(6) Neuro & Psych: Mood (4.1-4.4)

Question 1

Does Lithium have a narrow or broad therapeutic index?

Answer 1

Narrow

Question 2

What are the symptoms of acute Lithium toxicity?

Answer 2

GI Symptoms

Question 3

What are the symptoms of chronic Lithium toxicity?

Answer 3

(1) Tremor
(2) Ataxia

Question 4

What endocrine abnormalities are associated with Lithium use?

Answer 4

(1) Hypothyroidism
(2) Diabetes insipidus

Question 5

Name 2 classes of drugs which increase Lithium levels

Answer 5

(1) Diuretics
(2) NSAIDs

Question 6

What fetal abnormality is associated with Lithium use?

Answer 6

Ebstein’s anomaly

Question 7

Other than Lithium and antipsychotics, name 3 drugs used to treat bipolar disorder

Answer 7

(1) Valproate
(2) Carbamazepine
(3) Lamotrigine

Question 8

Describe Ebstein’s anomaly

Answer 8

Atrialization of right ventricle

(Due to severely incompetent tricuspid valve)

Question 9

Name 4 broad-spectrum antiepileptics

Answer 9

(1) Valproate
(2) Topiramate
(3) Lamotrigine
(4) Levetiracetam

Question 10

What type of seizures can be treated with broad-spectrum antiepileptics?

Answer 10

(1) Focal seizures
(2) Generalized seizure
(3) Juvenile myoclonic seizure
(4) Abscence seizures (less so)

Question 11

MOA: Valproate

Answer 11

(1) Increase inactivated phase of voltage-gated Na+ channels
(2) ↑ CNS GABA levels (somehow)
* (Open basket ∝ Open gate ∴ Closed lid represents drug holding the gate shut)*

Question 12

Adverse Effects (6) : Valproate

Answer 12

(1) GI distress
(2) Weight gain
(3) Fine tremor
(4) Fatal hepatotoxicity
(5) Pancreatitis
(6) Teratogen

Question 13

What type of congenital deformity does Valproate cause?

Answer 13

Neural tube defects

(∝ TMP-SMX)

Question 14

MOA: Topiramate

Answer 14

(1) Increases Na+ channel inactivation
(2) Allosterically activates GABAA receptor

Question 15

Adverse Effects (5) : Topiramate

Answer 15

(1) Somnolence
(2) Confusion and cognitive-slowing
(3) Weight loss
(4) Urolithiasis
(5) Acute angle-closure glaucoma
* (Treatment must be stopped if acute angle-closure glaucoma presents)*

Question 16

Which broad spectrum epileptic is most associated with Stevens-Johnson syndrome?

Answer 16

Lamotrigine

(Up to 10% of patients will experience a benign rash)

Question 17

Adverse Effects (2) : Lamotrigine

Answer 17

(1) Stevens-Johnson Syndrome
(2) Diplopia

Question 18

Adverse Effect: Levatiracetam

Answer 18

Somnolence

Question 19

How are antiepileptics metabolized?

Answer 19

Almost universally via CYP450

Question 20

Name 5 narrow-spectrum antiepileptics

Answer 20

(1) Carbamazepine
(2) Phenytoin
(3) Gabapentin
(4) Vigabatrin
(5) Tigabine

Question 21

Treatment: Trigeminal neuralgia

Answer 21

Carbamazepine

Question 22

Adverse Effects (9) : Carbamazepine & Phenytoin

Answer 22

(1) Ataxia
(2) Diplopia
(3) SIADH
(4) Agranulocytosis/Aplastic anemia
(5) CYP450 induction
(6) DRESS syndrome
(7) Teratogen
(8) Stevens-Johnson syndrome
(9) Drug induced lupus

Question 23

What type of fetal malformations is Carbamazepine associated with?

Answer 23

Neural tube defects

(As well as general fetal dysmorphisms)

Question 24

Name 4 adverse effects of Phenytoin not present in Carbamazepine

Answer 24

(1) Megaloblastic anemia
(2) Gingival hyperplasia
(3) Hirsutism
(4) Decreased bone density
* (Strong induction of CYP450 system ⇒ ↑ Steroid metabolism ⇒ ↑ Rate of Vit. D inactivation ⇒ Osteopenia)*

Question 25

What fetal malformations is Phenytoin associated with?

Answer 25

Cleft palate

Question 26

Define: Status epilepticus

Answer 26

Continuous (≥ 5-30 min) seizure

Question 27

Treatment: Status epilepticus (acute setting)

Answer 27

IV Benzodiazepine

(Ben’s diner is above the “order status” sign = Benzo first and Phenytoin second)

Question 28

Treatment: Status epilepticus (maintenance stage)

Answer 28

Phenytoin

(Ben’s diner is above and tow truck below the “order status” sign and the tow truck is below = Benzo 1st and Phenytoin 2nd)

Question 29

Treatment: Status epilepticus (refractory)

Answer 29

Barbiturate

Question 30

MOA: Gabapentin

Answer 30

Inhibits voltage-gated Ca2+ channels

(“Gabapentin does NOT bind to GABA receptors. I repeat, Gabapentin does NOT bind to GABA receptors”)

Question 31

Which anti-seizure medication is effective against neuropathic pain?

Answer 31

Gabapentin

Question 32

Adverse Effect: Gabapentin

Answer 32

Ataxia

Question 33

MOA: Vigabatrin

Answer 33

Irreversibly inhibits GABA transaminase

(Notice this is a degradative enzyme rather than ion channel/transmembrane receptor)

Question 34

MOA: Tiagabine

Answer 34

Inhibits GABA reuptake

Question 35

What type of seizures are narrow-spectrum anti-epileptics used for?

Answer 35

Focal seizures (and generalized tonic-clonic)

Question 36

Which antiepileptic is used ONLY for absence seizures?

Answer 36

Ethosuximide

Question 37

Describe an absence seizure

Answer 37

Sudden momentary lapses in awareness

(Most commonly seen in children)

Question 38

How do absence seizures manifest on EEG?

Answer 38

3 Hz spikes

(Similarily, Cretuzfeld-Jakob disease shows periodic synchronous sharp wave complexes)

Question 39

MOA: Ethosuximide

Answer 39

Inhibits thalamic T-type Ca2+ channels

(“If you think about it, thermos even kind of sounds like thalamus!”)

Question 40

Adverse Effects (2) : Ethosuximide

Answer 40

(1) GI distress
(2) Lethary

Question 41

Treatment: Absence seizure with occasional tonic-clonic

Answer 41

Valproate

Question 42

Which 2 broad-spectrum antiepileptics are most effective against absence seizures?

Answer 42

(1) Valproate
(2) Lamotrigine
* (Valproate > Lamotrigine)*