Health Promotion and Lab Monitoring

Question 1

Folate in Mental health treatment.

Answer 1

Patients may have a deficiency of folate
L-5-Methyltetrahydrofolate
Monoamine modulator
Activates synthetic enzymes requiring BH4 as a cofactor include tryptophan and tyrosinehydroxylase
Monoamine synthesis can be enhanced

Question 2

L-5 Methyltetrahydrofolate

Answer 2

A reduced monoamine synthesis may limit the presence of serotonin even with administrationof SSRI and SNRIs
One potential mechanism of action consists in enhancing monoamine synthesis
It can be used in combination with other antidepressants
Improvement of symptoms of depression

Question 3

S-adenosyl-methionine(SAMe)

Answer 3

Augmenting antidepressants efficacy
L-Methylfolate converted into methionine, then SAMe
A deficiency may be present in certain patients
High doses of SAMe may be administered to augment antidepressants
Improvement of symptoms of depression may occur

Question 4

Omega 3 Fatty Acids, Fish Oild, DHA, EPA Fatty Acids

Answer 4

A deficiency may be present in certain patients
The deficiency may potentially lead to depression
Replacement of Omega-3 Fatty Acids
Augmenting antidepressants efficacy
Improvement of symptoms of depression may occur

Question 5

Melatonin

Answer 5

FDA Approved forInsomnia
A product of tryptophan metabolism/Metabolite of serotonin
May improve thermoreglation and immune defense
Improves Circadian rhythm disorders
Jet Lag
Shift work
Delayed sleep onset
Improves sleep in children with autism and ADHD

Question 6

Hypericum Perforatum(St.John’s Wort)

Answer 6

Used as antidepressant and anxiolytic
The mechanism of action is unknown
Can be as effective as some SSRIs in mild to moderate depression
Limited research onefficacy insevere depression
Onset of antidepressant action can be 4 weeks from start of treatment.
Daily doses of 500-1,800 mg
Must avoid direct sunlight

Question 7

Hypericum Perforatum Drug interactions

Answer 7

Severe drug/drug interactions associated due to CYP 3A4, 2C9, 2C19 metabolism.
Alprazolam (Xanax),Amitriptyline,Nortriptyline
Nifedipine
Omeprazole
Oral contraceptives
Simvastatin
Verapamil
Contraindicated in pregnancy, strong abortifacient

Question 8

Ginkgo Biloba (ginkgo)

Answer 8

One of the oldest trees in the world
FDA approved as a supplement
Used for memory disorders
Asthma, inflammatory disease, GI disturbance
Induces CYP3A drugs in Asians
“Z” drugs
Sedatives/Hypnotics
Quetiapine (Seroquel)
Bupropion (Wellbutrin)
Usual doses for memory function 120mg to 240mg 3 times daily

Question 9

Actaea Racemose (Black Cohosh)

Answer 9

Non-hormonal treatment to vasomotor symptoms to treat:
Dysmenorrhea
Menopause
Premenstrual Syndrome (Analgesic properties)
Fertility (post IVF and PCOS)
Osteoporosis
Prostate and breast cancer
GI upset
Dosed at 40mg to 80mg daily
May take 2 weeks to see intended effect
Drug/drug interactions: antihypertensive, cardiac drugs, estrogen
Contraindicated in pregnancy, pts with cardiac history

Question 10

Valeriana Officinalis

Answer 10

Has high amounts of GABA, though it does not cross the blood brain barrier
Used as a sleep aid and mild anxiolytic
Increases time in deep sleep
May experience improvement in 10 days after onset of treatment
No known toxicity, drug/drug interactions
Contraindicated in pregnancy due to adverse effects on embryo

Question 11

Reasons to monitor blood levels of medications:

Answer 11

Clinical Applications
Increased efficacy of using an optimal amount ofmedications
Increased safety, decreased side effects and likelihood oftoxicity
Monitor patient adherence
Protection against potential legal actions

Question 12

Lithium monitoring

Answer 12

-0.6-1.2 meq/L, Toxic at >1.5 meq/L
-Clinical Applications
-Increased efficacy of using an optimal amount ofmedications
-Increased safety, decreased side effects and likelihood oftoxicity
-Monitor patient adherence
-Protection against potential legal actions
Get a Lithium Level
-5 days after first dose, then at 3 months and 6 months
-EKG: Baseline and annually
-CBC: Baseline and annually
-Thyroid Panel: TSH every 6 months
-CMP
-Weight
-Urinalysis (kidney monitoring)

Question 13

Carbamazepine Blood level Monitoring

Answer 13

-Check 5-7 days after initial dose then at 1-4 weeks.
-Goal level 4-12 micrograms/L. Toxic levels are more than 12 mg/L or 10 mg/kg.
-Labs should be drawn Baseline and annually
-CBC with differential
-CMP
-Hepatic function test
-HLA-B1502 or HLA-A3101
(Asians, Native Amer, European, Latin America)
Monitor for Maculopapular Exanthema

Question 14

Maculopapular Exanthema

Question 15

Valproic Acid monitoring

Answer 15

85-125 mcg/ml, toxic >150 mcg/ml.
CBC with differential
CMP (creatinine, electrolytes)
Weight
VPA level
1-2 weeks after first dose, then after dose changes

Question 16

Gabapentin Monitoring

Answer 16

Neurontin serum levels not required
Renal function test

Question 17

Lamictal monitoring

Answer 17

Lamictal serum levels not required
Renal function test
Hepatic function test
CBC
Monitor for Stephen Johnson Syndrome

Question 18

Topiramate monitoriong(Topamax)

Answer 18

Topiramate (Topamax)
Baseline and annually
CBC with differential
Renal function
Hepatic function test
Eye Exam
Weight (q 3 months)

Question 19

Monitoring during Antipsychotic Treatment

Answer 19

EKG
Baseline and annually
Monitor for QT prolongation (>450ms)
BMI and Waist Circumference
Weight (in pounds) X 703/height (in inches)
AIMS Test
Baseline and q 3 months
Vision
Annually

Question 20

AIMS Test

Question 21

Clozaril monitoring

Answer 21

-250-350 mcg/ml, toxic more than 350 mcg/ml.
Weekly X 6 months
Every 2 weeks 6 months to 12 months
Monthly after 12 months

Question 22

Antipsychotic monitoring

Answer 22

CBC
Baseline and ongoing
Clozapine (Clozaril) Monitoring Guidelines
Weekly X 6 months
Every 2 weeks 6 months to 12 months
Monthly after 12 months

BMI and Waist Circumference
Weight (in pounds) X 703/height (in inches)
AIMS Test
Baseline and q 3 months
Vision: Annually

Question 23

Nortriptyline blood levels

Answer 23

50-150 mg/ml

Question 24

Imipramine blood levels

Answer 24

200-250 mg/ml, toxic more than 450 mg/ml

Question 25

Desipramine blood levels

Answer 25

110-180 mg/ml

Question 26

Amitriptyline blood levels.

Answer 26

150-250 mg/ml.

Question 27

How to get serum blood levels of psychotropics

Answer 27

-Instruct the patient to take the medication consistently forat least 4 days
-Measure the drug levels 12 hours after last medicationdose
-Do not take the medication the morning a blood draw is scheduled
-Fasting is not required prior to blood draw

Question 28

When to change frequency of blood monitoring

Answer 28

Clinical relapse
Addition or discontinuation a new medication that may interact with the prescribed psychotropic
Onset of new side effects
Hospitalization or institutionalization
Non-compliance

Question 29

PMHNP application of clinical judgment in medication monitoring

Answer 29

-Clinical observation is critical
-Monitor patient’s functioning status
-Monitor patient’s emotional state
-Assess for side effects on each visit
-Evaluate the need for higher doses
-Subtherapeutic levels may work for certain patients