RECALL: pharmacology + ECT Flashcards
how do you treat lithium induced tremor
propanolol
“1. Young guy being treated with aripiprazole 15 mg for psychosis. Becomes depressed. Started on bupropion. Mood improves but now pacing, agitated, can’t sleep. What do you do?
a) decrease aripiprazole
b) stop bupropion
c) start propranolol
d) dimenhydrinate or diphenhydramine??”
A) decrease abilify
–> related to 2D6 inhibition by buproprion, and abilify is 2D6 substrate–> leads to higher abilify effective dose and thus akathesia
“101) What medication causes a differential in activation of 5HT1 and 5HT2?
a. Moclobemide
b. Mirtazapine
c. Citalopram
d. Amitriptyline”
“B) Mirtazapine = TRUE
Mirtazapine is a NaSSA. Antagonism at 5HT2, 5HT3, alpha-2, H1. It doesn’t directly act on 5HT1, thus, there is a differential in activation of 5HT1 and 5HT2. The other 3 either block SERT or MAO, which increases serotonin overall, acting on BOTH 5HT2 and 5HT1.
A) FALSE. RIMA
B) TRUE
C) FALSE. SSRI
D) FALSE. TCA (SERT blockade)”
“108. Which of the following neurotransmitters is responsible/involved in withdrawal from alcohol and benzodiazepines?
a. Glutamate
b. GABA
c. Norepinephrine
d. Dopamine”
“A) Glutamate
technically imbalance of too much glumate and too little GABA”
“108. Young man is admitted for schizophrenia and is started on haloperidol 10mg. He develops restlessness and is constantly pacing around. He feels like he needs to constantly move. What do you prescribe to help him?
A) Propranolol
B) Benztropine
C)
D)”
“A) Propanolol
Akathisia.
Tx per UTD:
- 1st line: Propanolol - 10 mg BID start, gradually (eg q7 d) to 40-60 mg BID
- 2nd line: Benzos (but more sx management)
- 3rd line: Benztropine (but why tho, more of a ““hope”” that dystonia related)
- Promising: Mirtazapine”
“108) Atomoxetine for a child. What is most important to disclose to the parent (or patient)?
a) increased suicidal thinking
b) increased BP
c) smaller effect size compared to stimulant”
“A) Increased suicidal thinking
Atomoxetine monograph has black box warning about increased SI in kids and adolescents with ADHD”
“11) 32 year old guy on methylphenidate for years for ADHD. On bupropion. for depression. On yohimbine. On trazodone for sleep. Which med is causing his sexual dysfunction?
a) yohimbine
b) bupropion
c) methylphenidate
d) trazodone”
“B) Bupropion
Discussed in review course
- Bupropion has highest rate of ““sexual side effects”” (surprisingly)
BUT, methylphenidate specifically mentions ““erectile dysfunction, so… ugh
A) FALSE. Purported to improve sexual dysfunction…but limited data
B) TRUE (surprisingly)
C) FALSE / LESS TRUE.
D) FALSE. Though among serotonergic agents, trazodone actually has relatively lower risk of sexual dysfunction (despite priapism risk).”
“114. Older man begins waking up in his sleep and eating, sleepwalking. He does not have good recollection of these episodes. Which medication is most likely causing these symptoms?
A) Citalopram
B) Zolpidem
C) Lorazepam
D) Mirtazapine (?)”
zolpidem
“115) where is the most concentration of dopamine in the brain?
a) amygdala
b) caudade nucleus
c) substantia nigra”
“B) Caudate
Highest concentration of dopamine is found in striatum (caudate and putamen)”
“117. What is therapeutic level of clozapine (different values recalled) - same in French exam:
a. 100-400
b. 500-800
c. 1000-1500
d. 2500-4000”
“C) 1000-1500 = TRUE
Depends on the units. Different version specifiies nmol/L. CPA Schizophrenia guideline says serum level of > 1100 nmol/L is considered adequate trial.
There is variability online in terms of recommended clozapine level. Most seem to say 300-450 ng/mL (900-1350 nmol/L)”
“121. Atypical antipsychotics:
a. 5HT1A < DA
b. 5HT2A > DA
c. 5HT2C > DA
d. 5HT3 ? DA
Other version: Most atypical antipsychotics are:
e. 5HT agonists > DA antagonists
f. 5HT antagonists > DA antagonists
g. DA antagonists > 5HT agonists
h. DA antagonists > 5HT antagonists”
“B) 5HT2A > DA = TRUE
F) TRUE
Atypicals have much higher affinity for 5HT2A receptor than for D2; this is the definition of ““atypical.”” The reverse is true for typicals. “
“126. Lady has been on paroxetine for years and abruptly discontinued it. What symptoms will she most likely present with?
A) Insomnia, nausea, headache
B) Sedation, runny nose, sore eyes
C) Tachycardia, torsades de pointe
D)”
“A) Insomnia, nausea, headache
"”FINISH”” mneumonic for SSRI discontinuation syndrome
F = Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating)
I = Insomnia (with vivid dreams or nightmares)
N = Nausea (sometimes vomiting)
I = Imbalance (dizziness, vertigo, lightheadedness)
S = Sensory disturbances (““burning,”” ““tingling,”” ““electric-like”” or ““shock-like”” sensations)
H = Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness)”
“128. What is true about medications in children vs adults?
A) Children have slower metabolism in general
B) Children have lower body water so they need lower doses
C) Children have poor oral absorption (other version: higher oral absoprtion)
D) Children generally require higher weight adjusted doses compared to adults”
“D) Children generally require higher weight adjusted doses compared to adults
Think tylenol weight adjustment.
Larger brain/body weight ratio, thus dosing in kids requires more adjusting per their weight vs adults.
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884865/
A) FALSE. Children have FASTER metabolism.
(Dean Elbe, BCCH)
B) FALSE. Children have higher body water.
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3857037/
C = FALSE. ““Beyond infancy, GI transit time, gastric pH
and oral drug absorption similar to adult”” -Dean. Own research says diff stuff.
D) TRUE. “
“150. Woman is being treated with psychotropic medication presents hyponatremic and with increased urine osmolality. Which agent is most likely to have caused this?
a. Lithium
b. Sertraline
c. Epival”
“B) Sertraline = TRUE
SIADH assoc with SSRI/SNRIs.
SIADH : ““Syndrome of inappropriate antidiuretic hormone (SIADH) is defined as euvolaemic, hypotonic hyponatraemia secondary to impaired free water excretion, usually from excessive arginine vasopressin (AVP) release.””
SSRIs can induce SIADH with hyponatremia. Risk increases with age (32% incidence), Female sex, low body weight, smoking, concomitant diuretic use.
A) FALSE.
B) TRUE
C) FALSE”
“151. Which of the following interferes the least with OCP (oral contraceptive pill)?
a. Epival
b. Lamotrigine
c. Carbamazepine
d. Topiramate”
“A) Epival = best answer
A) TRUE. OCP may decrease concentration of valproate - rating C
B) OCP induces metabolism of lamotrigine - rating D
C) CBZ induces metabolism of OCP - rating D
D) Topiramate induces metabolism of OCP - rating D
When interaction occurs, efficacy of OCP decreases and unplanned pregnancy can result.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848501/”
“153. You are treating a 45 year-old woman with metastatic breast cancer. She has depressive symptoms, anxiety, severe nausea, anorexia and sleep complaints. Which of the following would be the best pharmacological agent for her depressive and anxious symptoms?
a. Citalopram
b. Mirtazapine
c. Venlafaxine
d. Fluoxetine”
“B) Mirtazapine
Nausea → mirtazapine has 5HT3 blockade
It helps with sleep, nausea, and appetite, and the others don’t have those properties.
Even if in canadian guidelines for depression and anxiety, only venlafaxine come as first level of evidence/ first line for both – but there’s not a lot of difference between them.”
“156. Mechanism of action of Varenicline
a. Cholinergic receptor α4 β2 partial agonist
b. Cholinergic receptor α4 β2 antagonist
c. Partial agonist α3 β2”
“A) Cholinergic receptor α4 β2 partial agonist = TRUE
Partial neuronal α4 β2 nicotinic receptor agonist; prevents nicotine stimulation of mesolimbic dopamine system associated with nicotine addiction. Varenicline stimulates dopamine activity but to a much smaller degree than nicotine does, resulting in decreased craving and withdrawal symptoms.
A) TRUE
B) FALSE
C) FALSE”
“16- Recently referred an elderly woman (80 y/o) taking Citalopram 40 mg. Stable mild renal failure. Doing well. What first investigations as family doctor.
a. Do lytes
b. Do bone densitometry
c. EKG
d. CBC”
“C) ECG = true
First step
Monitor for QTc prolongation given higher dose
A) FALSE-> Hyponatremia usually presents within 2 weeks of drug initiation in elderly and would most likely be symptomatic
B) FALSE-> No increased risk of osteoporosis but increased risk of impaired balance & falls
C) TRUE -> *Limit dose of citalopram to 20mg/day in elderly due to risk of QT prolongation.
D) FALSE-> No clear gains to follow CBC”
“162. 13. Patient with SCZ on Clozapine, which medication is most likely to interact with clz?
a. Fluvoxamine
b. Paroxetine
c. Citalopram
d. Venlafaxine
“
“A) Fluvoxamine = TRUE
Fluvoxamine is a 1A2 inhibitor. Clozapine is mainly a 1A2 substrate (minor 3A4, some 2D6). Clozapine level would rise with fluvoxamine.
Clozapine serum concentrations were an average of 1.4- to 2.6-fold higher with concurrent administration of the strong CYP1A2 inhibitor fluvoxamine, with increases in clozapine serum concentrations (or dose-normalized concentrations) of at least 5-fold in individual subjects/patients, in several studies of this combination.
A) TRUE
B) FALSE. Paroxetine is mainly a 2D6 inhibitor
C) FALSE. Citalopram has limited CYP interactions
D) FALSE. Venlafaxine is mainly a 2D6 inhibitor (weak)
“
“188. Mechanisms of action of mirtazapine, all EXCEPT:
a. alpha2 Antagonist
b. 5 HT2 Antagonist
c. Reduces noradrenaline
d. Anti-H1”
“C) Reduced noradrenaline = FALSE
Mirtazapine is a NaSSA. Antagonist at alpha2, 5HT2, 5HT3, H1.
A) TRUE
B) TRUE
C) FALSE. Increases NE via alpha-2 blockade (autoreceptor).
D) TRUE
Mirtazapine is part of the group tetracyclic antidepressants (TeCA) that work by exerting antagonist effects on the central presynaptic alpha-2-adrenergic receptors, which causes an increased release of serotonin and norepinephrine.
potent antagonist of H1 histamine receptors (producing a sedating, calming effect) and 5-HT2A, 5-HT2C, and 5-HT3 serotonin receptors. “
“19. You are treating a 45 year-old woman with metastatic breast cancer. She has depressive symptoms, anxiety, severe nausea, anorexia and sleep complaints. Which of the following would be the best pharmacological agent for her depressive and anxious symptoms?
a. Citalopram
b. Mirtazapine
c. Venlafaxine”
“B) Mirtazapine = TRUE
Nausea → mirtazapine has 5HT3 blockade (Nausea/vomiting in a variety of clinical scenarios including cyclical vomiting syndrome; longer half-life and decreased cost relative to traditional 5‑HT3 antagonists but formal comparative trials are lacking) + may help for insomnia & anorexia
A) Citalopram = False
but following cochrane review below– might have safest profile but alternate effects profile doesn’t match clinical picture as well
C) Venlafaxine = FALSE
but can be prefered for cancer patients given benefits for hot flashes/ vasomotor sx (Hot flashes in menopausal women – double-blind studies have shown reduction by venlafaxine (for women with natural or surgical menopause as well as a history of breast cancer), desvenlafaxine (natural or surgical menopause)[63], and open label study by duloxetine (for those with concurrent depression)[64])
Interestingly – Cochrane review 2018
Authors’ conclusions: Despite the impact of depression on people with cancer, the available studies were very few and of low quality. This review found very low certainty evidence for the effects of these drugs compared with placebo. On the basis of these results, clear implications for practice cannot be deduced. The use of antidepressants in people with cancer should be considered on an individual basis and, considering the lack of head-to-head data, the choice of which agent to prescribe may be based on the data on antidepressant efficacy in the general population of individuals with major depression, also taking into account that data on medically ill patients suggest a positive safety profile for the SSRIs.
Nothing in CPA guidelines”
“20. Where does COMT act
a. Presynaptic
b. Postsynaptic
c. In vesicle
d. Interneuron space
e. Other version had as options:
synaptic cleft,
intracellular [was actually unclear if these were part of same answer or not]”
“B) Post-synaptic
Best ans = post-synaptic, membrane bound
2nd best = post-synaptic, intracellular
Background:
- 2 forms: MB-COMT (membrane bound), S-COMT (soluble)
- MB is the one far more in CNS
- MB-COMT definitely on post-synaptic membrane
-COMT possibly IN glial/astrocyte cells (dno form), which are in synaptic cleft, but it’s not as if COMT is floating around in the synaptic cleft (e.g. like acetylcholinesterase would be)
.:
- PRESYNAPTIC: definitely wrong
- VESICLES: definitely wrong
- SYNAPTIC CLEFT/INTERNEURON SPACE: wrong. this would imply that the soluble form is bumbling around the synaptic cleft. if it’s there, it’s in a cell
- POSTSYNAPTIC: bestanswer
- INTRACELLULAR: second best answer”
