Psych

Question 1

clozapine REMS monitoring

Answer 1

Risk of severe neutropenia (< 500).

Initiate treatment if ANC > 1500 for general population or > 1000 for BEN patients and monitor weekly for 6 months, then every other week for 6 months, then monthly.

If ANC < 500, interrupt treatment and do not rechallenge. If rechallenged, treat as a “new” patient.

Question 2

Highest risk of QTc prolongation (FGA/SGA)

Answer 2

FGA: chlorpromazine, haloperidol (avoid IV use), thioridazine
SGA: clozapine, ziprasidone, and iloperidone

Question 3

Akathisia

Answer 3

restlessness - lower dose or change to an SGA with lower EPS risk.

Insufficient data on use of propranolol, but it is used
BZD’s can reduce sx but beware if substance abuse disorder.

Question 4

FDA approved tx for tardive dyskinesia

Answer 4

Valbenazine, deutetrabenazine (black box warning for increased risk of suicide)

Question 5

Neuroleptic malignant syndrome

Answer 5

Treat with bromocriptine or dantrolene. High mortality rate.

Question 6

Clozapine

Answer 6

Neutropenia
Seizures
OH/bradycardia/syncope
Myocarditis and cardiomyopathy

Can add lamotrigine in patients on clozapine with a partial response schizophrenia

Metabolized by CYP1A2, which is induced by smoking. So if smoking cessation, causes supratherapeutic levels.

Question 7

Aripiprazole

Answer 7

Akathisia
Pathological gambling

LAI requires 21 day overlap with PO agent

Low risk of hyperprolactinemia or EPS

Question 8

Asenapine

Answer 8

SL formulation
Hypersentivity reactions
Avoid eating or drinking for 10 minutes after administration
High risk of sedation/orthostasis

Question 9

Brexpiprazole

Answer 9

Schizopherenia/MDD
Akathisia, weight gain, and somnolence
Compulsive behaviors

Question 10

Cariprazine

Answer 10

Mixed/manic episodes type I bipolar
Low incidence of weight gain
Can cause GI sx, parkinsonism, and seizures.
Don’t use if CrCl < 30

Question 11

Iloperidone

Answer 11

Low risk of metabolic side effects

QTc prolongation

Question 12

Lurasidone

Answer 12

Low risk of metabolic/cardiac effects
Take with minimum of 350 calories of food
Adjust for renal, hepatic, and CYP3A4 inhibitors

Question 13

Olanzapine

Answer 13

High risk of diabetes
Olanzapine pamoate - LAI, REMS for delirium/sedation
Can only be administered in an approved institution

Question 14

Quetiapine

Answer 14

Somnolence, weight gain
Low risk of EPS

Also indicated for depression associated with bipolar

Question 15

Risperidone

Answer 15

Tolerated better than haloperidol
Weight gain, sexual dysfunction, hyperprolactinemia
Monthly SC injection, no PO overlap required

Question 16

Ziprasidone

Answer 16

QTc prolongation
Take with 500 calories of food
Warning - skin reactions such as eosinophila and systemic syndrome (DRESS)

Question 17

Schizophrenia

Answer 17

SGA > FGA
*SGA may reduce negative symptoms/affect mood due to additional serotonin effects

Can use benzo’s for acute phase (agitation/anxiety) but careful due to risk of substance abuse behaviors

Question 18

Dystonia

Answer 18

EPS - torticollis, laryngospam, oculogyric crisis.

Treated with anticholinergics

Question 19

Adjunctive treatment options for schizophrenia

Answer 19

Lamotrigine + clozapine for partial response

Benzo’s in initial phase for agitation/anxiety

Question 20

SSRI’s

Answer 20

ADE: Sexual dysfunction, insomnia, GI,

Increase risk of bleeding, increased incidence of bone fractures, hyponatremia in adults.

Question 21

Levomilnacipran

Answer 21

Approved for depression; SNRI

Causes hyponatremia/bleeding risk, BP elevations, OH, do not open capsule. CYP3A4 inhibitor.

Question 22

Vilazodone

Answer 22

Viibryd - SSRI
Max dose 40 mg, take with food
Lower incidence of sexual dysfunction
Do not use in hx of seizures

Question 23

Vortioxetine

Answer 23

Trintellix - SSRI, also improves cognitive function. Lower incidence of sexual dysfunction. Max daily dose is 20 mg.

Question 24

Serotonin syndrome

Answer 24

SNRI, SSRI, lithium, MAO, linezolid, dextromethorphan
Sx: neuromuscular (tremors, rigidity), AMS, autonomic instability.

Tx includes DC’ing offending agent, clonazepam for myoclonus, nifedipine for BP and anticonvulsants

Question 25

Lithium Drug Interactions - increase toxicity risk

Answer 25

Thiazides, furosemide, NSAIDs, ACEI's Renal dysfunction Dehydration, salt restriction (lithium can cause hyperkalemia and hyponatremia)

Question 26

Lithium Drug Interactions - low Li levels

Answer 26

Theophylline Lithium can result in hypothyroidism

Question 27

Buspirone

Answer 27

Used for anxiety, long onset of action (weeks). Must cover with another agent. Dosed 2-3 times per day

Question 28

GAD - first line agents

Answer 28

SSRI's - escitalopram, paroxetine, sertraline | SNRI's - duloxetine, venlafaxine XR

Question 29

PTSD - first line

Answer 29

SSRI's fluoxetine, sertraline, paroxetine Venlaxfaxine XR Use BZD's for sleep disturbances, but use is limited

Question 30

ADE for BZD's insomnia

Answer 30

``` Tolerance (effective for only 2-4 weeks) Residual daytime sedation Rebound insomnia Anterograde amnesia Withdrawal Risk of falls ```

Question 31

Eszopiclone

Answer 31

Lunesta Used for chronic insomnia, must take immediately before bed, sleep for 7-8 hours (hangover effects) Metallic taste in mouth

Question 32

Ramelteon

Answer 32

Melatonin agent Used for chronic insomnia, use long-term Does not prolong sleep, but reduces sleep latency.

Question 33

Suvorexant

Answer 33

Belsomra | Decreases sleep latency and promotes sleep maintenance. Take within 30 minutes of bedtime, at least 7 hours of sleep.

Question 34

Zaleplon

Answer 34

Similar to zolpidem, shortens onset to sleep but does not promote sleep time. Short half life/short-term maintenance.

Question 35

Zolpidem

Answer 35

Reduces sleep latency. | CR tablets can help with staying asleep.

Question 36

Disulfram

Answer 36

If alcohol is used with it, can develop sx Use with caution in liver dx Reserved for patients with high motivation for adherence

Question 37

Naltrexone

Answer 37

Reduces alcohol cravings BBW - hepatocellular injury Extended release formulation - Vivitrol Must be off of opioids for 7-10 days before administration of LAI (14 days if buprenorphine/methadone)

Question 38

Acamprosate

Answer 38

Not metabolized by the liver Taken TID Reduce for renal dysfunction

Question 39

Methadone

Answer 39

Opioid agonist - blocks the euphoric effects of other opioids. Long half life. Preferred in pregnancy QTc prolongation Significant drug interactions - metabolized by CYP3A4

Question 40

Buprenorphine/naloxone

Answer 40

4:1 dosing, gives "ceiling effect" while naloxone reduces abuse potential. Drug interactions with CYP3A4 Taper patient to methadone 30mg/equivalent or less before initiation. 12-24 hours after last dose of short-acting opioid. First dose given in office (4/1 dose) and observed for 2 hours. If withdrawl sx not relieved, administer another 4/1 and maintenance dose will be 8/2. Adjust based on withdrawl sx, max is 32/8. Can continue indefinitely, or DC by tapering.

Question 41

NRT

Answer 41

If > 10 cigs per day, start with 21mg patch x 2 weeks. If less, start with 14mg patch. Chew between 9-24 pieces of gum. Pts > 25 cigs/day start with 4mg dose. Lozenges - if smoke within first 30 minutes of wakening - 4mg. Max 20 lozenges in 24 hours

Question 42

Bupropion SR (Smoking Cessation)

Answer 42

- Initiate 7 days prior to quit date | - Tx for a minimum of 8 weeks, continue for up to 6 months

Question 43

Varenicline

Answer 43

Nicotine receptor partial agonist. Start 1 week before quit date (or up to 35 days). Continue for a total of 12 weeks. BBW for depression, suicide, pyschosis, etc. Use with caution in CrCl < 30mL/min