Download Neurology survival drug list

Neurology survival drug list
Stroke
Aspirin 300 mg stat and 100mg OM
Persantin (Dipyridamole) start 50mg TDS  150mg TDS (Watch for headaches, giddiness)
Ticlid 250 mg BD (check FBC mthly x 3)
Clopidogrel 75mg OM
IV Heparin 20-25 units/kg/hr (Heparin calculator), aim PTT 60-80 sec check PTT Q6hr
SC Clexane 1mg/kg
Warfarin to titrate INR 2-3
BP keep high, treat if >220/120 mmHg
PO Captopril 6.25/12.5 mg stat & TDS (max 480mg/day)
Deterioration
Add Persantin, IV hydration, consider anti-coagulation (risk of bleed 4%)
Mass effect ~ onset 48-96h after stroke
IV Mannitol 20% 0.25-0.5g/kg over 20mins Q6H (max 2g/kg), usual dose 100ml over 20 min Q6H
Hyperventilate to pCO2 28-32 mmHg, maintain euvolemia with N/S
st
Ischaemic stroke BP <220/120 mmHg (not to decrease by > 15% of baseline BP in 1 24 hrs)
Haemorrhagic stroke BP keep between 140-160/80-90 mmHg
IV Labetalol 10 mg bolus Q10 min till max 150 mg/day
IV infusion Labetalol 200mg in 200ml D5% and run at 1-2mg/min (1-2ml/min), Watch for BP
IV Hydralazine 5-20 mg repeat Q15-30min up to max 50mg (not in IHD, watch for tachycardia)
IV Esmolol 05-1mg/kg bolus
IV Na Nitroprusside 0.5ug/kg/min titrate (CI in ACS, liver/renal failure)
IV GTN 5-10 ug/min titrate
Preventing vasospasm in SAH: PO Nimodipine 30-60mg Q4h x 3/52
Movement disorders
Parkinsonism look for atypical parkinson’s features eg autonomic dysfx, supranuclear gaze palsy
Early symptomatic: Selegiline, Benzhexol (esp for tremors), Amantadine 100-200mg BD
Symptomatic: Dopamine agonists +/- Levodopa
Madopar (L dopa + Benserazide) 250mg tab. Start 62.5 mg & titrate to optimal at 4-5 tab/day in 4-5
divided doses according to clinical response
Sinemet (L-dopa + Carbidopa) 100/25 tab. Start 0.5 tab & titrate to optimal at 8-10 tab/day in 4-5
divided doses, according to clinical response.
Motor complications: Comtan (Entacapone), Amantadine, surgery (deep brain stimulators
implantation)
Depression: SSRI Fluvoxamine (Faverin) 50mg ON, Fluoxetine (Prozac) 20-40 mg OM
Hallucinations: Quetiapine (Seroquel) 25-50 mg ON-TDS
Postural hypotension: Fludrocortisone 0.05-0.1mg OM-TDS (need Span K replacement),
Midodrine 2.5-5 mg BD-TDS
REM sleep disorders: Clonazepam 0.25-0.5mg ON
Constipation: laxatives
CHOREA (Copper/cirrhosis, Huntington, Oestrogen, Rheumatic, Endocrine, Autoimmune)
Clonazepam 0.5 – 3 mg/day
Haloperidol 0.5 – 8 mg/day
Tetrabenazine 12.5-100 mg/day
Dementia
Inv: electrolytes, Ca/Mg/PO4, RPR, VDRL, TFT, Vit B12, Folate, MRI/CT brain, MMSE
(educated >6yrs, cut off at 24/28, <6yr, cut off at 22/28)
Donepezil (Aricept) 5mg OM x 4/52 then increase to 10mg OM
Rivastigmine (Exelon) start 1.5 mg BD, increase by 3mg/day till max 6 mg BD
Galantamine (Razadyne or Reminyl) 4-12 mg BD
Risk factors control
Atorvastatin 80mg ON x 1/52 then (not all consultants use it)
Simvastatin 20-40 mg ON, Pravastatin 40 mg ON, Rosuvastatin 10-20 mg ON
Gemfibrozil 300 mg ON, Fenofibrate 100-300 mg ON
Aim LDL <2, Sugar control with insulin sliding scale, aim glucose 5 to 7 mmol/L
Refer to primary Dr to review BP in 2/52, kiv restart anti HTN meds, keep BP <130/80 mmHg
Meningitis/Meningoencephalitis
IV Ceftriaxone 2g Q12H/ IV Ceftazidine 1g Q8H
IV Acyclovir 10 mg/kg Q8H x 10-14/7
IV Ampicillin 3-4g Q6H (if suspect Listeria)
IV Cloxacillin 2g Q6H for MSSA (hardware or penetrating injury)
Penicillin allergy: IV Meropenam 2g Q8H (anaphylactic cross reactivity 5-10%)
IV Vancomycin 1g Q12H (for MRSA)
Young stroke workup
ESR, Anti-ds DNA, ANA, anti-cardiolipin, lupus anticoagulant, protein C, protein S, anti-thrombin
III, fasting homocysteine, factor V leiden, PT/PTT, 2DE/TEE and U/S carotids
Hyperhomocysteinemia – folate 5 mg OM +/- B6 25 mg om, B12 500 mcg OM
Avoid HRT for post-menopausal women
GBS – supportive treatment
IVIG 2g/kg over 5 days (0.4g/kg x 5/7 or 1g/kg x 2/7)
Plasma exchange
Seizures (recurrent vs breakthrough vs paradoxical)
Abort fits/status epilepticus
IV Diazepam 5-10mg stat & repeat (max 20mg)
Or IV Lorazepam 0.1mg/kg (<2mg/min)
IV Phenytoin load 20 mg/kg (dilute in 100ml n/s) run at rate <50 mg/min (over 0.5 – 1hr). If still
fit, additional 5-10 mg/kg up to max 30mg/kg, then maintain at 100 mg Q8H
Need BP, cardiac monitor during IV loading (CI in heart block)
IV Phenobarbitone load 20 mg/kg at 50-100mg/min (intubate before loading)
If seizures aborted, may give IV Phenobarbitone 100 mg Q4-6 H
If more frequent dosing is required eg IV Phenobarbitone 100 mg Q1-2 H
Phenytoin PO loading via NG 300 mg x 3 Q1H then 300 mg ON (use in flurry of fits, not in SE)
Sodium Valproate IV 15-20mg/kg at 3mg/kg/min bolus then continuous infusion at 1mg/kg/hr
starting 30min after bolus [keep levels >50]
Sodium Valproate CR PO (same dose as IV) start 500mg BD
Carbamazepine CR PO start at 200mg BD, titrate wkly, up to max 1600mg/day [levels 4-10]
Refractory Status Epilepticus
IV Lorazepam 0.1 mg/kg Q6-8H, if seizures persist, continuous infusion (eg 1 mg/hr) - titrate
upwards at increments of 1 mg/hr (provided BP holds) till seizures are aborted
IV Midazolam 2-10mg/hr
IV Propofol 2-10 mg/kg/hr
IV/PO Levitiracetam (Keppra) 0.5-1.5g BD
PO Topiramate (Topamax) titrate from 100mg BD upwards
Treat the cause (do AED drug levels)
Hypocalcemia: Ca glucoronate 10% 10 ml in 100ml N/S over 1 hr
Hypomagnesmia: MgSO4 (2.47g/5ml vaul) 5-10 ml in 100ml N/S over 1h
Hypophosphatemia: KH2PO4 10-20 ml in 100ml n/s over 1h
Hypokalemia: Premix KCL 10-20 mmol in 100ml water over 1 hr
Hyponatremia: Na deficit = (desired Na-serum Na) x 0.6 x BW then replace with 0.9% N/S 154
mmol/L (caution: avoid 3% saline, consult seniors)
IV Dextrose 50% 40 ml
IV Thiamine 100 mg stat & x 5/7, then PO Thiamine 100mg OM daily x 5/7, then a lower dose
Think pptg factors: non-compliance, sepsis, vascular, tumor, drugs, sugar, electrolytes, and alcohol
Transverse myelitis/MS/NMO
Acute attacks: IV Methylprednisolone 0.5-1g OM x 3-5 days, plasma exchange
Multiple sclerosis – immunomodulation
Interferon work in 30% of MS patients
Neuromyelitis optica (NMO) - immunosuppression
Prednisolone 60 mg OM
Azathioprine (steroid sparing) start at 25mg OM, increase by 25 mg every 3/52 (check FBC, LFT)
Other drugs: Cyclophosphamide, MMF, Mitoxantrone, Rituximab (may cause predispose to PML)
Myasthenia Gravis (aim FVC >15ml/kg, NIF –20 to –60 cmH2O)
Tensilon test: IV Edrophonium (dilute to 10 ml) 1 to 2 mg & watch for response  no effect in 1
min, give 3 mg  no effect in 1 min, give 6 mg. (prepare IV Atropine 0.4-0.6mg for bradycardia,
sensitivity of test 80-90%)
Avoid drugs like: β blockers, NM blockers, MgSO4, quinine, phenytoin, lignocaine, gabapentin
Pyridostigmine (Mestinon) 30 mg TDS to 90 mg QDS (120 mg TDS)
Prednisolone 60-80 mg OM
Steroid sparing agents: Azathioprine, MMF, Cyclosporine
IVIG 2g/kg over 5 days
Plasma exchange (about 5 exchanges with 3-5L of plasma each)
For secretions: IV Glycopyrrulate 0.1-0.2 mg TDS (lesser systemic SE than atrophine)
Diarrhoea: Lomotil 1 tab TDS
Thymectomy
Cholinergic crisis is uncommon especially if Pyridostigmine dose is <120mg TDS
Neuroleptic malignant syndrome – off the offending agent!
Benzodiazepines
Bromocriptine 2.5-10 mg TDS-QDS up to 50mg/day
Dantrolene IV 1-3 mg/kg over 10-15 min not to exceed 10mg/kg/day
Dantrolene PO 50-400 mg/day
Migraine
Abortive therapy
Cafergot 1 tab TDS/PRN not more than 3/day or 8/wk
Sumatriptan 50-100 mg stat PRN, not more than 200 mg/day
Zolmitriptan 2.5 mg stat PRN, rpt once 2 hrs later if necessary
Eletriptan 40 mg stat PRN, rpt once 2 hrs later if necessary
Preventive therapy
Amitriptylline 5-10 mg ON
Propranolol 20-40 mg BD/TDS (NOT for asthmatics)
Epilim CR 500 mg ON
Flunarizine 5-10 mg ON
Topiramate 25-50 mg ON
Gabapentin 300 mg ON  300 mg BD - 300 mg TDS
Vertigo/”Tau Hin, Tau Gong Gong”
Think central causes especially if elderly/gaze evoked in all directions
Vestibular sedatives
Phenothiazines
Sturgeron (Cinnarizine) 25 mg TDS
Stemetil (Prochlorperazine) 5mg TDS, IM 12.5 mg TDS, IV 10 mg TDS
Promethazine PO 25 mg TDS, IV/IM 25 mg TDS
Metoclopramide PO/IV 10 mg TDS
Ondansetron PO 8 mg BD or IV/IM 4mg BD
Antihistamines
Diphenhydramine PO 25-50 mg TDS, IV 10-50mg TDS
Betahistine PO 8-16 mg TDS with meals
Vestibular neuronitis
Prednisolone 1 mg/kg OM x 7-10/7 (No evidence to give acyclovir, unless in Ramsay Hunt)
Bell’s palsy - Early treatment (within 3 days)
Prednisolone 1 mg/kg/day x 5/7 then tail off over 5/7
(No evidence to give Acyclovir 400 mg 5x/day x 10/7, unless in Ramsay Hunt)
Severe Bell’s try: Prednisolone with Valacyclovir 1g TDS x 1/52
Central hypoventilation
Diamox (Acetazalomide) 250 mg BD
Theophylline 125mg BD/TDS
BIPAP / tracheostomy
Gastroparesis
Domperidone 10 – 20 mg TDS
Metoclopromide (Maxalon) 10 mg TDS (avoid in seizures)
Erythromycin (evidence is for IV 250 mg Q8h, PO forms improvement seen in small studies)
Anti-histamines
Miscellaneous
Overdose
IV Flumazenil (Anexate) 0.2 mg +/- 0.1mg/min up to 1mg
IV Naloxone 0.01 mg/kg (max 2mg)
Occulogyric crisis
IV Benztropine 1-2 mg stat
IV Diphenhydramine 25-75 mg stat
Acute delirium
Haloperidol IM 0.5-2mg bolus up to 10m, maintain at ½ max dose Q6H
In case you need to intubate,
ETT size female 6.5-7, male 7.5-8
Drugs (pain control, sedate, paralyse, in sequence)
IV Fetanyl 50-100 mcg or IV Morphine 2-10 mg (titrate to size) then
IV Midazolam 2-5mg titrate or IV Propofol 1-2 mg/kg bolus or IV Etomidate 0.2 mg/kg then
IV Succinylcholine (Sux) 50-100mg stat (onset 30-45s) or IV Atracurium 0.5mg/kg (onset 2-3 min)
Initial ventilation settings (in general, try SIMV Rate 12, Tidal vol 6-8ml/kg, PEEP +5, PS+10-12)
Common calculations
Corrected phenytoin = phenytoin / [(0.02 x alb) + 0.1] {levels 15-20}
Estimate creatinine clearance = {[(140-age) x BW]/ Cr} x 1.04 (female) or 1.23 (male)
MAP = (sBP+2dBP)/3
Corrected Ca = (40-albumin) x 0.02 + serum calcium
Ideal BW = 50 + [0.9 x (Ht in cm – 152)] males; 45.5 + [0.9 x (Ht in cm -152)]
Adjusted BW = IBW + 0.4 (actual BW – IBW)
BSA (m2) = Square root of [Ht (cm) x Wt (kg)] / 3600
……………………………….
Neurology survival drug list is meant purely as an aid to manage commonly encountered problems
on neurology calls. This list is not exhaustive and discretion should be exercise in applying to
individual patients. Please do not mass distribute or quote.
Author: Jaime Chien, Oct 2008. Version 1.21.