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Bipolar Disorder Flashcards

1
Q

Which of the following medications are used for treat Acute Depression for Bipolar Type I?

A. Lithium

B. Divalproex (Depakote)

C. Lamotrigine (lamotrigine)

D. Carbamazepine (Tegretol)

E. Quetiapine (Seroquel)

A

A, C, E

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2
Q

Which of the following medications is not sometimes utilized, but have limited evidence to support use in BD?

A. Clonidine

B. Gabapentin

C. Fish Oil

D. Verapamil

E. Oxacarbazepine

F. Amantadine

A

F

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3
Q

Which of the following statements is true? (select all that apply)

A. When a patient is starting lamotrigine they are at risk for TENS and SJS

B. When a patient is starting Depakote they are at risk for TENS and SJS

C. When a patient is starting lamotrigine they are at risk for agranulocytosis

D. When a patient is starging divalproex/ valproic acid (Depakote) they are at risk for hepatic faiure

A

A, D

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4
Q

You work with Dr. Scratch and Sniff and he just started a patient on Lithium. He wants you to take of the monitoring of the patient and let him know if there is anything abnormal in the labs. What labs are not necessary for you to order?

A. Kidney Function Tests

B. Thyroid Function Tests

C. CBC and Electrolytes

D. EKG

E. Liver Function Tests

A

E. Liver Function tests…liver function tests are for carbamazepine because it can cause elevated LFTs

a. kidney function bc lithium gets eliminated renally
b. thyroid bc lithium can cause a toxic goiter that can cause hypothyroidism
c. cbc and electroyltes becasue lithium looks like Na and K
d. ekg because of the cardiovascular adverse effects and if they are elderly

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5
Q

Which of the following is the black box warning for lithium?

A. Toxicity is closely related to serum concentrations and can occur at therapeutic doses.

B. Risk of developing anemia or agranulocytosis is increased during treatment.

C. Severe and sometimes fatal dermatologic reactions, including toxic epidermal necrolysis (TENS) and SJS may occur during therapy.

D. Kidney Failure resulting in fatalities has occured in patients

E. Cases of life-threatening pancreatitis occuring at the start of therapy.

A

A.

b and c are the black box warning for carbamazepine

d is fake, liver failure is seen in depakote

e is the black box warning for depakote

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6
Q

What is the therapeutic range for valproic acid?

A. 25-125mcg/ml

B. 50-125mcg/ml

C. 75-125mcg/ml

D. None of the above

A

B.

NOTE: levels greater than 94mcg/ml are associated with more strong effects

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7
Q

Match the following MOA to the drug…

I. Inhibits release of glutamate and inhibits voltage-sensitive sodium channels

II. Enhance GABA levels in the CNS

III. Inhibits depolarization-invoked and calcium dependent release of NE and DA

IV. Limits repetitive firing of AP mediated by stabilizing the inavctive state of voltage-gated Na channels

A. Lithium

B. Carbamazepine

C. Lamotrigine

D. Divalproex

A

I=C

NOTE: Not understood in BD

II. D

NOTE: Not well understood in BD

III. A

NOTE: According to Sharpe there is 3 possible MOA

  1. Similarity to Na and K causes altered ionic distribution across neurons and muscles
  2. Inhibits depolarization-invoked and calcium dependent release of NE and DA
  3. Inhibits 2nd messenger system (IP3, PKC)

IV. B

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8
Q

Which of the following medications should not be used for acute mania?

A. Olanzapine (Zyprexa)

B. Quetiapine (Seroquel)

C. Lurasidone (Latuda)

D. Asenapine (Saphris)

A

C. Lurasidone (Latuda)

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9
Q

Which of the following are counseling points for carbamazepine? (select all that apply)

A. Takes 6 months to optimize dosing

B. May cause a rash

C. Pregnancy Category C

D. Not recommended in lactation; it enters breast milk

E. Avoid sudden discontinuation

A

B, D, E

it takes 2 months to optimize dosing

this is a category D medication

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10
Q

Francine comes to get blood work done, when you get the results the you notice she has leukopenia and hyponatremia. The nurse also mentioned you the patient was complaing of ataxia.What medications is Francine taking that could cause this?

A. Lithium

B. Carbamazepine

C. Divalproex ( depakote)

D. Lamotrigine

A

B

NOTE: Carbamazepine Side Effect Profile

Ataxia

Sedation

Dizziness

Elevated LFTs

Nausea

Rash

Thrombocytopenia

Hyponatremia

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11
Q

Which of the following are counseling points for lithium? (Select all that apply)

A. Moderate salt intake, maintain proper hydration

B.Signs and symptoms of toxicity are upset stomach, hand tremor, you won’t be able to think or walk straight

C. May cause a rash

D. avoid sudden discontinuation

A

A, B

c and d are for carbamazepine

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12
Q

Which of the following medications is the first line treatment for acute mania? ( select all that apply)

A. Lithium

B. Divalproex

C. Lamotrigine ( Lamictal)

D. Carbamazepine (Tegretol)

E. Quetiapine ( Seroquel)

A

A, B, E

NOTE: A and B can be with or without SGA

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13
Q

Howie is a pharmacy techinician you work who has been calling in all the time. Afte talking to him you find out it is because his sister has been hospitalized due to an acute mania. He says he doesnt understand why that happened because he makes sure she takes her lithium everymorning before they take off to work with her coffee. Since you love chisme you butt into the conversation and say….

A. You don’t butt in becasue there is nothing wrong

B. You say that the coffee is decreasing her lithium

C. you say that the coffee is increasing her lithium and she went into lithium toxicity

D. You say she should take her Lithium with the coffee and NSAID because coffee will decrease lithium but the NSAID causes the lithium to increase so it will be ok

A

B.

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14
Q

When treating acute mania, what symptoms are you targeting?

A. Behavior Symptom Control

B. Sleep

C. Mood Stabilization

D. All of the above

A

D.

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15
Q

Which is not an FDA approved indication for divalproex?

A. Treatment of acute mania

B. Treatment of Mixed Episodes

C. Seizures Disorders Indication

D. Suicide risk reduction

E. Migraine Prophylaxis

A

D.

suicide reduction is for lithium

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16
Q

Which of the following medications would be inappropriate to give a patient who is non-adherent?

A. Lithium

B. Carbamazepine

C. Lamotrigine

D. Divalproex

A

C. Lamotrigine

because if they miss 5 days the will have to restart the titration

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17
Q

Which of the medication causes a non-toxic goiter?

A. quetiapine (seroquel)

B. Lithium ( Lithobid)

C. Divalproex (Depakote)

D. Lamotrigine ( Lamictal)

A

B. Lithium

Note: if you do get a goiter then either take away the lithium or give levothyroxine

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18
Q

What are the FDA indications of Lamotrigine?

A. Maintenance treatment in BD-Type I

B. Acute Manic Episodes

C. Seizure-Disorder Inications

D. Bipolar Depression

A

A, C, D

NOTE: not traditionally used as monotherapy in practice

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19
Q

Which of the following medications increase valproic acid drug levels? (select all that apply)

A. Salicylates
B. NSAIDs

C. Carbamazepine

D. Topiramate

E. Ertapenem

A

A, D

The rest of the medications decrease valproic acid

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20
Q

Which of the following statements is true? (select all that apply)

A. Divalproex/ Valproic Acid is pregnancy category D for migraines

B. Divalproex/ Valproic Acid is pregnancy category D for epilepsy and BD

C. Divalproex/ Valproic Acid is pregnancy category X for migraines

D. Divalproex/ Valproic Acids is pregnancy category X for epilepsy and BD

E. Divalproex/ Valproic acid enters the breast milk

A

B,C,E

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21
Q

A patient is an the ICU and she begins to have seizures, it is noted in the patient’s history that she takes valproic acid for seizures. Which of the following medications caused her to have seizures?

A. Zosyn (pipercillin-tazobactam)

B. Merrem ( merropenem)

C. Unasyn ( ampicillin-sulbactam)

D. Zithromax ( azithromycin)

A

B. Merrem

Merrem is a carbapenem that decreases the valproic acid

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22
Q

Which of the following levels of Toxicity levels is incorrect?

A. GI complaints/tremors: 1.5-2mEq/L

B. Confusion/Somnolence: 2-2.5mEq/L

C. Seizures/Death: >3mEq/L

D. None of the above

A

C.

Seizures/Death is at >2.5mEq/L

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23
Q

Which of the following SGA can be used to treat BP maintenance? (select all that apply)

A. Olanzapine (Zyprexa)

B. Quetiapine ( Seroquel)

C. Risperidone ( Risperdal)

D. Ziprasidone ( Geodon)

E. Aripriprazole (Abilify)

A

B,C,D,E

NOTE: Ziprasidone is used as adjunct therapy

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24
Q

Which of the following doesnt decrease depakote?

a. phenytoin
b. rifampin
c. guanfacine
d. carbamazepine

A

c. guanfacine increases valproic acid

25
Q

What is the off-label use for lithium? (select all that apply)

A. Suicide Risk

B. Treatment of acute mania

C. Maintenance Treatment of Bipolar Disorder

D. Anti-Depressant Augmentation

A

A,D

26
Q

What are the acute mania blood levels?

A. 0.5-0.8mEq/L

B. 0.8-1.5 mEq/L

C. 0.6-1 mEq/L

D. 1.5-2 mEq/L

A

B. 0.8-1.5mEq/L

C is for maintenance

D is for Toxicity

27
Q

Bryan is a psychiatriac resident taking care of Jessica ( she is taking Lithium for maintenace treatment). He sent her home with her lithium, but has her come back to clinic 3 days later to check her blood lithium levels. You explain to Bryan that he shouldn’t draw up Lithium levels yet because…

A. Medication does not need to be monitored

B. The steady state of this medication is not reached until after 5 days

C. The steady state of this medication is not reached until after 4 days

D. Bryan is correct, the steady state of this medication is reached int 3 days

A

B.

C. is true for carbamazepine

D. is true for divalproex/ valproic acid

28
Q

Dr. Huard ordered the following labs for Mary Jane a 25 yo female with mixed episodes of Bipolar Disorder I….

  1. CBC to check for hematologic risk/ leukopenia
  2. Liver function tests becasue carbamazepine can increase LFTs
  3. Platelets because thrombocytopenia
  4. EKG

what labs is Dr. Huard missing for Mary Jane? (select all that apply)

A. Urine Pregnancy Test

B. Kidney Function Tests

C. Thyroid Function Tests

D. Electrolytes

A

A, D

remember b and c are laboratory monitoring values for lithium

Urine Pregnancy is needed because Carbamazepine is a category D drug

Electrolytes are needed especially sodium becasue it can cause hyponatremia

29
Q
A
30
Q

which of the following medications is pregnancy category C?

A. Lithium

B. Carbamazepine

C. VPA
D. Lamotrigine

A

D. Lamotrigine

Lithium is category D

Carbamazepine is category D

VPA is X ( if used for migraines) and D ( if used for seizures/ BP)

31
Q

What are the uses of lithium? ( select all that apply)

A. Antidepressant-augmentation agent

B. Maintenance Treatment of BD

C. Treatment of Acute Mania

D. Suicide risk reduction in patients with BD or MDD

A

B, C

32
Q

Which of the following medications cause thrombocytopenia? (select all that apply)

A. Divalproex

B. Carbamazepine

C. Lithium

D. Lamotrigine

A

A, B

33
Q

True or False: Patients with mixed features can be treated with monoamine antidepressants?

A

False

34
Q

True or False

Depakote is dose dependent: risk of thrombocytopenia increases with valproate levels > 135mcg/mL in females and > 110mcg/mL males

A

False

females is >110

Males is >135

35
Q

Dr. J. Huard is a resident at Da Panda Psychiatric Institution (DPPI) Hospital. He wants to draw up levels of Carbamazepine to monitor his patient’s Bipolar Disorder, what do you respond?

A. He wants to maintain levels between 8-12mcg/mL

B. Carbamazepine has defined levels for seizure disorders, they are not well defined for Bipolar disorder

C. Therapeutic Range is 50-125mcg/mL, levels >94 are associated with a stronger effect

D. Levels of carbamazepine do not have to be monitored

A

B.

36
Q

Which of the following medications does a patient have to do self-skin examinations? (Select all that apply)

A. Lithium

B. VPA

C. Carbamazepine

D. Lamtrigine

A

C,D

37
Q

Dr. Yanez ordered blood levels for valproic acid @ 1200 2/1/17. The patient’s valproic acid was admnistered at 0000 2/2/17. Your preceptor notices this and asks you what you notice about this. What do you respond?

A. Valproic Acid takes 3 days to reach steady state

B. Valproic Acid take 4 days to reach steady state

C. Valproic Acid takes 5 days to reach steady state

D. It is ok to draw up levels 12 hours after the last dose

A

a.

38
Q

Which of the following statements is true regarding lithium and pregnancy? (select all that apply)

A. Lithium will cause neural malformations

B.Lithium is a Category D

C. Lithium given during the first trimester will cause ebstein anomaly

D. there is no with dosage up to 600 mg/day

E. Lithium does not enter the breast milk

A

B, C,

NOTE: remember that organogenesis occurs in the first trimester, you can stop administering lithium during the first trimester and intiated in the second trimester

a is actually for carbamazepine…it is not in the notes but it is category D

d is actually for Lamotrigine

e lithium does enter the breast milk..do not use

39
Q

You are called up to counsel a patient on their lithium medication. When you ask what other medications they are taking they mention Microzide. How do you counsel the patient?

A. There is no drug-drug interactions

B. There is no drug-drug interactions with microzide, just with caffeine because it will decrease the lithium

C. Patient should avoid the Microzide and NSAIDs because it will increase the Lithium

D. Patient should avoid the Microzide and NSAIDs becasue it will decrease the Lithium

A

C.

40
Q

Which of the following medications cause diplopia?

A. Lithium

B. Carbamazepine

C. Depakote

D. Lamotrigine

A

C. Depakote

Other Side Effects include:

GI upset

Sedation

Tremor

Edema

Weight Gain

Alopecia

Thromocytopenia

41
Q

Which of the following is the black box warning for SGAs?

a. Elderly patients with dementia-related psychosis treated with antipsychotics are at increased risk of death
b. Elderly patients are at high risk of suicide if treated with antipsychotics.

C. Patients under the age of 24 are at high risk of suicide if treated with antipsychotics

D. Patients under the age of 25 are at high risk of schizophrenia-Parkinsonian symptoms if treated with antipsychotics

A

A.

42
Q

Which of the following labs are taken at both baseline and every 6-12 months? ( select all that apply)

A. LFTs

B. CBC+ Differential

C. Platelets

D. Valproate Levels

E. Pregnancy Tests

A

A, B, C,

Pregnancy tests is done at baseline

Valproate levels are every 6-12 months

43
Q

Which SGA is NOT an option for SGA for bipolar depression?

A. Quetiapine (Seroquel)

B. Lurasidone ( Latuda)

C. Olanzapine (Zyprexa) and Fluoxetine (Prozac)

D. Aripriprazole (Abilify)

A

D.

44
Q

Select all that apply. Which medications cause weight gain?

A. Carbamazepine ( Tegretol)

B. Divalproex/ Valproic Acid ( Depakote)

C. Second Generation Antipsychotics

D. Lithium

E. Lamotrigine

A

B, C, D

45
Q

Gabriel is a 25 yo patient who was started on lamotrigine, he was initiated at 25mg/day and was being titrated by 25mg/day every 2 weeks to target a dose of 200mg daily. During the first week he was taking his medication everyday but after his dose was titrated the following week he started missing a doses here and there. How many days does the patient have to miss to re-tritrate?

A. 3 days

B. 4 Days

C. 5 Days

D. 7 Days

E. Does not matter, patient should take medication as soon as they remember

A

C. 5 Days

46
Q

Which of the following is the black box warning for carbamazepine?

A. Risk of developing anemia or agranulocytosis is increased during treatement.

B. Hepatic Failure resulting in fatalities has occured in patients, usually in the inital 6 months of therapy.

C. Cases of life-threatening pancreatitis occuring at the starts of therapy or follwing years of use have been reported.

D. Toxicity is closely related to serum concentrations and can occur at therapeutic doses

A

A.

b and c are for valproic acid/Divalproex (Depakote)

d is for lithium

47
Q

Which of the following statements is true about carbamazepine?

A. Steady State is reached after 3 days

B. Steady State is reached after 4 days

C. Steady State is reached after 5 days

D. Steady State is reached after 7 days

A

B. Steady State is reached after 4 days

3 days is for Depakote

5 days is for lithium

7 days is for phenytoin ( not in da notes)

48
Q

Which of the following medications is not used for maintenance of Bipolar Disoder?

A. Lithium

B. Divalproex (depakote)

C Lamotrigine (lamictal)

D. Carbamazepine ( Tegretol)

E. Quetiapine (seroquel)

A

D.

NOTE: lamotrigine is first line, but people don’t like using it first because of the titration that is required.

49
Q

If a regimen inclues divalproex and lamotrigine, which of the following statments is true?

A. double the dose of lamotrigine

B. Double the dose of the divalproex

C. half the dose of the lamotrigine

D. half the dose of the divalproex

A

C.

NOTE:

Valproic Acid is an INHIBITOR

Carbamazepine is and INDUCER

50
Q

Jose and his wife Carol comes up to your pharmacy and ask…if they were to get pregnant, can Carol still take her Lithium?

A. Yes,It is a Category A it is the safest drug to take during pregnancy

B. Yes,It is a Category B, no risks have been found in humans

C. No/YesIt is a Category C, not enough research has been done to determine if the drug is safe, she should talk to her OBG

D. No,It is a Category D adverse reactions have been found in human

E. No, it is a category X and should not be taken

A

D.

51
Q

Which of the following medications causes acne?

A. Carbamazepine ( Tegretol)

B. Divalproex/ Valproic Acid (Depakote)

C. Lamotrigine ( Lamictal)

D. Lithium ( Lithobid, Eskalith)

A

D.

52
Q

Which of the following medications is used to treat Acute Depresssion in Bipolar Disorder Type II?

A. Lithium

B. Divalproex (Depakote)

C. Lamotrigine ( Lamictal)

D. Carbamazepine (Tegretol)

E. Quetiapine ( Seroquel)

A

E

53
Q

Penelope is a 23 yo patient who needs to be counseled on her birth control. When you ask her what other medications she is on she mentions lamotrigine. What do you do next?

a. Oral contraceptions increase the concentrations of lamotrigine

B. Oral contraceptions decrease the concentrations of lamotrigine

C. There is not interaction between oral contraceptions and lamotrigine

D. Lamotrigine and Oral contraceptions are contraindicated together due to high risk of DVT

A

B.

NOTE: Only the Estrogen component of the birth control decreases the lamotrigine

54
Q

Dr. Estrada is a doctor who calls you to ask about what he should do if the wants to add carbamazepine to his patient’s BD therapy management ( which includes lamotrigine). What do you respond

A. Carbamazepine and Lamotrigine are contraindicated, he should not start the med.

B. Carbamazepine will increase levels of lamotrigine, he should decrease the dose of lamotrigine

C. Carbamazaepine will decrease levels of lamotrigine, he should increase the dose of lamotrigine

D. Lamotrigine will decrease levels of Carbamazepine, he should increase the dose of the carbamazepine.

A

C

55
Q

Which of the following is NOT FDA approved indications for carbamazepine (Tegretol)?

A. Acute manic or mixed episodes of Bipolar Type I (monotherapy or adjunct)

B. Seizure Indications

C. Trigeminal Neuralgia

D. Migraine Prophylaxis

A

D. Migraine Prophylaxis if FDA approved for Divalproex (Depakote)

56
Q

Which of the following statements of Carbamazepine is false.

A. Strong inducer of CYP3A4 and CYP2D6

B. Decreases the effects of contraceptions

C. Do not dispense for someone taking Clozapine

D. This medication is not first line

A

A.

this is a strong inducer of CYP3A4 and CYP1A2, it can even induce its own metabolism

57
Q

Which of the following statements is false? (select all that apply)

A. Don’t use monoamine antidepressants monotherapy for bipolar disorder

B. If a patient is on an antidepressant it should be in conjunction with a mood stabilizer.

C. The worst offender for manic switch are the SGAs (especially risperidone) and FGAs

D. SSRI may be used in conjunction with a mood stabilizer for 6-8 weeks

A

C.

the worst offenders for manic switch are SNRI especially venlafaxine

She said to commit to memory

58
Q

Which of the following is the black box warning for Depakote? ( Select all that apply)

A. Kidney Failure resulting in fatalaties has occured in patients, usually in the initial 6 months of therapy.

B. Hepatic Failure resulting in fatalities has occured in patients, usually in the initial 6 months of therapy.

C. Cases of threatening pancreatis, occuring at the start of therapy or following years of use

D. Cases of threatening meningitis, if sudden discontinuation.

A

B,C

Note you do have to avoid sudden discontinuation due to risk of seizures

59
Q

Which of the following medications cause toxic epidermal necrolysis (TENS) and Steven-Johnson syndrome ( SJS)? (select all that apply)

A. Lithium (Lithobid)

B. Carbamazepine (Tegretol)

C. Divalproex/ Valproid Acid ( Depakote)

D. Lamotragine (Lamictal)

A

B, C

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