Exam 2 practice questions Flashcards
DSM-5 TR® Criteria: Schizophrenia
A.) 2 or more of the following symptoms, each persisting for a significant portion of time during a 1 month period, one symptom must include (1), (2), or (3):
- DELUSIONS
- HALLUCINATIONS
- DISORGANIZED SPEECH
- GROSSLY DISORGANIZED/CATATONIC BEHAVIOR
- NEGATIVE SYMPTOMS
B.) Social/Occupational Dysfunction > 1 area of functioning below level prior to onset of illness - WORK - INTERPERSONAL RELATIONSHIPS - SELF-CARE
C.) Duration
- Continuous signs of disturbance for > 6 months
1st Generation/Typical Antipsychotics
- chlorpromazine (Thorazine)
* haloperidol (Haldol)
2nd Generation/Atypical Antipsychotics
- aripiprazole (Abilify)
- asenapine (Saphris)
- clozapine (Clozaril)
- olanzapine (Zyprexa)
- quetiapine (Seroquel)
- risperidone (Risperidal)
- iloperidone (Fanapt)
- paliperidone (Invega)
- lurasidone (Latuda)
- ziprasidone (Geodon)
Treatment Goals
• Acute phase
o Initiate pharmacotherapy ASAP
o Titrate to ___________(maximum/lowest) therapeutic dose based on tolerability
lowest
only need lowest effective dose
–> higher the dose = more side effects
FGAs
- Higher affinity for _____ receptor, acts as _______ (agonist/antagonist)
- alleviate primarily _____ symptoms
- causes an increase in _____, _______, and _____ ________
- inexpensive
- D2, antagonist
- positive
- EPS, prolactin, tardive dyskinesia (TD)
SGAs
- ↑ _________ vs. ________ receptor affinity
- Thought to treat negative/cognitive symptoms???
- ↓ ___, ↓ _______, ↓ ______ _______
- ↑ ______ _______
- More expensive
- ↑ Serotonin (5HT2) vs. dopamine (D2) receptor affinity
- ↓ EPS, ↓ prolactin, ↓ TD
- ↑ Metabolic effects
Which of these is not a sx of schizophrenia?
a. Positive sx (hallucinations, delusions)
b. Negative sx (loss of motivation, asocial
c. Mania
d. Lack of Salience
e. Cognitive sx (d1R mediated)-inability learn
c. Mania
mania is a sx of bipolar; salience means knowing what’s important when you are getting a lot of input into your brain
Matching: DA projects from VTA and substantia nigra; what do they mediate?
a. VTA to frontal cortex 1. movement
b. Sub. Nigra to striatum 2. Motivations, emotions
c. VTA to nucleus accumbens 3. ADRs/prolactin release
d. Hypothalamus projection 4. Rewards/psychosis
a. VTA to frontal cortex - Motivations, emotions
b. Sub. Nigra to striatum - movement
c. VTA to nucleus accumbens - Rewards/psychosis
d. Hypothalamus projection - ADRs/prolactin release
True or False?
According to dopamine hypothesis, high levels of DA to the frontal cortex is what causes the cognitive side effects
False.
It is low levels of DA from the VTA to the cortex that cause cognitive side effects. High levels of DA in mesolimbic pathway that cause the psychosis and positive sx
According to the glutaminergic hypothesis, which NT is there a deficiency of in the cortex to cause an increase in DA upstream?
a. Glutamate
b. GABA
c. serotonin
d. Dopamine
GABA
NMDA receptors on the GABA receptor are not working properly according to this hypothesis causing less GABA to be released. This doesn’t allow for inhibition of the glutamate neuron that releases glutamate and allows for DA to increase on a dopaminergic neuron (excitatory) in the limbic neuron. It is a PROBLEM from the NMDA receptor though, which causes the deficiency in GABA. This explains positive, negative, cognitive sx; it can also explain the DA hypothesis
Which receptor antagonism causes the tremors in chlorpromazine (Thorazine)
a. 5ht2
b. D1R
c. D2R
d. D5R
D2R
Which of these are reasons why it takes a few weeks for a typical antipsychotic to decrease DA levels?
a. Remodeling
b. Action on autoreceptors
c. Increasing breakdown of DA
Remodeling.
If it acts on autoreceptors it is increasing DA levels in the synapse which wouldn’t help what we want since we want antagonism
Which of these is a partial D2R agonist?
a. Chlorpromazine
b. Loxapine
c. Thiothixene
d. Aripiprazole
Aripiprazole
Which drugs are more likely to cause EPS? Select all
a. Geodon
b. Perphenazine
c. Haldol
d. Abilify
Perphenazine
Haldol
the typicals are more likely to cause it; abilify has partial agonism so it would be less likely to cause EPS
Which of these is more likely to cause metabolic syndrome?
a. Clozapine
b. Haldol
c. Chlorpromazine
d. Loxapine
Clozapine
more of a concern in atypicals; mostly clozapine and olanzapine
Which atypical antipsychotic has an active metabolite that inhibits NET?
a. Olanzapine
b. Abilify
c. Quetiapine
d. Ziprasidone
Quetiapine
What are the anticonvulsants used in bipolar disorder?
Lamotrigine, Tegretol, Depakote, Oxcarbazepine
Which of the following is NOT a usual hallmark sx of schizophrenia & psychosis?
a. Depression
b. Cognitive impairment
c. Negative sx
d. Positive sx
depression
Which of the following neurotransmitters was mentioned in the video as being related to schizophrenia?
a. Acetylcholine
b. Norepinephrine
c. Serotonin
d. Dopamine
e. GABA
dopamine
Cognitive sx of schizophrenia are primarily due to dysfunction of the dopamine projections to the cortex.
a. True
b. False
True
Schizophrenia is possibly due to:
a. Genetics (only)
b. Physical stressor on mom during pregnancy (only)
c. All of the factors above
d. None of the above
All of the factors above
Imaging & post-mortem studies on schizophrenic patients have shown an enlargement of the brain mass and shrinking of the ventricles compared to non SCZ patients.
a. True
b. False
False
Which of these drugs should not be used with CBZ (carbamazepine) due to it’s inhibition of epoxide hydroxylase?
a. VPA - valproic acid
b. OXC - oxcarbazepine
c. LTG - lamotrigine
d. Seroquel
VPA
Which of these induces its own metabolism? Select all
a. VPA
b. Lithium
c. oxcarbazepine
d. CBZ
c. oxcarbazepine
d. CBZ
It induces 3a4 which causes slow therapeutic levels
Which drug has its major activity in its metabolite?
a. VPA
b. Lithium
c. Carbazepine
d. Oxcarbazepine
d. Oxcarbazepine
Answer: MHD is the active metabolite that has a half life of 9 while OXC has a half life of 2h. Abilify also has an active metabolite that has a longer half life than the main drug
Which drug has 20 metabolites via 3a4 from the first pass effect?
a. Quetiapine
b. Olanzapine
c. Oxcarbazepine
d. Haloperidol
e. Lithium
a. Quetiapine
Which of these drugs undergoes stereoselective metabolism to give an active metabolite that is sold in the market?
a. Quetiapine
b. Olanzapine
c. Oxcarbazepine
d. Haloperidol
e. Risperidone
e. Risperidone
Answer: 3a4/2d6 gives it stereoselective metabolism into paliperidone (Invega)
Which drug undergoes osmotic pressure to release its contents and makes it longer acting?
a. Olanzapine
b. Oxcarbazepine
c. Paliperidone
d. Haloperidol
e. Lithium
c. Paliperidone
Which are the IM depot antipsychotics? SELECT ALL
a. Invega Sustenna
b. haloperidol
c. Fluphenazine
d. Perphenazine
e. Thiothixene
f. Abilify Maintena
a. Invega Sustenna
b. haloperidol (DECANOATE)
c. Fluphenazine (DECANOATE)
f. Abilify Maintena
These are long acting and help with compliance and relapse issues; haloperidol decanoate & fluphenazine decanoate = IM depots
SGA Dosing: risperidone paliperidone iloperidone aripiprazole asenapine olanzepine quetiapine clozapine lurasidone ziprasidone
Usual Target Dose (mg/day) risperidone 2 – 8 paliperidone 3 – 12 iloperidone 12 – 24 aripiprazole 10 – 15 asenapine 10 – 20 olanzapine 10 – 20 quetiapine 150 – 800 clozapine 300 – 450 lurasidone 40 – 80 ziprasidone 40 – 100
What drugs are metabolized by 1A2? Select all
a. Abilify
b. Saphris
c. Latuda
d. Geodon
e. Fanapt
f. Clozaril
g. Zyprexa
Saphris / asenapine
Clozaril / clozapine
Zyprexa / olanzapine
What drugs are metabolized by 2D6? Select all
a. Abilify
b. Saphris
c. Latuda
d. Geodon
e. Fanapt
f. Clozaril
g. Zyprexa
h. Risperdal
Fanapt
Abilify
Risperdal
“FAR”
What drugs are metabolized by 3A4? Select all
a. Abilify
b. Saphris
c. Latuda
d. Geodon
e. Fanapt
f. Clozaril
g. Zyprexa
h. Seroquel
Fanapt / iloperidone Latuda / lurasidone Abilify / aripiprazole Geodon / ziprasidone Seroquel / quetiapine
“FLAGS”
Which drug is the only one to go through non-CYP metabolism?
a. Latuda
b. Geodon
c. Invega
d. Fanapt
e. Clozaril
Invega
Which drug that is metabolized by 3A4 is contraindicated with a strong 3a4 inhibitors and inducers?
a. Latuda
b. Abilify
c. Fanapt
d. Seroquel
Latuda
If you are giving fluvoxamine with olanzapine, you would have to:
a. Increase the dose of olanzapine
b. Increase the dose of fluvoxamine
c. Decrease the dose of olanzapine
d. Decrease the dose of fluvoxamine
c. Decrease the dose of olanzapine
olanzapine is metabolized by 1A2 and fluvoxamine is a 1A2 inhibitor
Which drug can you not give along with short acting IM olanzapine?
a. IV lorazepam
b. IV carbazepine
c. IV fluvoxamine
d. Sertraline
IV lorazepam
IM olanzapine is not to be given concomitantly with parenteral BZDs. Wait an hour first
Which of these BBWs of clozapine are dose related? Select all
a. Myocarditis
b. Agranulocytosis
c. CV/respiratory effects
d. Elderly mortality increase
e. Seizures
c. CV / respiratory effects
e. Seizures
Seizures are dose related, and the CV effects may occur with rapid dose escalation
You have a patient that needs to be started on Clozaril. They have failed most other therapy. They have an ANC of 2500/mm3 and WBC of 3500/mm3. What dose of Clozaril would you start?
a. Clozapine 300 mg
b. Clozapine 12.5 mg
c. Don’t start Clozapine
d. Clozapine 400 mg
b. Clozapine 12.5 mg
Clozapine must be titrated up and the WBC values are okay to start clozapine. Start over titration if missed >/= 2 days
The patient comes back in a week and has an ANC of 500 and WBC of 1500. Do you adjust the dose of Clozaril?
a. Keep patient at current dose
b. Increase dose to normal titration
c. Discontinue Clozaril
d. Decrease dose of Clozaril
c. Discontinue Clozaril
D/c clozaril when ANC
Which SGA antipsychotics are NOT approved in acute manic episodes?
a. Latuda
b. Asenapine
c. Olanzapine
d. Quetiapine
e. Clozaril
f. Fanapt
g. Risperidone
h. Geodon
i. Abilify
j. Invega
Clozaril
Latuda
Invega
Fanapt
“CLIF”
Which SGA antipsychotics are approved for acute depressive episodes?
Clozaril / clozapine (treatment refractory)
Latuda / lurasidone
Seroquel / quetiapine
Symbyax / olanzapine-fluoxetine
“CLSS”
Which pain killer is recommended to be avoided with the use of Lithium?
a. APAP
b. Aspirin
c. Sulindac
d. Ibuprofen
d. ibuprofen
NSAIDs should generally be avoided with Li, but the 3 pain killers listed above are okay to use. Lithium increases with concomitant use
Which of these increases Lithium concentrations when used in combo?
a. Caffeine
b. Pregnancy
c. ACE inhibitors
d. Theophylline
ACE Inhibitors
the other 3 decrease Li concentration. ACEis, NSAIDs, and diuretics increase Li concentration
With Depakote DR you must wait ____ days and ____ hours post dose to check a level.
a. 5 days, 12 hours
b. 3 days, 12 hours
c. 5 days, 18 hours
d. 3 days, 18 hours
3 days, 12 hours
5 days wait is with lithium; 18 hours is for the ER Depakote
Due to the risk of thrombocytopenia, we always want to check ____ while a patient is on Depakote
a. Platelets
b. WBC
c. ANC
d. Blood glucose
platelets
With which side effect of VPA do you not have to discontinue the drug?
a. Hyperammonia
b. Tremor
c. significant hepatic dysfunction
d. Pancreatitis
tremor
the other 3 are rare but serious and must not retry VPA after discontinuing; BBWs of VPA are hepatotoxicity, pancreatitis, and teratogenicity
Carbamazepine can decrease levels of all these drugs EXCEPT:
a. Lamotrigine
b. Phenytoin
c. Oral contraceptives
d. Protease inhibitors
phenytoin
MN is a 24 year-old female recently diagnosed with BPAD. Her physician is going to place her on a mood stabilizer. Which of the following mood stabilizers will not decrease the effectiveness of her birth control, Alesse® (ethinyl estradiol and levonorgestrel)? Select all that apply.
a. Carbamazepine
b. Lithium
c. Oxcarbazepine
d. Divalproex
Lithium
Divalproex
GG presents to the inpatient psych unit in a bipolar depressive episode. He had been stabilized on divalproex 1500 mg/day as an outpatient until this recent episode. You and the medical team decide to increase the dose of divalproex to 2000 mg/day and add lamotrigine. What is the target dose of lamotrigine?
A. 200 mg/day
B. 100 mg/day
C. 400 mg/day
D. Lamotrigine should not be given with divalproex
100 mg/day
MG presents to your inpatient psych unit in a current manic episode. Her lithium trough level is 0.7 mEq/L at a dose of 900 mg PO QHS. To adequately treat mania, trough levels should typically be around: a. 0.6-0.8 mEq/L b. 1.0-1.2 mEq/L c. >1.5 mEq/L d.
b. 1.0-1.2 mEq/L
HH was initiated on carbamazepine during his inpatient hospitalization. A trough level is drawn 5 days after increasing the dose to 400 mg/600 mg and returns at 9 mcg/mL. A month later, at his outpatient appointment, another trough level is drawn and returns at 5 mcg/mL. The physician suspects that HH has not been compliant with his carbamazepine. Another reason his trough may be low is due to:
a. Autoinduction of metabolism by CYP2D6
b. Drug interaction with alcohol
c. Use of interacting OTC medications (NSAIDs)
d. Autoinduction of metabolism by CYP3A4
d. Autoinduction of metabolism by CYP3A4
Due to autoinduction of metabolism by CYP3A4; autoinduction takes several weeks to occur, that’s why it is higher at first
A patient newly started on lithium carbonate IR tablets (300 mg/600 mg)comes to your pharmacy complaining of diarrhea. He would like to know what can be done to stop to his diarrhea. What do you recommend to his physician?
a. Switch to Lithobid
b. Switch to lithium citrate
c. Discontinue lithium
d. Consolidate dose to bedtime
lithobid would make it worse, d/c is not helpful, and bedtime is for the sedation ADR
Of the mood stabilizers listed below, which plasma level correlates with efficacy in BPAD?
a. Lithium
b. Divalproex
c. Carbamazepine
d. Lamotrigine
Lithium
We check levels of VPA and CBZ but they don’t correlate and LTG we don’t take levels
When to check trough level
a. Lithium
b. VPA
c. CBZ
Valproic acid (divalproex) - 3 days
Tegretol (carbamazepine) - 4 days
Lithium - 5 days
“Very True Level”
All of the following are FDA-approved as monotherapy for bipolar maintenance EXCEPT: A. Quetiapine B. Aripiprazole C. Olanzapine D. Risperidone long-acting injectable
quetiapine
All of the following will increase lithium levels EXCEPT: A. Ibuprofen B. Lisinopril C. Caffeine D. Furosemide
caffeine
HH comes to your pharmacy complaining of frequent bruising, hair loss, and GI upset. She said she recently started a mood stabilizer but cannot remember its name. These side effects most likely result from which mood stabilizer? A. Lithium B. Divalproex C. Carbamazepine D. Lamotrigine
divalproex
Divalproex causes alopecia and thrombocytopenia
FP was recently started on oxcarbazepine and would like to know what her options are for birth control. She may receive treatment with all of the following EXCEPT:
A. Progestin-only pill
B. Medroxyprogesterone depot injection- Depo Provera®
C. Hormone-releasing intrauterine system (levonorgesterel- releasing intrauterine system)- Mirena ®
D. Copper IUD
A. Progestin-only pill
True or False.
All drugs of abuse increase dopamine levels
True
True or False.
If you are dependent on a drug, you are addicted
False.
Opioid users may not be addicted, but their body is dependent and may go into withdrawal if they are chronic users
Alcohol _______ GABA causing sedation, and ______ glutamate.
a. decreases, decreases
b. increases, increases
c. decreases, increases
d. increases, decreases
d. increases, decreases
Which drug is not to be used while ingesting alcohol or being a chronic alcoholic?
a. ibuprofen b. APAP c. Sulindac d. ASA
APAP
APAP forms toxic NAPQI. Glutathione metabolizes NAPQI into inactive metabolites and clears it from the body. Toxic NAPQI levels increase due to alcohol depleting glutathione levels. Risk of hepatotoxicity
True or False.
If you have alcoholism dependence and stop drinking immediately, your brain decreases GABA and increases glutamate causing an excitatory effect in the brain which may lead to seizures.
True
What is acamprosate?
a. an NMDA antagonist b. anticonvulsant c. antidepressant d. anxiolytic
a. an NMDA antagonist
Why is naltrexone an appropriate agent to use in alcoholism?
a) it is an opioid antagonist b) it is a gaba antagonist c) it is a glutamate agonist d) it is a serotonin agonist
a) it is an opioid antagonist
- which will prevent alcohol from binding to opioid receptors
True or False.
Nicotine has its main effects in the VTA
True.
It has little effect on the nucleus accumbens; mostly in VTA-SHARPE
How does Chantix work to help smoking cessation?
A. it is a n. ach receptor antagonist
b. it is an n. ach receptor partial agonist
c. it is a DAT and NET inhibitor
d. It is used as replacement therapy
b. it is a nicotinic ACh receptor partial agonist
- this blocks the euphoric effects given from smoking by inhibiting nicotine to bind to it’s receptor but still giving some of the feeling
True or false.
Cocaine has 2 MOAs. It is a competitive substrate for DAT, blocking DAT. Once it is taken up, it blocks VMAT from taking up DA causing a higher concentration of DA to build up in the presynaptic terminal, ultimately moving it into the synapse.
False.
Amphetamine and methamphetamine do this. Cocaine just blocks DAT
True or false. There is FDA approved pharmacologic therapy to treat meth addiction.
False.
Only behavioral therapy is approved
True or false: Opioids are depressants
True.
not stimulants, hint: alcohol also agonizes opioid receptor, alcohol depresses
Methadone has the same activity as heroin. Why is it used as a pharmacological agent?
a. It has a faster onset and a steady level b. It has a slower onset and a steady level c. It isn’t used as an agent d. It is just as euphoric and addictive as heroin so it helps the patient
b. It has a slower onset and a steady level
it does cause addiction still but usually when it is abused such as being crushed and injected IV
Which of these causes mu opioid receptor ANTAGONISM?
a. naltrexone b. buprenorphine c. methadone d. acamprosate
a. naltrexone
b and c cause agonism/partial agonism, and acamprosate is an NMDA antagonist
Mu opioid receptor causes (select all)
a. aversion b. sedation c. respiratory depression d. reward (reinforcement)
a. aversion
kappa causes aversion
Which THC derivative is an antagonist?
a. Dronabinol
b. Nabilone
c. Rimonabant
c. Rimonabant
The others are agonists
Which of these drugs has its MAJOR effects through 5ht (select all)
a. Methamphetamine b. Nicotine c. Alcohol d. Ecstasy e. Heroin f. LSD
d. Ecstasy
f. LSD
still has effects at DA but major effect through 5ht according to SHARPE
Which of these is not a stimulant given in ADHD? Select all
a. Adderall b. Vayarin c. Ritalin d. Intuniv e. Straterra
b. Vayarin
d. Intuniv
e. Straterra
Alcohol-containing products, such as hand sanitizer and mouth wash, cannot be used until 2 weeks after discontinuing which agent?
a. Disulfiram
b. Naltrexone
c. Buprenorphine
d. Acamprosate
a. disulfiram
bc they can cause the reaction to occur with a build up of acetylaldehyde; don’t use with Flagyl either
Which agent, used for opioid detoxification and maintenance therapy, has the potential to prolong the QT interval?
a. Naltrexone
b. Buprenorphine
c. Methadone
d. Acamprosate
c. Methadone
Which agent produces a “ceiling-effect” around doses of 16-20 mg/day, making it less effective for use in patients requiring higher opioid maintenance therapy doses?
a. Naloxone
b. Naltrexone
c. Methadone
d. Buprenorphine
d. Buprenorphine
All of the following are known risk factors for substance use disorders EXCEPT:
a. Widowed, divorced, or separated
b. Male
c. Old age
d. Lower socioeconomic status
c. Old age
What is the treatment of choice for alcohol withdrawal syndrome and delirium tremens?
a. Carbamazepine
b. Diazepam
c. Alprazolam
d. Acamprosate
b. Diazepam
True or False.
The presence of liver disease does not influence GGT levels but does effect CDT levels.
False
What does RIPS in the DSM5 for substance abuse stand for?
Risky use, impaired control, pharmacological criteria (dependence/withdrawal), social impairment
Which BZDs are approved in treating seizures in alcohol withdrawal pts that are elderly or have hepatic dysfunction? Select all
a. diazepam b. Lorazepam c. chlordiazepoxide d. oxazepam
b. Lorazepam
d. oxazepam
The others are approved in treating seizures in younger pts; the others have a long half life and fewer rebound withdrawal sx
True or False
If pts have a CIWA score of <10 then we could give them a sx triggered regimen of BZDs.
False
Should be >10
Wernicke’s is caused by what deficiency?
a. sodium b. thiamine c. potassium d. magnesium
b. thiamine
give it prophylactically and with glucose. Korsakoff’s is the permanent version characterized by memory impairment; doesn’t respond to thymine
Which drug should not be used concommitently with opioids or if pt is experiencing opioid withdrawal?
a. Disulfiram
b. Revia
c. Buprenorphine
d. Acamprosate
b. Revia
it is an mu opioid antagonist that will make the withdrawal worse or the opioid not work; also not in liver failure: BBW-hepatotoxicity. Vivitrol is used in opioid dependence
True or false.
You could have ADHD as an adult if you didn’t have sx of ADHD as a child.
False
you don’t need to be diagnosed as a child, but you need to have the sx
If a 4 y/o child is diagnosed with ADHD. What is the best tx for them?
a. behavioral therapy b. antidepressants c. methylphenidate d. Adderall
a. behavioral therapy
4-6 yo only get behavioral therapy, <4 don’t diagnose, 6-11- drug therapy but prefer to start with behavioral 12-18 yo- drug therapy
First line drug in adult adhd?
a. bupropion b. STratera c. Adderall d. methylphenidate
d. methylphenidate
b and c are second line and a is third; most stimulants are effective; usually BID and don’t give at night
True or False.
Stimulant therapy is weight dependent.
False
use lowest dose possible, only take weight and height to check baseline for adrs. Increase dose until target sx resolvement; switch to ER if having sx before next dose in BID dosing
True or False.
You see an immediate effect with stimulants in ADHD.
False
titrate q 1-3 weeks, you can see doctor after 1 week if it isn’t working. Monitor BP and HR, height and weight q3 month and q 6 months
Stimulants for ADHD are CI in all these pts except:
a. Anxiety pt b. Psychosis pt c. those with HTN d. Pre existing tics
c. those with HTN
only use caution
True or false.
Patients who were treated for ADHD were more likely to abuse substances
False
less likely
Select all. Weight based dosing for which of these in ADHD?
a. Ritalin b. Intuniv c. Straterra d. Adderall
b. Intuniv
c. Straterra
Which drug among these can be used in monotherapy for ADHD and comorbid conditions?
a. venlafaxine b. bupropion c. Modafinil
b. bupropion
Which of the following is NOT a usual hallmark symptom of schizophrenia and psychosis? A. Depression B. Cognitive impairment C. Negative symptoms D. Positive symptoms
depression
Which of the following neurotransmitter was mentioned in the video as being related to schizophrenia? A. Acetylcholine B. Norepinephrine C. Serotonin D. Dopamine E. GABA
dopamine
True or false
The cognitive symptoms of schizophrenia are primarily due to dysfunction of the dopamine projections to the cortex.
True
Schizophrenia is possibly due to: A. Genetics (only) B. Physical stressor on mom during pregnancy (only) C. Psychosocial factors (only) D. All of the above E. None of the above
all of the above
True or false
Imaging and post-mortem studies on schizophrenic patients have shown an enlargement of the brain mass and shrinking of the ventricles compared to non-SCZ patients.
False
shrinking of the brain mass and enlargement of the ventricles
Provide a rationale for Valproic acid’s high PO bioavailability of higher than 80%.
Carboxylic acid FG → environment is acidic (stomach), ionization is minimal therefore can cross into systemic circulation
Low potency first-generation antipsychotics (FGA) differ from high potency FGAs because (select 2 answers):
A. High potency FGA have higher binding affinity to D2 receptors
B. High potency FGA have higher binding affinity to histamine (H1) muscarinic (M1), and alpha-1 receptors
C. Low potency agents have higher binding affinity to D2 receptors
D. Low potency agents have higher binding affinity to H1, M1 and alpha-1 receptors
A. High potency FGA have higher binding affinity to D2 receptors
D. Low potency agents have higher binding affinity to H1, M1 and alpha-1 receptors
Risk factors for tardive dyskinesia include all of the following EXCEPT:
A. Older age
B. Long duration of antipsychotic treatment
C. African-American
D. Female gender
C. African-American
MN is a 24-year-old female recently diagnosed with BPAD. Her physician is going to place her on a mood stabilizer. Which of the following mood stabilizers will not decrease the effectiveness of her birth control, Alesse (ethinyl estradiol and levonogestrel)? Select all that apply. A. Carbamazepine B. Lithium C. Oxcarbazepine D. Divalproex
B. Lithium
D. Divalproex
GG presents to the inpatient psych unit in a bipolar depressive episode. He has been stabilized on divalproex 1500 mg/day as an outpatient until this recent episode. You and the medical team decide to increase the dose of divalproex to 2000 mg/day and add lamotrigine. What is the target dose of lamotrigine?
A. 200 mg/day
B. 100 mg/day
C. 400 mg/day
D. Lamotrigine should not be given with divalproex.
B. 100 mg/day
Lamotrigine usual target dose is 200 mg/day but since divalproex increases the concentration of lamotrigine 2-fold, it’s dose should be decreased by half.
MG presents to your inpatient psych unit in a current manic episode. Her lithium trough level is 0.7 mEq/L at a dose of 900 mg PO QHS. To adequately treat mania, trough levels should typically be around: A. 0.6-0.8 mEg/L B. 1.0-1.2 mEq/L C. >1.5 mEq/L D.
B. 1.0-1.2 mEq/L
HH was initiated on carbamazepine during his inpatient hospitalization. A trough level is drawn 5 days after increasing the dose to 400 mg/600 mg and returns at 9 mcg/mL. A month later, at his outpatient appointment, another trough level is drawn and returns at 5 mcg/mL. The physician suspects that HH has not been compliant with his carbamazepine. Another reason his trough may be low is due to:
A. Autoinduction of metabolism by CYP2D6
B. Drug interaction with alcohol
C. Use of interacting OTC medications (NSAIDs)
D. Autoinduction of metabolism by CYP3A4
D. Autoinduction of metabolism by CYP3A4
A patient newly started on lithium carbonate IR tablets (300 mg/600 mg) cones to your pharmacy complaining of diarrhea. He would like to know what can be done to stop to his diarrhea. What do you recommend to his physician? A. Switch to Lithobid B. Switch to lithium citrate C. Discontinue lithium D. Consolidate dose to bedtime
B. Switch to lithium citrate
Of the mood stabilizers listed, which plasma level correlates with efficacy in BPAD? A. Lithium B. Divalproex C. Carbamazepine D. Lamotrigine
Lihium
All of the following are FDA-approved as monotherapy for bipolar maintenance EXCEPT: A. Quetiapine B. Aripiprazole C. Olanzapine D. Risperidone long-acting injectable
Quetiapine
All of the following will increase lithium level EXCEPT: A. Ibuprofen B. Lisinopril C. Caffeine D. Furosemide
caffeine
AA comes to your pharmacy complaining of frequent bruising, hair loss, and GI upset. She said she recently started a mood stabilizer but cannot remember its name. These side effects most likely result from which mood stabilizer? A. Lithium B. Divalproex C. Carbamazepine D. Lamotrigine
divalproex
FP was recently started on oxcarbazepine and would like to know what her options are for birth control. She may receive treatment with all of the following EXCEPT:
A. Progestin-only
B. Medroxyprogesterone depot injection – Depo Provera
C. Hormone-releasing intrauterine system (levonorgestrel-releasing intrauterine system) – Mirena
D. Copper IUD
A. Progestin-only
True or false.
A drug that is injected or smoked is more likely to be abused than the same drug taken orally.
True
All drugs of abuse have in common that they cause: A. An increase in dopamine in the brain B. A decrease in dopamine in the brain C. An increase in serotonin in the brain D. A decrease in serotonin in the brain
A. An increase in dopamine in the brain
Withdrawal is a hallmark sign of: A. Drug addiction B. Drug abuse C. Tolerance D. Sensitization E. Dependence
E. Dependence
Which of the following drugs is NOT approved for use to help keep an alcoholic abstinent from alcohol use? A. Naloxone B. Buprenorphine C. Disulfiram D. Acamprosate
B. Buprenorphine
Which of the following drugs is NOT approved for use in helping someone quit tobacco use? A. Buproprion B. Acamprosate C. Varenicline D. Nicotine patch
B. Acamprosate
True or false
Acamprosate can be used to treat the seizures that occur in alcohol withdrawals.
False
Ephedrine and pseudophedrine are good for beginning synthesis of:
A. Cocaine
B. Methamphetamine
B. Methamphetamine
True or false
Physical dependence to opiates can happen in absence of addiction.
True
True or false
It is possible to become physically dependent on marijuana.
True
Why is withdrawal less common with marijuana and THC?
A. They are less potent drugs than others
B. They are smoked or ingested, not injected
C. THC is stored in fat
D. They are quickly metabolized and eliminated
C. THC is stored in fat
Which of the following is NOT a hallmark symptom of ADHD? A. Hyperactivity B. Impulsivity C. Inattention D. Mania
Mania
ADHD is linked to deficits of which of the following neurotransmitters? A. Serotonin B. GABA C. Glutamate D. Dopamine E. Histamine
dopamine
True or false
Guanfacine is a stimulant used to treat ADHD.
False
JP is a 21 yo male who presents to his PCP for difficulty maintaining focus in his college courses.
Symptoms include:
difficulty sustaining attention
forgetfulness
frequently losing things
being easily distracted
depressed mood
difficulty sleeping
JP denies a history of childhood ADHD.
He reports these symptoms began several months ago after the loss of his grandfather.
He also works evenings on the weekends at a local fast food establishment. He does not notice the symptoms while working.
The majority of JP’s symptoms per DSM V ADHD criteria:
A. Inattentive
B. Hyperactive/impulse
C. Combined
Inattentive
JP is a 21 yo male who presents to his PCP for difficulty maintaining focus in his college courses.
Symptoms include:
difficulty sustaining attention
forgetfulness
frequently losing things
being easily distracted
depressed mood
difficulty sleeping
JP denies a history of childhood ADHD.
He reports these symptoms began several months ago after the loss of his grandfather.
He also works evenings on the weekends at a local fast food establishment. He does not notice the symptoms while working.
JP meets the DSM V criteria for a diagnosis of adult ADHD.
A. True
B. False
False
Choose a contraindication to methylphenidate use? A. History of substance abuse B. Severe anxiety disorder C. Mild hypertension D. Controlled seizures
B. Severe anxiety disorder
If a patient is abusing illicit drugs, which ADHD medication should be initially prescribed?
A. Methylphenidate
B. Atomoxetine
B. Atomoxetine
CC: CB is a six year old boy brought into clinic by his mother after she was told by a teacher that her son was having difficulty adjusting to first grade.
PMH: Asthma since age 2; Fam Hx: Single parent family; one sister, aged 9
Social HX: enrolled in first grade at public school. Hobbies: bike riding, exploring. Diet: no veggies, candy, ice cream; Very active and talkative; good hygiene.
Won’t sit for more than 5 – 10 seconds, pulls books from shelves after being reprimanded by mother.
Friendly, demands attention.
Since age 4, in preschool, in kindergarten and now first grade, teachers complain that he is disruptive and impulsive, displaying little consideration for other children.
Medication history: Albuterol inhaler 1 – 2 puffs PRN breathing difficulty
Wt 25 kg (90th percentile) Ht 3’10”(75th percentile)
HEENT: runny nose
What non-pharmacological treatment would be best to start? A. EEG biofeedback B. Behavior modification C. Chelation therapy D. High Vitamin B dosing
B. Behavior modification
Which medication should be started if parents agree? A. Buproprion B. Venlafaxine C. Methylphenidate D. Modafinil
C. Methylphenidate
Depending on the medication chosen, what baseline medical evaluation should be done? A. EKG B. EEG C. Diet history D. Hepatic function
EKG (minimum HR & BP, also height and weight)
After starting this medication, how long until would you need to see the patient for monitoring? A. 1 week B. 4 weeks C. 6 months D. 1 year
1 week
What is the treatment of choice for alcohol withdrawal syndrome and delirium tremens? A. Carbamazepine B. Diazepam C. Alprazolam D. Acamprosate
B. Diazepam
True or False.
The presence of liver disease does not influence GGT levels but does effect CDT levels.
False
All of the following are known risk factors for substance use disorders EXCEPT: A. Widowed, divorced, or separated B. Male C. Old age D. Lower socioeconomic status
old age
Which agent produces a “ceiling-effect” around doses of 16-20 mg/day, making it less effective for use in patients requiring higher opioid maintenance therapy doses? A. Naloxone B. Naltrexone C. Methadone D. Buprenorphine
D. Buprenorphine
Which agent, used for opioid detoxification and maintenance therapy, has the potential to prolong the QT interval? A. Naltrexone B. Buprenorphine C. Methadone D. Acamprosate
C. Methadone
Alcohol-containing products, such as hand sanitizer and mouth wash, cannot be used until 2 weeks after discontinuing which agent? A. Disulfiram B. Naltrexone C. Buprenorphine D. Acamprosate
A. Disulfiram
This medication can be used for the treatment of both alcohol and opioid dependence and carries a black box warning for hepatotoxicity.
Naltrexone
ReVia, Vivitrol
This type of receptor down-regulates, while this other type of receptor up-regulates secondary to chronic alcohol use, which increases the risk of _____upon alcohol cessation
GABA receptors down-regulate;
NMDA receptors up-regulate; seizures
List 2 benefits of using symptom-triggered administration of benzodiazepines for alcohol withdrawal symptoms vs. fixed-dose scheduling.
- Shorter duration of treatment required
2. Less total medication administered
List 4 biomarkers of heavy drinking.
- GGT
- CDT
- AST/ALT
- MCV
If ≥ ___ consecutive days of methadone are missed, the patient may be at risk of overdose due to loss of tolerance. Also, methadone’s peak ______ effects occur later and persist longer than its peak analgesic effects, thereby increasing the risk of overdose.
3 days
Respiratory Depressant Effects
Bupropion, fluoxetine, and paroxetine can increase the concentration of ______, an ADHD medication, due to inhibitory effects on the CYP___ enzyme.
Atomoxetine (Strattera); CYP2D6
Divalproex can increase levels of this medication, thereby increasing the risk of Stevens Johnson Syndrome.
Lamotrigine (Lamictal)
_______, a CYP1A2 inducer, decreases clozapine levels while _______ , a CYP1A2 inhibitor, increases clozapine levels.
Decrease clozapine levels: cigarette smoke, rifampin, carbamazepine, phenytoin, phenobarbital
Increase clozapine levels: ciprofloxacin, fluvoxamine
_________, an antihypertensive agent, increases lithium concentrations while ______, the active ingredient in a Starbucks latte, decreases lithium concentrations.
Increase Lithium concentrations: ACEIs/ARBs, Thiazides, Furosemide
Decrease Lithium concentrations: caffeine
______, a mood stabilizer, decreases the effectiveness of oral contraceptives through inducing the metabolism of estrogen and progesterone, while estrogen decreases the concentration of _____, a different mood stabilizer.
Decreases Effectiveness of oral contraceptives:
carbamazepine (Tegretol) and Oxcarbazepine (Trileptal)
Estrogen: Increases lamotrigine (Lamictal) clearance
Patients missing greater than _____ days of clozapine therapy must be retitrated back-up to their previous dose due to the risk of ______.
2 Days; dose-related seizures
YR is being initiated on Risperdal Consta. He must continue to take oral therapy for a minimum of ______ after the first injection.
3 weeks
RY is a 20 y/o male who was initiated on haloperidol 20 mg BID within the past week. He is now febrile, displaying muscular rigidity and an altered mental status, and is hypertensive. RY most likely is displaying symptoms of ______. Haloperidol is discontinued and the team would like to know how long they must wait until they can initiate a different antipsychotic.
NMS; 2 weeks after symptom resolution
RY is stabilized on haloperidol 10 mg PO BID. The team would like to initiate him on haloperidol decanoate. Please recommend a loading dosing and injection interval for this patient.
200 mg IM on day 1 followed by 200 mg IM 3-7 days later;
maintenance dose: 300 mg IM month 2 then 225 mg IM month 3
To initiate clozapine, WBCs must be greater than ____ /mm3 and the ANC must be greater than ____/mm3 due to the risk of ______.
WBC> 3.5/mm3
ANC > 2.0/mm3
Agranulocytosis
TY is a 32 y/o female who presents to your pharmacy complaining of headaches. She is currently being treated with lithium 300 mg PO BID and divalproex 1000 mg PO QHS. She would like to know which OTC pain reliever will not interact with her current medication regimen.
Aspirin, Acetaminophen
Its important to educate patients on the risk of suicidality associated with these two classes of medications.
Antidepressants and Antiepileptic Drugs
___ and ___, both atypical antipsychotics, should be taken with food to enhance absorption.
Ziprasidone (Geodon) and Lurasidone (Latuda)
Patients may notice an empty capsule-shaped tablet in their stool when taking _____, an antidepressant, or ____, an antipsychotic, or ______, a stimulant, due to their osmotic drug release technology.
Desvenlafaxine (Pristiq), Paliperidone (Invega), Long-acting methylphenidate (Concerta)
Patients should be instructed that if they miss ≥ ______ days of therapy, they need to retitrate iloperidone due to the risk of __________.
Orthostatic Hypotension
Name 6 monitoring parameters for stimulants that are assessed at baseline and every 3 months.
Height/weight
Eating/sleeping pattern
Blood pressure/HR
RG’s mother would like his Daytrana patch to be effective by 8 AM, when he starts school. When should she apply the patch and how long can she leave the patch on RG?
Apply patch 2 hours (6 AM) before desired effect and total wear time of patch should not exceed 9 hours (3 PM).
Name 3 medications that can be used as first-line agents for the treatment of acute manic episodes in bipolar disorder.
Lithium, Divalproex,
Atypical Antipsychotics*
or Haloperidol
*clozapine use reserved for treatment refractory cases; No evidence yet for lurasidone or iloperidone
This medication is a good option for ADHD in adults with a history of substance abuse or in those who are unable to tolerate stimulants; however, it takes ____ amount of time for its effects to be seen.
Atomoxetine (Strattera):
Onset- 2 to 4 weeks
(adequate trial: 6 weeks at max dose)
Bupropion (Wellbutrin):
Onset- 4 to 6 weeks
(adequate trial: 6 weeks at max dose)
Drowsiness, slurred speech, ataxia, confusion, n/v/d, polyuria/polydipsia, cardiac conduction abnormalities
Lithium Toxicity
CD is stabilized on carbamazepine 400 mg PO BID for treatment of bipolar disorder. She would like to know which forms of contraception she can use. What are her options.
- Medroxyprogesterone depot injection (Depo-Provera)
- Copper IUD
- Levonorgesterel-releasing intrauterine system (Mirena)
- Barrier methods
