Scientific Foundation & Advanced Practice Flashcards
1
Q
Lithium Levels
A
0.6-1.2 mEq/L
2
Q
What is the gold standard to treating mania?
A
Lithium
3
Q
Which mood stabilizer has evidence of anti-suicidal effects?
A
Lithium. It is the neuroprotective treatment of choice for Bipolar D/O.
4
Q
What level can Lithium toxicity occur?
A
1.5 mEq/L or higher
5
Q
What are the baseline labs to initiate Lithium?
A
- 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
6
Q
How can enzyme inDucers alter pharmacokinetics?
A
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
7
Q
How can enzyme inHibitors alter pharmacokinetics?
A
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
8
Q
What are some S&S of Lithium toxicity?
A
- Severe nausea
- Vomiting
- Diarrhea
- Confusion
- Convulsions
- Drowsiness
- Blurred vision
- Slurred speech
- Muscle weakness
- Heart palpitations
- Coarse hand tremors
- Unsteadiness while standing and walking (ataxia)
9
Q
What do you do if a patient has Lithium toxicity?
A
- Immediately D/C Lithium
- Check their serum lithium levels
10
Q
What are some clinically significant side effects of lithium?
A
- Fine hand tremors
- Coarse hand tremors with toxicity
- GI upset becomes severe
- Leukocytosis – Lithium can increase WBC so MONITOR CBC
11
Q
What is the BBW for Carbamazepine (Tegretol)?
A
- Agranulocytosis (decreased WBCs)
- Aplastic anemia (pallor, fatigue, headache, fever, nose bleeds, bleeding gums, skin rash, shortness of breath)
12
Q
What is a major side effect to watch out for with Carbamazepine (Tegretol)?
A
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
13
Q
What is Stevens-Johnson Syndome (SJS)?
A
SJS is a rare, potentially life-threatening immune reaction to a foreign antigen that can occur with exposure to any anticonvulsant drug.
14
Q
How do you treat SJS?
A
Treatment includes stopping the offending agent with supportive measures, often in a hospital burn unit.
15
Q
What are the S&S of SJS?
A
- 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
16
Q
What is the BBW for Valproic Acid/Divalproex Sodium?
A
- Hepatotoxicity
- Pancreatitis
17
Q
What is the BBW for Lamotrigine?
A
- Serious rash
- SJS but does not have HLA-B1502 screening
18
Q
What are the drugs used for mood disorders?
A
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
19
Q
What should be checked before starting a female patient of childbearing age (12-51 yo) on a psychotropic medication?
A
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
20
Q
Lithium & Pregnancy
A
- Ebstein’s Anomaly – heart defect
- Avoid in pregnancy, especially the first trimester
21
Q
What to monitor when a patient is on Lithium?
A
- Risk for hypothyroidism
- Kidney function is important
- Concurrent use of NSAIDs and ACE inhibitors may DOUBLE lithium level
22
Q
What to monitor when a patient is on Carbamazepine?
A
Monitor LFTs
23
Q
Valproic Acid & Pregnancy
A
Neural tube defects
24
Q
Which mood stabilizer can cause SIADH?
A
Carbamazepine
- SIADH – syndrome of inappropriate antidiuretic hormone secretion
- SIADH is impaired water excretion leading to hyponatremia with hypervolemia or euvolemia
25
When does a hypertensive crisis occur?
It occurs when a MAOI is taken in conjunction with foods containing tyramine
26
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
27
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**
28
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**
29
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
30
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
31
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
32
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
33
What is the normal ANC level?
2,500 - 6,000
34
What is the normal range of WBCs in blood?
4,500 to 11,000 WBC per microliter
35
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)**
36
Explain the management of **Clozaril**?
- Monitor ANC labs
- **First 6 months: weekly**
- **Second 6 months: Q2weeks**
- **Then monthly if ANC is normal**
37
What are the BMI categories?
- **Underweight: <18.5**
- **Normal weight: 18.5 - 24.9**
- Overweight: 25 - 29.9
- Obesity: 30 or greater
38
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**
39
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
40
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)
41
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**
42
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)
43
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
44
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
45
What is the appropriate medication to prescribe for someone with **depressed/low energy/fatigue**?
- **NDRI (Norepinephrine Dopamine Reuptake Inhibitor)**
-- **Wellbutrin**
46
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**
47
What type of antidepressants help with chronic neuropathic pain?
SNRIs (Duloxetine)
48
Which atypical antipsychotic is metabolized by the cytochrome P450 enzyme CYP1A2?
**Clozapine (Clozaril)**
49
NSAIDs, thiazides, ACE inhibitors
Reduce renal clearance which can increase concentration of drugs
50
Inducers Mnemonic:
**B**ull**S**hit **CRAP** **GPS** INDUCES my rage!
- **B**arbiturates
- **S**t. John's Worts
- **C**arbamazepine
- **R**ifampin
- **A**lcohol (chronic)
- **P**henytoin
- **G**riseofulvin
- **P**henobarbital
- **S**ulfonylureas
- **Plus cigarette smoking**
51
Inhibitors Mnemonic:
**SICKFACES.COM**
- **S**odium Valproate
- **I**soniazid
- **C**imetidine
- **K**etoconazole
- **F**luconazole
- **A**lcohol (acute)
- **C**hloramphenicol
- **E**rythromycin
- **S**ulfanomide
- **C**iprofloxacine
- **O**meprazole
- **M**etronidazole
52
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
53
Which part of the brain regulates and receives pain?
Prefrontal cortex
54
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)
55
Left Hemisphere
- Dominant in most people
- Logical, analytical side
56
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
57
What is the corpus callosum?
- Large bundle of white matter that connects the two cerebral hemispheres
-- communication between hemispheres
58
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
59
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**
60
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
61
Parietal Lobe
- **Primary sensory area**
- Taste
- Reading and writing
- Problems in this area can lead to sensory-percetual disturbances and agnosia
62
Limbic System
- Essential system for the *regulation* and modulation of *emotions* and *memory*
- Composed of the hypothalamus, thalamus, hippocampus, and the amygdala
63
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*
64
Thalamus
- Sensory relay station except for smell
- Modulates flow of sensory information to prevent overwhelming the cortex
- Regulates emotions, memory, and related affective behaviors
65
Hippocampus
Regulates memory and converts short-term memory into long-term memory, *regulates motivation, stress, emotions, and learning*
66
Amygdala
- Responsible for *mediating mood, fear, emotional memories, aggression, anxiety, anger, and emotions*
- Responsible for connecting sensory smell information with emotions
67
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
