Scientific Foundation & Advanced Practice Flashcards
Lithium Levels
0.6-1.2 mEq/L
What is the gold standard to treating mania?
Lithium
Which mood stabilizer has evidence of anti-suicidal effects?
Lithium. It is the neuroprotective treatment of choice for Bipolar D/O.
What level can Lithium toxicity occur?
1.5 mEq/L or higher
What are the baseline labs to initiate Lithium?
- Thyroid panel – assess for hyperthyroid which can mimic mania.
- Serum creatinine
- Blood urea nitrogen (BUN)
- Pregnancy test – do no want female patients on this while pregnant
- ECG for >50 yo – cardiac side effects
How can enzyme inDucers alter pharmacokinetics?
Enzyme inducers can DECREASE the serum level of other drugs that are substrates of that enzyme – can cause sub therapeutic drug levels
- I.E. tobacco and carbamazepine
- Example: X dose of Olanzapine (Zyprexa)
– Start smoking = increase dose of Olanzapine
– Stop smoking/start smoking cessation program = decrease dose
How can enzyme inHibitors alter pharmacokinetics?
Enzyme inhibitors can INCREASE the serum level of other drugs that are substrates of that enzyme – causing toxic levels.
- I.E. Clarithromycin & Ketonazole
- Think inHibitor – think High
What are some S&S of Lithium toxicity?
- Severe nausea
- Vomiting
- Diarrhea
- Confusion
- Convulsions
- Drowsiness
- Blurred vision
- Slurred speech
- Muscle weakness
- Heart palpitations
- Coarse hand tremors
- Unsteadiness while standing and walking (ataxia)
What do you do if a patient has Lithium toxicity?
- Immediately D/C Lithium
- Check their serum lithium levels
What are some clinically significant side effects of lithium?
- Fine hand tremors
- Coarse hand tremors with toxicity
- GI upset becomes severe
- Leukocytosis – Lithium can increase WBC so MONITOR CBC
What is the BBW for Carbamazepine (Tegretol)?
- Agranulocytosis (decreased WBCs)
- Aplastic anemia (pallor, fatigue, headache, fever, nose bleeds, bleeding gums, skin rash, shortness of breath)
What is a major side effect to watch out for with Carbamazepine (Tegretol)?
Stevens-Johnson syndrome (particularly in Asian) – screen for HLA-B 1502 allele before initiating – HLA-B*1502 is highly associated with the outcome of carbamezapine-induced SJS
What is Stevens-Johnson Syndome (SJS)?
SJS is a rare, potentially life-threatening immune reaction to a foreign antigen that can occur with exposure to any anticonvulsant drug.
How do you treat SJS?
Treatment includes stopping the offending agent with supportive measures, often in a hospital burn unit.
What are the S&S of SJS?
- Facial swelling
- Tongue swelling
- Macules, papules, and “burning,” confluent erythematic rash
- skin sloughing
- prodromal headache, malaise, arthralgia, and painful mucous membranes may occur before rash occurs
What is the BBW for Valproic Acid/Divalproex Sodium?
- Hepatotoxicity
- Pancreatitis
What is the BBW for Lamotrigine?
- Serious rash
- SJS but does not have HLA-B1502 screening
What are the drugs used for mood disorders?
Anticonvulsants:
1. Lithium
2. Carbamazepine/Tegretol – Alternate to lithium & valproic acid
3. Valproic Acid/Depakote – effective for rapid cycling and mixed bipolar
4. Lamotrigine/Lamictal – maintenance only, helps in depressive phase of bipolar
5. Topamax – can be used as well but can cause kidney stones
What should be checked before starting a female patient of childbearing age (12-51 yo) on a psychotropic medication?
Check pregnancy status (human chorionic gonadotropin (HCG))
- Folic acid supports neural tube development during the first month that a woman is pregnant – take 0.4 - 0.8 mg daily
Lithium & Pregnancy
- Ebstein’s Anomaly – heart defect
- Avoid in pregnancy, especially the first trimester
What to monitor when a patient is on Lithium?
- Risk for hypothyroidism
- Kidney function is important
- Concurrent use of NSAIDs and ACE inhibitors may DOUBLE lithium level
What to monitor when a patient is on Carbamazepine?
Monitor LFTs
Valproic Acid & Pregnancy
Neural tube defects
Which mood stabilizer can cause SIADH?
Carbamazepine
- SIADH – syndrome of inappropriate antidiuretic hormone secretion
- SIADH is impaired water excretion leading to hyponatremia with hypervolemia or euvolemia
When does a hypertensive crisis occur?
It occurs when a MAOI is taken in conjunction with foods containing tyramine
What is a hypertensive crisis?
When MAO is inhibited, tyramine exerts a strong vasopressor effect, stimulating the release of catecholamines, epinephrine, and norepinephrine, which can increase blood pressure and heart rate.
- It is life-threatening and can’t be reversed unless more MAO is made by the body
What medications can cause hypertensive crisis and death when taken with MAOIs?
- Meperidine
- Decongestants
- TCAs
- Atypical antipsychotics
- St. John’s wort
- L-tryptophan
- Stimulants and other sympathomimetics
- Asthma medications
- These are strictly prohibited in patients taking any MAOIs
What are symptoms of a hypertensive crisis?
- Sudden, explosive-like headache, usually in occipital region
- Elevated blood pressure
- Facial flushing
- Palpitations
- Pupillary dilation
- Diaphoresis
- Fever
What is the treatment for a hypertensive crisis?
- Discontinue the MAOI
- Give phentolamine (binds with norepinephrine receptor sites/blocks norepinephrine
- Stabilize fever
- Reevaluate the patient’s diet and adherence, reiterate medication guidelines as necessary
What foods have tyramine in them?
- Cheese: aged cheeses (blue, brie, Camembert, Roquefort)
- Meat: smoked, aged, cured (sausages, pastrami, salami)
- Fish: smoked, aged, cured (pickled herring, salted fish)
- Beverages: aged, fermented (red wine, aged liquors, whiskey, beer)
- Other: bean curd (tofu), soy products, sauerkraut, miso, yeast extract, MSG, ripe bananas, avocado
What are the teratogenic risks of common psychiatric medications?
- Benzodiazepines – floppy baby syndrome, cleft palate
- Carbamazepine – neural tube defect
- Lithium – Ebstein’s anomaly
- Divalproex/Depakote – neural tube defect, specifically spina bifida, atrial septal defect, cleft palate, and possible long-term developmental defects
What is the association between Clozaril & Carbamazepine with neutropenia?
- There is a risk for neutropenia.
- Absolute neutrophil count (ANC) needs to only be monitored for neutropenia, NOT in conjunction with WBC
What is the normal ANC level?
2,500 - 6,000
What is the normal range of WBCs in blood?
4,500 to 11,000 WBC per microliter
When do you D/C Clozaril/Carbamazepine?
- ANC less than 1000 mm3 (bc of risk of neutropenia)
- WBC of 2,000 to 3,000 (bc of risk of agranulocytosis)
- Monitor for signs of infection (sudden fever, chills, sore throat, weakness)
Explain the management of Clozaril?
- Monitor ANC labs
- First 6 months: weekly
- Second 6 months: Q2weeks
- Then monthly if ANC is normal
What are the BMI categories?
- Underweight: <18.5
- Normal weight: 18.5 - 24.9
- Overweight: 25 - 29.9
- Obesity: 30 or greater
What is bulimia nervosa?
- Recurrent, episodic binge eating
- Both binge eating and inappropriate compensatory behaviors occur at least 2x weekly for 3 months
- BMI is usually within normal range
What are the recurrent, inappropriate compensatory behaviors that occur to prevent weight gain with bulimia?
- Self-inducing vomiting
- Laxatives
- Enemas
- Diuretics
- Stimulants
- Abuse of diet pills
- Fasting
- Excessive exercise
What are the two types of bulimia?
- Purging type: regularly engage in purging or the misuse of laxatives, enemas, or diuretics
- Nonpurging type: use other inappropriate compensatory behaviors (fasting, excessive exercise without engaging in purging as mentioned above)
What are some physical exam findings in bulimia?
- Weight is within normal limits
- Erosion of dental enamel
- Russell’s sign
- Hypertrophy of salivary glands
- Rectal prolapse
What are some physical exam findings in anorexia nervosa?
- Low body mass index
- Amenorrhea
- Emaciation (being abnormally thin)
- Erosion of dental enamel (repeated self induced vomiting)
What are the pharmacological management of eating disorders?
- Med management is adjunctive therapy to psychotherapy
- There is no specific medication for anorexia nervosa
- Fluoxetine is FDA-approved for bulimia nervosa
- SSRIs and TCAs are effective in reducing the frequency of bingeing and purging
- Treat associated symptoms (depression, anxiety) with appropriate pharmacological therapy
What are the nonpharmacological management of eating disorders?
- Medical and nutritional stabilization
– weight restoration
– correction of electrolyte disturbance
– vitamin supplementation
– nutrition counseling - Psychotherapeutic interventions
– individual psychotherapy
– behavioral therapy
– cognitive behavioral therapy (overcome distorted thinking)
– family therapy
– group therapy
What is the appropriate medication to prescribe for someone with depressed/low energy/fatigue?
-
NDRI (Norepinephrine Dopamine Reuptake Inhibitor)
– Wellbutrin
What type of patient is Wellbutrin contraindicated in?
- Seizure disorders/history of seizures
-
Conditions that increase the risk of seizures (anorexia nervosa, bulimia)
– increases seizure risks by decreasing seizure threshold
What type of antidepressants help with chronic neuropathic pain?
SNRIs (Duloxetine)
Which atypical antipsychotic is metabolized by the cytochrome P450 enzyme CYP1A2?
Clozapine (Clozaril)
NSAIDs, thiazides, ACE inhibitors
Reduce renal clearance which can increase concentration of drugs
Inducers Mnemonic:
BullShit CRAP GPS INDUCES my rage!
- Barbiturates
- St. John’s Worts
- Carbamazepine
- Rifampin
- Alcohol (chronic)
- Phenytoin
- Griseofulvin
- Phenobarbital
- Sulfonylureas
- Plus cigarette smoking
Inhibitors Mnemonic:
SICKFACES.COM
- Sodium Valproate
- Isoniazid
- Cimetidine
- Ketoconazole
- Fluconazole
- Alcohol (acute)
- Chloramphenicol
- Erythromycin
- Sulfanomide
- Ciprofloxacine
- Omeprazole
- Metronidazole
What are the lobes of the brain and their responsibilities?
- Frontal Lobe: thinking, planning, problem solving, emotions, behavioral control, decision making
- Parietal Lobe: perception, object classification, spelling, knowledge of numbers, visuospatial processing
- Temporal Lobe: memory, understanding language, facial recognition, hearing, vision, speech, emotion
- Occipital Lobe: vision, visual processing, color identification
- Cerebellum: gross and fine motor skills, hand eye coordination, balance
- Brain Stem: regulates body temperature, heart rate, swallowing, breathing
Which part of the brain regulates and receives pain?
Prefrontal cortex
What is the cerebrum?
- Largest part of the brain
- Divided into 2 halves
– Right cerebral hemisphere
– Left cerebral hemisphere
– Each hemisphere is divided into 4 major lobes (frontal, temporal, occipital, parietal lobes)
Left Hemisphere
- Dominant in most people
- Logical, analytical side
Right Hemisphere
- Controls most left-sided body functions
- Facial expression, recognition, aspects of musical and visual processing
- Impairment in this area can affect tasks such as clock drawing
What is the corpus callosum?
- Large bundle of white matter that connects the two cerebral hemispheres
– communication between hemispheres
Frontal Lobe
- Largest and most developed
- Functions:
–motor function (voluntary motor activity)
– premotor area (coordinates movement of multiple muscles)
– association cortex (trigger memory and decision-making)
– seat of executive functions (working memory, reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgement, impulse control, behavioral cueing, intelligence, abstraction)
– language (Broca’s area): expressive speech
– personality variables (personality development) - Problems in this area can lead to personality changes, emotional, and intellectual changes
Temporal Lobe
- Language (Wernicke’s area): receptive speech or language comprehension
- Primary auditory area
- Memory
- Emotion
- Integration of vision with sensory information
- Problems in this area can lead to visual or auditory hallucinations, aphasia, and amnesia
Occipital Lobe
- Primary visual cortex
- Integrates vision with other sensory info
- Problems in this area can lead to visual field defects, blindness, and visual hallucinations
Parietal Lobe
- Primary sensory area
- Taste
- Reading and writing
- Problems in this area can lead to sensory-percetual disturbances and agnosia
Limbic System
- Essential system for the regulation and modulation of emotions and memory
- Composed of the hypothalamus, thalamus, hippocampus, and the amygdala
Hypothalamus
Plays key role in various regulatory functions: appetite, sensations of hunger and thirst, water balance, circadian rhythm, body temperature, libido, hormonal regulation, and satiety
Thalamus
- Sensory relay station except for smell
- Modulates flow of sensory information to prevent overwhelming the cortex
- Regulates emotions, memory, and related affective behaviors
Hippocampus
Regulates memory and converts short-term memory into long-term memory, regulates motivation, stress, emotions, and learning
Amygdala
- Responsible for mediating mood, fear, emotional memories, aggression, anxiety, anger, and emotions
- Responsible for connecting sensory smell information with emotions
What is the clock drawing test (CDT)?
- Screens for signs of neurological problems such as Alzheimer’s and other dementias
- Also used to assess executive function and cognitive dysfunction
- Only requires a minute or two for completion
- Impairments on the CDT can be associated with damage to the Right Parietal Lobe (Right Hemisphere)
-
Constructional apraxia: an inability or difficulty to build, assemble, or draw objects
– may be caused by lesions in the parietal lobe following a stroke or it may serve as an indicator for Alzheimer’s disease
