE DIZZINESS
Anticonvulsants Ethosuximide, levetiracetam,
tiagabine, vigabatrin, lacosamide
Gabapentin and pregabalin (ataxia)
Lamotrigine (diplopia)
Retigabine (blurred vision)
Sedative/Hypnotics Ramelteon
Buspirone
Flumazenil
Chemotherapy Drugs Vertigo without ototoxicity
Cetuximab
Dasatinib
Imatinib
Sunifinib
Taxtuzeumab
Tretinioin
Mefanamic acid
Azathiprine
Tacrolimus
Natalizumab
Hypotension Etoposide
Docetaxel
Bortezomib
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542
DRUGS THAT CAUSE DIZZINESS
AlcoholEnhanced with smoking
Tobacco Products (including oral tobacco)
Caffeine
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542
Medications with Negative Side Effects
Medications used to Treat/Prevent
Using knowledge to effect patient care
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OTOTOXICITY - PROTECTION
Statin drugs
Simvastatin - Protection in vitro
Atorvastatin – irreversible ototoxicity
Brand et al. BMC Neuroscience 2011,12:114Liu et al. Pharmacotherapy 2012, Vol 32 Number 2, e27-34
OTOTOXICITY - PROTECTIONDexamethasoneTacrolimusMelatonin
Prevent hair cell death by acting at different points in cell death pathway Melatonin – potent antioxidant and free radical scavenging hormone
Dexamethasone – anti-inflammatory, anti-allergy drug that inhibits AP-1
Tacrolimus – immunosuppressant that limits formation of AP-1
Activating Protein-1 (AP-1) Gentamicin increases AP-1 activity in outer hair cells
British Journal of Pharmacology (2012) 166 188-1904
OTOTOXICITY
Development of local long-term delivery techniques to the cochlea will be a breakthrough in terms of reducing the levels of drugs required for effective treatment, decreasing or eliminating side effects and avoiding alteration of drugs by liver metabolism, thereby assuring that the desired concentration of a drug is achieved only in the target area 9ie, the perilymph within the scala tympani. The results of our study show that local treatment of cochlea with dexamethasone, melatonin or tacrolimus can conserve auditory function and prevent hair cell loss.
British Journal of Pharmacology (2012) 166 188-1904
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TINNITUS
Supplements Traditional treatments
Lipo-Flavonoid (B Vitamins, Vitamin C)
Quietus, RingStop(homeopathic dilutions of cinchona)
Ginkgo biloba
Melatonin
Zinc
NO DRUGS APPROVED FOR TINNITUS
Antidepressants (TCAs, SSRIs)
Benzodiazepines (alprazolam)
Anticonvulsants (carbamazepine, gabapentin)
Glutamate Antagonists (memantine, acamprosate)
AHRQ Comparative Effect5iveness Review 122; Evaluation and Treatment of Tinnitus: Comparative EffectivenessPharmacist’s Letter Detail Document #260195
TREATING TINNITUS
Lifestyle Modifications Therapy
Avoid: Salt
Caffeine
Simple Sugars
MSG
Artificial Sweeteners
Food dyes
Cognitive Behavioral Therapy
Counseling
Sound therapy
Meditation
Pharmacist’s Letter Detail Document #260195; 9/2010, Volume 26, number 260915)
TREATING DIZZINESS AND BALANCE DEFICIENCIES
Suppress Vestibular System: Manage Symptoms of Nausea:
Antihistamines
Meclizine (anticholinergic, antiemetic)
Dimenhydrinate (Dramamine)
Anticholinergics
Scopolamine (Transderm Scop)
Atropine
Benzodiazepines
Diazepam (Valium)
Lorazepam (Ativan)
Clonazepam (Klonipin)
Calcium Channel Antagonists
Nimodipine
Phenothiazines Prochlorperazine (Compazine)
Promethazine (Phenergan)
Metoclopramide (Reglan)
Ondansetron (Zofran)
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542
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TREATING DIZZINESS AND BALANCE DEFICIENCIES
Baclofen Used in patients with microvascular compression of CN VIII
Vestibulocochlear nerve
Amantadine Promote compensation in patients with brain injury
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542
Medications with Negative Side Effects
Medications used to Treat
Using knowledge to effect patient care
CASES
Dysphagia in a 62 yr old female patient Medical History includes:
Diabetes
Hypertension
Cough
Medications include: Lisinopril 10mg daily for hypertension
Tessalon Perles 200mg three times daily as needed for cough
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CASES
Tardive Dyskinesia in a 12 yr old
Paradoxical Delirium in a 74 yr old post op patient
REFERENCES
Cianfrone G, et al. Pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus: a reasoned and updated guide, European Review for Medical and Pharmacological Sciences 2011;15: 601-636.
Gallagher L, Naidoo P, Prescription Drugs and Their Effects on Swallowing, Dysphagia (2009)24:159-166.
Lin E, Aligne K, Pharmacology of balance and dizziness, NeuroRehabilitation 32(2013) 529-542.
Mitchell JF, Oral Dosage Forms That Should Not Be Crushed; http://www.ismp.org/tools/donotcrush.pdf ; accessed February 2015.