Adverse effects

Question 1

Lithium induced hypothyroidism is much more common in

Select one:
1. Children
2. Elderly females
3. Young males
4. Young females
5. Elderly males

Answer 1

Young females

Lithium induced hypothyroidism is much more common in middle-aged women (up to 3-4%)

Question 2

Which one of the following is a common and early side effect of lithium?

Select one:
1. Hypothyroidism
2. Weight gain
3. Fine tremor
4. Coarse Tremor
5. Nephrogenic diabetes insipidus

Answer 2

Fine tremor

Lithium has been shown to be effective in the treatment of bipolar affective disorder where it reduces both the number and severity of relapses. The mechanism of action of lithium remains unclear but appears to reduce the neurotransmitter-induced activation of second messenger systems. The effect may be via G-proteins and can affect adenylate cyclase and phosphatidylinositol cycle. Early and common side effects include fine tremors, polyuria, polydipsia, nausea, and bad
metallic taste and transient raised leucocyte and platelet count. Propranolol can be useful in the treatment of lithium-induced tremors.

Question 3

Which one among the following statements about neuroleptic malignant syndrome (NMS) is false?.

Select one:
1. Patients on tricyclic antidepressants can develop NMS
2. 2-3% of all patients treated with conventional antipsychotics develop NMS
3. It lasts for 10-14 days if left untreated.
4. Fluctuating blood pressure is a feature of NMS
5. It evolves rapidly over 24-72 hours

Answer 3

2-3% of all patients treated with conventional antipsychotics develop NMS

The risk is estimated to be less than 0.5-1%. It evolves rapidly over 24-72 hours and lasts for 10-14 days if left untreated. NMS is also seen very rarely with other drugs such as antipsychotics and lithium. The important clinical features of NMS would include Fluctuating consciousness, Fluctuating blood pressure, tachycardia, fever, confusion, diaphoresis, rigidity. Signs of NMS would include elevated creatinine kinase, leucocytosis, and altered liver function tests.

Question 4

Which of the following is not a dose-dependent effect when using clozapine?

Select one:
1. Agranulocytosis
2. Seizures
3. Sedation
4. Weight gain
5. Hypersalivation

Answer 4

Agranulocytosis

Agranulocytosis is idiosyncratic and can occur at any dose; unlike sedation, seizures and to some extent weight gain, it is not dose dependent. Note that weight gain may also be relatively dose-independent in a
number of patients.

Question 5

Which of the following diuretics can be used to control lithium-induced polyuria without causing lithium toxicity?

Select one:
1. Amiloride
2. Caffeine
3. Frusemide
4. Ethacrynic acid
5. Thiazide

Answer 5

Amiloride

One of the major side effects of lithium is nephrogenic diabetes insipidus. The established treatment for the disorder is thiazide diuretics, but these are associated with hypokalemia and reduced lithium excretion, predisposing the patient to lithium toxicity. Amiloride is a potassium-sparing diuretic that reduces lithium-induced polyuria without affecting lithium or potassium levels. ( Treatment of severe lithium-induced polyuria with amiloride.

Question 6

A patient presents to you on the ward with a ‘muscle spasm’ on his neck. He was started on 5mg Haloperidol (bd) few days ago. What is the most likely problem?

Select one:
1. Neuroleptic malignant syndrome
2. Acute dystonia
3. Parkinsonism
4. Akathisia
5. Tardive dyskinesia

Answer 6

Acute dystonia

An acute dystonic reaction consists of sustained, often painful muscular spasms, producing twisting abnormal postures. 50% occur within 48 hours of administering an antipsychotic for the first time.

Question 7

Which of the following is an important difference between NMS and serotonin syndrome clinically?

Select one:
1. Presence of myoclonus in NMS
2. Subacute onset in serotonin syndrome
3. Hyperreflexia in serotonin syndrome
4. CPK elevation in serotonin syndrome
5. Hypomanic presentation in NMS

Answer 7

Hyperreflexia in serotonin syndrome

Symptoms such as hyperreflexia and myoclonus are attributed to the enhanced release of serotonin in serotonin syndrome and are not seen in NMS.

Question 8

Which of the following drugs is contraindicated for a patient receiving a monoamine oxidase (MAO)
inhibitor?

Select one:
1. Trifluoperazine
2. Meperidine
3. Atropine
4. Chlorpromazine
5. Budesonide

Answer 8

Meperidine

Meperidine is an opioid that can interact with monoamine oxidase inhibitors resulting in serotonin syndrome.

Question 9

Cheese Reaction is one of the most common and dangerous side-effects of

Select one:
1. TCAs
2. SNRIs
3. Atypical Antipsychotics
4. SSRIs
5. MAOIs

Answer 9

MAOIs

The gut MAO-A generally breaks down the tyramine in the diet. If tyramine enters the circulation in large amounts, this results in a release of noradrenaline from endogenous storage sites, causing a sudden and fatal rise in blood pressure. This can take place when an individual taking MAO-A inhibitors (that reduces
the activity of gut MAO) ingests large quantities of foods containing tyramine.

Question 10

Which of the following skin problems can prove to be fatal in those started on Lamotrigine?

Select one:
1. Steven Johnson’s syndrome
2. Psoriasis
3. Jarisch-Herxheimer reaction
4. Acanthosis nigricans
5. Lichen planus

Answer 10

Steven Johnson’s syndrome

Rzany B et al. Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis during first weeks of antiepileptic therapy: a case-control study. Study Group of the International Case Control Study on Severe Cutaneous Adverse Reactions. Lancet 1999;353:2190-4.

Question 11

Which one among the following is associated with a lower risk of weight gain than the others?

Select one:
1. Aripiprazole
2. Clozapine
3. Quetiapine
4. Chlorpromazine
5. Olanzapine

Answer 11

Aripiprazole

Ziprasidone has been associated with minimal weight gain, which could distinguish it among other second-generation antipsychotics. Similarly, aripiprazole appears to cause little or no weight gain. During long-term treatment, clozapine and olanzapine have the largest effects on weight gain; risperidone produces intermediate weight gain. Weight gain does not appear to be dose dependent, tends to plateau between 6 and 12 months after initiation of treatment, and is mainly due to an increase in body fat. Conventional agents such as chlorpromazine can cause as much weight gain as atypicals.

Question 12

What percentage of patients develop Tardive Dyskinesia with every year of typical antipsychotic exposure?

Select one:
1. More than 50%
2. 2-5%
3. 5-10%
4. 20-25%
5. 10-20%

Answer 12

2-5%

TD-2-5% ; Dystonia-2-10%; Pseudo-parkinsonism-20%; Akathisia- 25%

Question 13

The principal cause of death following tricyclic antidepressant (TCA) overdose is

Select one:
1. cerebral oedema
2. seizures
3. malignant hypertension
4. Cardiac arrhythmia.
5. respiratory failure

Answer 13

Cardiac arrhythmia

A membrane stabilizing effect can precipitate dysrhythmias and altered myocardial conduction. This activity
occurs from blockade of inward/fast sodium channels, resulting in altered repolarization and conduction. This effect occurs distal to the AV node, producing a depression of the His-Purkinje conduction system and a direct negative inotropic effect. Intravenous sodium bicarbonate is the preferred pharmacologic treatment
of choice to reverse TCA-induced cardiac conduction defects. This is the commonest cause of death in an overdose with TCAs.

Question 14

A patient with a known diagnosis of depression does not want to get obese. Drugs acting on which of the following receptors should be avoided?

Select one:
1. 5HT-2A
2. 5HT3
3. Dopamine D2 receptors
4. Alpha-adrenergic
5. 5HT-2C

Answer 14

5HT-2C

The mechanism by which weight gain occurs during treatment with psychotropics is poorly understood, but the broader receptor affinities of the agents and their antagonism of histamine H1 and serotonin 5-HT2C receptors have been implicated.

Question 15

Which one among the following drug is not advocated for the treatment of clozapine-induced hypersalivation?

Select one:
1. Amitriptyline
2. Hyoscine
3. Benzhexol (trihexyphenidyl)
4. Pirenzepine
5. Clomipramine

Answer 15

Clomipramine

Extensive clinical experience suggests that Pirenzepine is effective for the treatment of Clozapine induced hypersalivation. Pirenzepine is a selective M1, M4 antagonist. Other drugs of use include benzhexol (trihexyphenidyl), hyoscine, Amitriptyline, and combination of benztropine and terazosin.

Question 16

Which one of the following SSRIs is relatively unsafe for post-MI patients?

Select one:
1. Paroxetine
2. Citalopram
3. Fluoxetine
4. Fluvoxamine
5. Sertraline

Answer 16

Citalopram

In normal doses, citalopram has no effect on QTc, but one if its metabolite may prolong QTc interval. Sertraline is an SSRI with some safety data in post-MI patients (SADHART trial).

Question 17

Priapism is a dreaded side effect associated with

Select one:
1. Imipramine
2. Phenelzine
3. Fluoxetine
4. Trazodone
5. Clomipramine

Answer 17

Trazadone

Trazadone has been associated with priapism in rare cases; this must be treated urgently to avoid long-term impairment. Risperidone is also associated with the rare side effect of priapism.

Question 18

Which drug has been licensed for the treatment of Tardive Dyskinesia in the UK?

Select one:
1. Clonazepam
2. Vitamin E
3. Clonazepam
4. Tetrabenazine
5. Amitryptiline

Answer 18

Tetrabenazine

Tetrabenazine has been licensed for the treatment of TD in UK. Other drugs that may be useful include vitamin E, clonazepam and diazepam.

Question 19

Which one of the following is a common side effect of MAOIs

Select one:
1. Hepatocellular jaundice
2. Bone marrow suppression
3. Cardiac arrhythmias
4. Postural hypotension
5. Peripheral neuropathy

Answer 19

Postural hypotension

Common side effects of MAOIs would include insomnia, postural hypotension, peripheral oedema, restlessness, nausea, dizziness, sexual difficulties, sweating and tremor. Rare side effects would include
hepatocellular jaundice, Peripheral neuropathy, bone marrow suppression, and cardiac arrhythmias.

Question 20

Which of the following is not a recognised side effect of acetylcholinesterase inhibitors?

Select one:
1. Nausea
2. Anorexia
3. Urinary retention
4. Muscle cramps
5. Seizures

Answer 20

Urinary retention

The most common cholinergic side effects of AChEIs involve the gastrointestinal tract. These side effects are usually mild and have been reported to occur in approximately 20% of patients taking these medications. Among the side effects reported in the package inserts of currently available AChEIs are nausea (11%-47%), vomiting (10%-31%), diarrhea (5%-19%), and anorexia (4%-17%). These can be minimized with the use of longer titration periods and the administration of these medications with food.

Question 21

A 73-year-old lady was admitted to the medical ward with a history of increasing confusion, lethargy and dizziness over the last three days. She is on Fluoxetine 30 mg, and her other medications would include
Furosemide, Aspirin and Ramipril. She has a history of chronic renal failure. Her vital signs were within normal limits. What do you think would be the most likely diagnosis?

Select one:
1. Serotonin syndrome
2. Tyramine Reaction
3. Acute Dystonic reaction
4. Neuroleptic malignant syndrome
5. Antidepressant-induced hyponatraemia

Answer 21

Antidepressant-induced hyponatraemia

Most antidepressants have been associated with hyponatraemia. Serotonergic antidepressant drugs are relatively more likely to cause hyponatraemia. Signs of hyponatraemia would include nausea, lethargy, dizziness, confusion, seizures, cramps and coma.

Question 22

A 36-year-old woman with schizoaffective disorder, living in a psychiatric rehabilitation unit is admitted to a medical ward for treatment of a suspected intestinal infection resulting in dehydration, vomiting and fever.
Her psychiatric condition has been managed with a stable dose of clozapine for the last nine months. At the medical ward, she appears confused with reduced orientation to time and appears lethargic. She also has stiffness and some rigidity in movements. The most appropriate recommendation at this stage would be to

Select one:
1. Add a benzodiazepine
2. Add an antiepileptic
3. Switch to a typical antipsychotic
4. Add benztropine
5. Discontinue clozapine

Answer 22

Discontinue clozapine

Atypical NMS can present in this manner.

Question 23

Which of the following psychotropics is relatively contraindicated when ACE inhibitors are prescribed?

Select one:
1. Lithium
2. Olanzapine
3. Lorazepam
4. Valproate sodium
5. Risperidone

Answer 23

Lithium

A number of drugs may interact with ACE inhibitors. In particular, non-steroidal anti-inflammatory drugs (NSAIDs), diuretics and lithium (leads to increased serum levels of lithium).

Question 24

Which one among the following is not a feature of hyperprolactinaemia?

Select one:
1. Polymenorrhoea
2. Galactorrhoea
3. Reductions in bone mineral density
4. Amenorrhoea
5. Gynaecomastia

Answer 24

Polymenorrhoea

Persistent hyperprolactinaemia can lead to galactorrhoea, amenorrhoea, hypogonadism, gynaecomastia, sexual dysfunction and an increased risk of osteoporosis. Risperidone, Amisulpride and Zotepine have potent prolactin-elevating effects, similar to conventional drugs.

Question 25

The anticholinergics should be prescribed for the treatment of patients with which of the following effects of neuroleptic use?

Select one:
1. Pseudoparkinsonism
2. Dystonia
3. Tardive dystonia
4. Tardive dyskinesia
5. Akathisia

Answer 25

Dystonia

While dystonia generally responds well to anticholinergics, other EPSEs do not. Parkinsonian rigidity but not tremor may be reduced with anticholinergic use.

Question 26

Which one among the following SSRIs is present in high concentrations in breast milk?

Select one:
Sertraline
Paroxetine
Fluvoxamine
Fluoxetine
Citalopram

Answer 26

Fluoxetine

Antidepressants are excreted in varying degrees in breast milk, so breastfeeding in antidepressant-treated women should be done with caution. Fluoxetine’s long half-life and potential for accumulation in breast milk have prompted some recommendations to avoid its use in women who are breast-feeding young infants.

Question 27

A specific side effect of Mianserin that requires regular monitoring is

Select one:
1. Anticholinergic activity
2. Risk of serotonin syndrome
3. Cardiotoxicity
4. QT prolongation
5. Bone marrow suppression

Answer 27

Bone marrow suppression

Mianserin was the first of the second-generation antidepressants to be developed. It lacked the amine reuptake inhibitory and MAOI actions of the first-generation drugs and also lacked the cardiotoxicity and anticholinergic activity of the TCAs. However, it was sedative (antihistaminic), caused postural hypotension (alpha-1 blockade) and also caused blood dyscrasias and agranulocytosis in a small number of patients. This has limited the use of Mianserin in recent years.

Question 28

Which one among the following is not a specific risk factor for QTc prolongation?

Select one:
1. Anorexia nervosa
2. Extremes of age
3. Bradycardia
4. Myocarditis
5. Use of atypical antipsychotics rather than typicals

Answer 28

Use of atypical antipsychotics rather than typicals

The effect of many but not all antipsychotic drugs on the QT interval appears to be dose-related. Several antipsychotic drugs have infrequently been associated with malignant arrhythmias such as torsade de
pointes though atypicals have been rarely implicated in this specific fatal effect of QTc prolongation. Risk factors for QTc prolongation include female gender, extremes of age, extreme physical exertion, stress or shock, anorexia nervosa, left ventricular hypertrophy, myocardial infarction, hypokalemia, hypocalcaemia and hypomagnesemia, bradycardia, myocarditis and congenital long QT syndrome.

Question 29

A 31-year-old patient was started on antipsychotic medication for the first time. He developed fluctuating BP, hyperthermia, confusion, urinary incontinence and has raised creatinine kinase. The diagnosis is

Select one:
1. Parkinsonism
2. Acute dystonia
3. Neuroleptic malignant syndrome
4. Tardive dystonia
5. Tardive dyskinesia

Answer 29

Neuroleptic malignant syndrome

The neuroleptic malignant syndrome (NMS) is rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is
characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.

Question 30

Patients on tranylcypromine should not take an excess of

Select one:
1. Cheese
2. Swede
3. Potatoes
4. Banana
5. Salt

Answer 30

Cheese

Cheeses, particularly any type of ripe cheese, Broad beans (fava beans) Sausages, Salami, Pickled fish, etc must be avoided due to the fear of tyramine induced crisis. It appears that foods containing more than 10mg of tyramine must be consumed in order to produce a significant rise in blood pressure.

Question 31

Which of the following is a prominent side effect of venlafaxine controlled by terazosin, alpha-adrenergic blocker?

Select one:
1. Nausea
2. Headaches
3. Tremors
4. Postural drop in blood pressure
5. Sweating

Answer 31

Sweating

Terazosin, a blocker of alpha-1 receptors, is observed to be effective in reducing excessive sweating caused by antidepressant treatment, especially venlafaxine and SSRIs.

Question 32

What percentage of patients with Tardive Dyskinesia may show recovery within a year with antipsychotic reduction?

Select one:
1. Approximately 1-2%
2. Approximately 20-25%
3. Approximately 2-4%
4. Approximately 50-55%
5. Approximately 10-20%

Answer 32

Approximately 50-55%

Approximately 50% of cases with TD are reversible. As a first line intervention, stop anticholinergics if these were prescribed previously. Reduce the dose of antipsychotic and consider changing to an atypical drug.
Clozapine is the antipsychotic most associated with resolution of symptoms.

Question 33

Which of the following drugs is associated with a ‘creeping creatinine levels’ on long term use?

Select one:
1. Duloxetine
2. Lamotrigine
3. Carbamazepine
4. Lithium
5. Valproate

Answer 33

Lithium

Lithium dosage will require a compensatory increase because glomerular filtration rate increases gradually. But long term use can cause both reversible and irreversible renal damage.

Question 34

In managing the hypertensive crisis associated with monoamine oxidase (MAO) inhibitors and the ingestion of food with tyramine, the agent of choice is:

Select one:
1. propranolol
2. chlorpromazine
3. phentolamine
4. carvedilol
5. reserpine

Answer 34

Phentolamine

Hypertensive crisis during MAOI use can be managed using phentolamine or phenoxybenzamine.

Question 35

Bupropion is associated with which of the following side effects?

Select one:
1. Anticholinergic action
2. Weight loss
3. Sedation
4. Loss of libido
5. Increase seizure threshold

Answer 35

Weight loss

Bupropion is an antidepressant that induces weight loss and even seems to be effective in obesity when combined with calorie-restricted diets. It is contraindicated in anorexia and other eating disorders.

Question 36

The toxic confusional state caused by antipsychotics is mainly due to which of the following mechanisms?

Select one:
1. Nicotinic receptor blockade
2. Alpha adrenergic blockade
3. Muscarinic receptor blockade
4. Histaminergic receptor blockade
5. All of the above

Answer 36

Muscarinic receptor blockade

The toxic confusional state caused by antipsychotics is due to muscarinic receptor blockade. It also causes dry mouth, difficulty urinating, constipation, and blurred vision.

Question 37

A trainee doctor working at a medical ward asks your advice while on call. She is requesting an assessment for an agitated and hallucinating inpatient on the medical ward. She reports that he appears flushed with a hot and dry skin, mydriasis, rapid pulse and diminished bowel sounds. Which of the following is the best suggestion for you to make at this stage?

Select one:
1. Administer atropine
2. Prescribe IM olanzapine
3. Discontinue anticholinergic drugs
4. Prescribe diazepam
5. Prescribe haloperidol.

Answer 37

Discontinue anticholinergic drugs

Anticholinergic delirium constitutes a medical emergency. Symptoms of anticholinergic delirium include hot, dry skin; dry mucous membranes; dilated pupils; absent bowel sounds; and tachycardia. Physicians must
first determine and remove the offending agent because patients are at a high risk for a cholinergic crisis. Atropine can be used to treat anticholinergic delirium symptoms once the agent has been removed.

Question 38

A 34-year-old man is being treated with carbamazepine and levothyroxine for a rapid cycling bipolar disorder. As his illness was poorly controlled, clozapine was added after which his condition has stabilized. The patient’s most recent white blood cell count is below 3,000/cu mm. The most appropriate immediate intervention is

Select one:
1. discontinue the carbamazepine
2. discontinue the thyroxine
3. decrease the dose of clozapine
4. discontinue the clozapine.
5. decrease the dose of carbamazepine

Answer 38

Discontinue the clozapine.

If there is a red alert when taking clozapine, it must be immediately discontinued.

Question 39

Which of the following psychotropics is associated with an increased risk of GI bleed in the elderly?

Select one:
1. Neuroleptics
2. SSRIs
3. Z group hypnotics
4. Atypical antipsychotics
5. Methadone

Answer 39

SSRIs

Risk of GI bleeds in the elderly can be increased by SSRIs. By increasing central and peripheral cholinergic stimulation cholinesterase inhibitors, may also increase gastric acid secretion, increasing the risk of GI
bleeding especially in patients with ulcer disease or those taking anti-inflammatories.

Question 40

Which one among the following benzodiazepines is more toxic than others in overdose?

Select one:
1. Nitrazepam
2. Alprazolam
3. Lorazepam
4. Temazepam
5. Diazepam

Answer 40

Alprazolam

Toxic dose of benzodiazepines is probably more than 100 mg diazepam equivalents. Fatality is unusual if taken alone. Alprazolam is the most toxic agent. Isbister GK et al. Alprazolam is relatively more toxic than other benzodiazepines in overdose. Br J Clin Pharmacol 2004;58:88-95.

Question 41

Weight gain as a side effect of antipsychotics is caused due to all of the following mechanisms except

Select one:
1. H-1 antagonism
2. Hyperprolactinaemia
3. Increased serum leptin leading to leptin desensitisation.
4. 5HT2-a antagonism
5. 5HT2-c antagonism

Answer 41

5HT2-a antagonism

The suggested mechanisms for weight gain as a side effect of antipsychotics include 5HT2-c antagonism, H-1 antagonism, hyperprolactinaemia and increased serum leptin as a result of secondary leptin
desensitisation.

Question 42

The upper limit of safe QTc interval for men is

Select one:
1. 440 msec
2. 470 msec
3. 500 msec
4. 490 msec
5. 410 msec

Answer 42

440 msec

The safe QTc interval for men is 440 msec and for women is 470 msec. If QTc is greater than 440 ms (men) or 470 ms (women) when taking antipsychotics, consider a switch to drug of lower effect; reperform ECG and consider referral to cardiologist. If the QTc is greater than 500ms in both genders, immediately stop the suspected causative drugs and refer to a cardiologist.

Question 43

Agranulocytosis as a side effect of Clozapine occurs most commonly during the

Select one:
1. First 48 weeks of treatment
2. First 8 days of treatment
3. First 18 weeks of treatment
4. First 8 weeks of treatment
5. First 28 weeks of treatment

Answer 43

First 18 weeks of treatment

80% of the cases develop during the first 18 weeks of treatment but may occur at any time.

Question 44

The sexual side effects caused by SSRI antidepressants are related to the consequence of stimulating which of the following receptors?

Select one:
1. 5HT-3 receptors
2. 5HT-1 and 2 receptors
3. 5HT-1 receptors
4. 5HT-2 receptors
5. 5HT-2 and 3 receptors

Answer 44

5HT-2 receptors

Clinically significant consequences of stimulating 5HT1-a receptors leads to antidepressant actions, anti obsessive-compulsive disorder properties, anti-panic and anti-phobic properties and anti-bulimic properties. Clinically significant consequences of stimulating 5HT2 receptors includes agitation, akathisia, anxiety, panic attacks, insomnia and sexual dysfunction.

Question 45

Which one of the following statements regarding antidepressants is false?

Select one:
1. Orofacial Dyskinesia has been reported with Paroxetine
2. Hyponatraemia has been reported with Fluvoxamine
3. Hypoglycaemia has been reported on using Fluoxetine
4. Fluovaxamine causes less sexual dysfunction than other SSRIs
5. Withdrawal syndrome has been reported most commonly with Fluoxetine

Answer 45

Withdrawal syndrome has been reported most commonly with Fluoxetine

Hyponatraemia has been reported with Fluvoxamine and Fluoxetine. Withdrawal syndrome has been reported most commonly with Paroxetine. Dystonias and Orofacial Dyskinesia have been reported with Paroxetine.

Question 46

Which one among the following is not a potentially high-risk factor for developing neuroleptic malignant syndrome (NMS)?

Select one:
1. Low potency typical drugs
2. Abrupt withdrawal of anticholinergics
3. Recent or rapid dose increase of antipsychotics
4. High-potency typical drugs
5. Rapid dose reduction of antipsychotics

Answer 46

Low potency typical drugs

The independent risk factors would include psychomotor agitation, mental retardation, psychosis, organic brain disease, Parkinson’s disease, hyperthyroidism, and alcoholism.

Question 47

Which of the following is NOT a common side effect of rivastigmine?

Select one:
1. Drowsiness
2. Nausea
3. Constipation
4. Vomiting
5. Weight loss

Answer 47

Constipation

Rivastigmine have experienced nausea, vomiting, diarrhoea, high blood pressure and hallucinations but constipation is very rare.

Question 48

The patients who are prescribed clozapine or olanzapine should have their serum lipids measured every

Select one:
1. 6 days whilst on treatment
2. One year whilst on treatment
3. 3 months for the first year of treatment
4. 6 weeks for the first year of treatment
5. 6 months for the first year of treatment

Answer 48

3 months for the first year of treatment

Clozapine, Olanzapine, quetiapine and phenothiazine-suggested monitoring- fasting lipids and cholesterol at baseline then every 3 months for a year, then annually according to national guidelines. Other antipsychotics-fasting lipids and cholesterol at baseline and 3 months and then annually.

Question 49

Which class of antidepressant drugs must be avoided while treating depression in a patient who does not want to gain weight?

Select one:
1. Tricyclics
2. Reboxetine
3. SSRIs
4. Venlafaxine
5. MAOIs

Answer 49

Tricyclics

Any psychotropic can cause weight gain; in the given list tricyclics have a higher risk than others. Note that up to 30% of patients on SSRIs also experience this side effect, with increases of 8 kg or more.

Question 50

Which of the following drugs is associated with nephrolithiasis?

Select one:
1. Lithium
2. Carbamazepine
3. Topiramate
4. Valproate
5. Quetiapine

Answer 50

Topiramate

Topiramate is a weak inhibitor of carbonic anhydrase and can promote the development of renal stones. It is weight neutral and can even cause weight loss.

Question 51

Which one among the following drugs may cause appetite suppression and weight loss?

Select one:
1. Gabapentin
2. Valproate
3. Lamotrigine
4. Lithium
5. Topiramate

Answer 51

Topiramate

Topiramate causes appetite suppression leading to weight loss. Topiramate blocks glutamate at non-NMDA receptors. Gabapentin is effective against anxiety symptoms but not effective as a mood stabiliser in bipolar disorder. It is not associated with hepatic or haematological problems.

Question 52

Which of the following tricyclics is most toxic in overdoses?

Select one:
1, Nortriptyline
2. Imipramine
3. Clomipramine
4. Dosulepin
5. Lofepramine

Answer 52

Dosulepin

Dosulepin and amitriptyline are the most toxic (seizures and cardiac arrhythmia) tricyclics.

Question 53

Which antidepressant is contraindicated in closed-angle glaucoma?

Select one:
1. Bupropion
2. Mirtazapine
3. Paroxetine
4. Buspirone
5. Sertraline

Answer 53

Paroxetine

Anticholinergic side effects include dry mouth, constipation, urinary retention, blurred vision, and less commonly narrow-angle glaucoma. These effects are usually dose-related and worse in patients with pre-existing defects. Paroxetine has significant anticholinergic properties

Question 54

Botulinum toxin may have a role in the treatment of

Select one:
1. Tardive Dyskinesia
2. Akathisia
3. Tardive dystonia
4. Parkinsonism
5. Acute Dystonias

Answer 54

Tardive dystonia

Although a large number of agents have been studied for their therapeutic effects on TD, there is no definitive drug treatment for it. Botulinum may help in some but not all cases.

Question 55

A patient recently started on clozapine developed chest pain dizziness, vomiting, fever and some pedal oedema. He is short of breath, and ECG is abnormal. What is the likely side effect?

Select one:
1. Pneumonic consolidation
2. Cardiomyopathy
3. Agranulocytosis
4. Ventricular tachycardia
5. Myocardial infarction

Answer 55

Cardiomyopathy

Clozapine therapy is known to be associated with potentially fatal myocarditis and cardiomyopathy in
physically healthy young adults with schizophrenia. The clinical features includes asymptomatic patients who may have electro-cardiographic abnormalities; some patients may have signs and symptoms of clinical heart failure and ventricular dilatation. Non-specific flu-like symptoms, tachycardia, elevated cardiac
enzymes are the key features. ESR and eosinophils may be higher.

Question 56

Moclobemide is an antidepressant that requires dietary restrictions when prescribed. The mechanism of
action for the drug Moclobemide is

Select one:
1. MAOI - irreversible
2. 5HT 1A agonist
3. Noradrenaline reuptake blockade
4. 5HT2A antagonist
5. MAOI- reversible

Answer 56

MAOI-reversible

Moclobemide is a reversible monoamine oxidase A (MAO-A) inhibitor.

Question 57

Choose an antibiotic that can cause serotonin syndrome if combined with
MAOIs:

Select one:
1. Ciprofloxacin
2. Linezolid
3. Amoxicillin
4. Erythromycin
5. Trimethoprim

Answer 57

Linezolid

Linezolid, an antibiotic of the oxazolidone family, is a reversible, nonselective MAOI used in the treatment of methicillin-resistant Staphylococcus aureus. Case reports of serotonin syndrome resulting from the interaction of linezolid and the SSRIs citalopram, sertraline, and paroxetine have been published.

Question 58

A 50 yr old man who had a red alert with clozapine 10 years ago is now having a severe relapse where all treatment strategies have failed. What is the best management choice?

1. Clozapine and lithium can be given together
2. No clozapine should be given
3. Clozapine can be given with more frequent monitoring
4. Clozapine can be given in low doses
5. Clozapine can be given on alternate days

Answer 58

No clozapine should be given

According to the central clozapine monitoring regulations, (CPMS: Clozaril patient monitoring service), a ‘green’ alert indicates satisfactory count, an ‘amber’ alert requires a repeat FBC test while clozapine can be continued, and a ‘red’ alert warrants immediate cessation of clozapine. Re-introduction must be avoided
unless there is a specialist supervision.

Question 59

Which one of the following drugs has a pronounced effect on QTc Prolongation?

Select one:
1. Zotepine
2. Olanzapine
3. Thioridazine
4. Sulpiride
5. Haloperidol

Answer 59

Thioridazine

Drugs with a high effect on QTc include sertindole, thioridazine, pimozide and droperidol. There have been reports of sudden death with Pimozide due to drug-induced QT prolongation.

Question 60

Which one among the following statements regarding drug interactions is false?

Select one:
1. TCAs interact with MAOIs and can cause serious toxicity like serotonergic syndrome
2. Cimetidine increases TCAs levels
3. Warfarin action is potentiated by TCAs
4. The plasma levels of tricyclics and antipsychotics are decreased if co-administered.
5. TCAs reduce the antihypertensive action of clonidine and guanethidine.

Answer 60

The plasma levels of tricyclics and antipsychotics are decreased if co-administered.

TCAs potentiate the effects of alcohol, hypnotics, anxiolytics and antipsychotics. The plasma levels of tricyclics and antipsychotics are increased if co-administered.

Question 61

Which group of patients are not associated with an increased risk of developing Tardive Dyskinesia?

Select one:
1. Patients with organic brain damage
2. Females
3. Patients on atypical antipsychotics
4. Patients with affective disorders
5. Older patients

Answer 61

Patients on atypical antipsychotics

Risk factors for TD-Older patients, females, patients with organic brain damage and patients with affective disorders, and those who have had acute EPSEs (Extra pyramidal side effects) early on treatment.

Question 62

Which of the following statements concerning CATIE is incorrect?

Select one:
1. First-generation drugs do as well as second generation drugs
2. Haloperidol was not included in the trial
3. Patients taking perphenazine showed more EPSEs
4. Quetiapine group had less EPSEs
5. 25% of patients taking olanzapine discontinued the drug

Answer 62

25% of patients taking olanzapine discontinued the drug

In the CATIE trial, irrespective of the prescribed drug - 74% discontinued treatment in 18 months (surprisingly high despite naturalistic design). Median time to discontinue was 4.6 months. Olanzapine had lowest discontinuation rate (still 64%) - but highest side effect burden. 64% discontinued olanzapine; 75%, perphenazine; 82%, quetiapine; 74%, risperidone; and 79%, ziprasidone.

Question 63

Which of the following is true concerning the side effects of escitalopram when compared to citalopram?

Select one:
1. Escitalopram is associated with greater gastrointestinal effects.
2. Escitalopram is associated with greater weight gain.
3. Escitalopram is associated with fewer sexual side effects
4. Escitalopram and citalopram have similar side-effect profiles
5. Escitalopram is associated with greater cardiovascular effects

Answer 63

Escitalopram and citalopram have similar side-effect profiles

Citalopram is a racemate consisting of a 1:1 mixture of the R(-)- and S(+)-enantiomers. Non-clinical studies show that the serotonin reuptake inhibitory activity of citalopram is attributable to the S-enantiomer, escitalopram. Escitalopram is the active S- isomer of the antidepressant citalopram. It is claimed that escitalopram has more efficacy and a faster onset of effect than citalopram. The side effect profile of escitalopram is similar to that of other SSRIs.

Question 64

The CNS side effects like anxiety and agitation in the initial few weeks of treatment with SSRIs are proposed to be due to

Select one:
1. Under stimulation of 5HT3 receptors in the limbic system
2. Over stimulation of 5HT3 receptors in the limbic system
3. Over stimulation of 5HT2 receptors in the limbic system
4. Under stimulation of 5HT2 receptors in the limbic system
5. Under stimulation of 5HT1 receptors in the limbic system

Answer 64

Over stimulation of 5HT2 receptors in the limbic system

This effect may be due to over stimulation of 5HT-2 receptors in the limbic system though this is far from being conclusive. Fluoxetine has a high anxiogenic effect while citalopram has the least propensity to induce anxiety.

Question 65

Floppy baby syndrome is a recognised complication associated with the use of which of the following psychotropic drugs in pregnancy?

Select one:
1. Antipsychotics
2. Anti-dementia drugs
3. Methadone
4. Antidepressants
5. Benzodiazepines

Answer 65

Benzodiazepines

First- trimester exposure to benzodiazepines appears to be associated with an increased risk of oral clefts in newborns while late third-trimester use is commonly associated with the floppy baby syndrome.

Question 66

In treating serotonin syndrome which of the following receptor antagonism is useful for controlling neurological signs?

Select one:
1. Alpha
2. H1
3. 5HT2A
4. 5HT7
5. 5HT3

Answer 66

5HT2A

Any agent that increases serotonergic function can put patients at risk of a central serotonergic syndrome. This syndrome most commonly affects patients on multiple serotonergic drugs and involves multiple systems. The CNS effects are thought to be related to 5HT-2A stimulation.

Question 67

Postural hypotension as a side effect of tricyclic antidepressants are related to

Select one:
1. Alpha-adrenergic blockade
2. 5-HT2 Blockade
3. Anticholinergic effect
4. Antihistaminergic effect
5. Beta blockade

Answer 67

Alpha-adrenergic blockade

Postural hypotension, dizziness, tachycardia and arrhythmias are caused due to alpha-adrenergic blockade. 5-HT2c Blockade is related to weight gain.

Question 68

Which of the following is the most common adverse effect of valproate?

Select one:
1. Ataxia
2. Persistent elevation of hepatic transaminases
3. Reversible thrombocytopenia
4. Diarrhoea
5. Hair loss

Answer 68

Diarrhoea

Nausea, vomiting, dyspepsia and diarrhoea are the most common adverse effects of valproate.

Question 69

A 27-year-old man with bipolar depression was started on one of the mood stabilisers. He developed a rash immediately, which subsequently progressed to causing Steven Johnson syndrome. Which one of the following is most likely to be the mood stabiliser that was prescribed to this man?

Select one:
1. Topiramate
2. Lamotrigine
3. Valproate
4. Zonisamide
5. Lithium

Answer 69

Lamotrigine

Lamotrigine stabilises neuronal membranes and reduces the release of excitatory amino acids (especially glutamate) by blocking voltage dependent sodium channels. Lamotrigine is associated with Stevens-Johnson syndrome in 1% of the population with the risk being greatest in the first 8 weeks. The risk is reduced with slow dose titration and special dosing guidelines especially when valproate is used concomitantly as is often the case in psychiatric usage.

Question 70

Choose one side effect NOT seen with tricyclics commonly

Select one:
1. Sedation
2. QT prolongation
3. Delirium on overdose
4. Weight gain
5. Hypothyroidism

Answer 70

Hypothyroidism

The most frequent and treatment-limiting side effect of TCAs is orthostatic hypotension, followed by sedation, dry mouth and constipation. Hypothyroidism is not a side effect of TCAs.

Question 71

The tricyclic with highest antihistaminic activity is

Select one:
1. Amitriptyline
2. Imipramine
3. Amoxapine
4. Clomipramine
5. Doxepine

Answer 71

Doxepine

Has a lower risk of orthostatic hypotension but has a higher antihistaminergic effect.

Question 72

The risk of Ebstein’s anomaly is increased by how many times in children of mothers taking lithium while pregnant?

Select one:
1. 20 times
2. 10 times
3. 1000 times
4. 2 times
5. 100 times

Answer 72

20 times

The most common teratogenic effect of lithium involves cardiac valves especially Ebstein’s anomaly of the tricuspid valves. The risk of Ebstein’s malformation in lithium-exposed foetuses is 1 of 1,000 (20 times the risk in the general population).

Question 73

A 45-year-old gentleman started on risperidone complained of feeling anxious and was constantly found crossing/ uncrossing legs on the ward. What is the most likely cause among the following?

Select one:
1, Akathisia
2. Dystonia
3. Pseudoparkinsonism
4. Tardive dystonia
5. Tardive dyskinesia

Answer 73

Akathisia

Akathisia is characterised by a subjectively unpleasant state of inner restlessness when there is a strong desire or compulsion to move. e.g., foot stamping when seated, constantly crossing/ uncrossing legs, rocking from foot to foot and constantly pacing up and down.

Question 74

Which one among the following is not a significantly high-risk factor for developing drug-induced hyponatraemia?

Select one:
1. Reduced renal function
2. Extreme old age
3. Obesity
4. Co-therapy with diuretics
5. Medical co-morbidity such as diabetes

Answer 74

Obesity

The high risk factors would include extreme old age, female sex, warm weather, low body weight, reduced
renal function, co-therapy with diuretics, NSAIDs, carbamazepine, cancer chemotherapy, medical co-morbidity such as diabetes, hypertension, COPD, hypothyroidism, head injury, CVA.

Question 75

Commonest side effect of methylphenidate is

Select one:
1. Tics
2. Psychosis
3. Insomnia
4. Diarrhoea
5. Headaches

Answer 75

Insomnia

The most common side effects with methylphenidate are nervousness, agitation, anxiety, and insomnia.

Question 76

Which one among the following as a side effect of tricyclic antidepressants is not related as due to anticholinergic receptor blockade?

Select one:
1. Urinary retention
2. Constipation
3. Dry mouth
4. Blurred vision
5. Sedation

Answer 76

Sedation

Anticholinergic effect: Dry mouth, constipation, urinary retention, blurred vision, and glaucoma. Antihistaminic effect: sedation, weight gain.

Question 77

From the following list choose the pair of medications where the former producing side-effects that are ameliorated by the second drug.

Select one:
1. clozapine-furosemide
2. reboxetine-doxazosin
3. citalopram-hyoscine
4. Zopiclone-atomoxetine
5. Phenytoin-danazol

Answer 77

Reboxetine-doxazosin

Urinary hesitancy can be an uncomfortable side effect during treatment with antidepressants such as the selective noradrenaline reuptake inhibitor reboxetine. The use of selective a1A-adrenoceptor antagonists such as doxazosin or tamsulosin can treat the urinary hesitancy - especially in the elderly with associated prostate enlargement.

Question 78

Which one among the following is associated with erectile dysfunction more often than the other SSRIs?

Select one:
1. Fluvoxamine
2. Fluoxetine
3. Citalopram
4. Paroxetine
5. Sertraline

Answer 78

Paroxetine

Sexual dysfunction due to activation of post synaptic 5-HT 2 receptors is more prominent with paroxetine than with the other SSRIs.

Question 79

The cardiotoxic effects of tricyclic antidepressants would include all of the following except

Select one:
1. Arrhythmias
2. ST elevation or depression
3. Atrioventricular Block
4. Reduction in cardiac output
5. QT Prolongation

Answer 79

Reduction in cardiac output

TCAs affect cardiac conduction; as a result, they have antiarrhythmic properties and can slow cardiac conduction. These effects are responsible for the cardiotoxicity of TCAs and their danger in overdose. TCAs
do not affect cardiac output. However, they should not be used in patients with a pre-existing conduction delay greater than a first-degree block or in patients immediately after myocardial infarction.

Question 80

Sustained abnormal postures or positions called tardive dystonias are sometimes seen during neuroleptic treatment. Tardive dystonia occurs after

Select one:
1. Months to years of antipsychotic treatment
2. Days to weeks of starting antipsychotics
3. Within hours to weeks of starting antipsychotics
4. Within hours of starting antipsychotics
5. Within minutes of starting antipsychotics

Answer 80

Months to years of antipsychotic treatment

Generally, acute dystonia occurs within hours of starting antipsychotics. Pseudo-parkinsonism occurs days to weeks of starting antipsychotics. Akathisia occurs within hours to weeks of starting antipsychotics. Tardive Dyskinesia and tardive dystonia occurs after months to years of antipsychotic treatment. (tardy =
slow).

Question 81

What is the risk of developing fatal agranulocytosis in patients treated with clozapine in the UK?

Select one:
1. 1 in 10000
2. 1 in 1300
3. 1 in 4500
4. 1 in 5000
5. 1 in 1000

Answer 81

1 in 5000

Fatal agranulocytosis - 1 in 5000 patients; fatal pulmonary embolism - 1 in 4500 patients treated; fatal myocarditis or fatal cardiomyopathy -1 in 1300 patients treated.

Question 82

Which of the following receptors is involved in hypersalivation that occurs during clozapine therapy?

Select one:
1. Beta adrenergic
2. Alpha adrenergic
3. Muscarinic
4. Nicotinic
5. Histaminic

Answer 82

Muscarinic

The pharmacological basis of clozapine-related hypersalivation remains unclear. Suggested mechanisms include muscarinic M4 agonism, adrenergic alpha 2 antagonism and inhibition of the swallowing reflex.

Question 83

A reduction in akathisia symptoms may not be seen on treatment with

Select one:
1. Propranolol
2. Cyproheptadine
3. Anticholinergics
4. Clonazepam (low dose)
5. Trazadone

Answer 83

Anticholinergic

A reduction in akathisic symptoms may be seen with Propranolol, Clonazepam (low dose), Cyproheptadine, Trazadone, and Mianserin. Anticholinergics are generally unhelpful.