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Flashcards in 54. Depression Deck (71):
1

Frank is a 45 year-old male who recently lost his job. This has caused significant anxiety and depression. At first, he tried to just "be happy" but he is very low and has felt low for so long that he is having difficulty applying for work. He has asked for an antidepressant. His height is 5'10", and weight is 199 pounds, blood pressure 155/92 mmHg, pulse 86 BPM. Current medications are Adderall XR and a multivitamin. Choose the safest option for Frank:

A. Duloxetine
B. Escitalopram
C. Venlafaxine
D. Parnate
E. Nardil

B. Frank has elevated blood pressure. The SNRIs, such as venlafaxine, duloxetine and desvenlafaxine can raise blood pressure. They are not contraindicated in hypertension; however, his blood pressure is not controlled at the present time. The stimulants are contraindicated with monoamine oxidase inhibitors. Although the MAO Is are not commonly used, they are used, and if a drug interaction is missed, it could be a fatal mistake.

2

Paroxetine comes in various formulations. Which of the following are brand names of paroxetine? (Select ALL that apply.)

A. Prozac
B. Paxil
C. Brisdelle
D. Viibrid
E. Pexeva

B, C, E. Paroxetine is used for depression, different types of anxiety, PMDD, PTSD and vasomotor symptoms of menopause.

3

A patient gave the pharmacist a prescription for Zoloft 100 mg daily. Which of the following is an appropriate generic substitution for Zoloft?

A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Paroxetine
E. Sertraline

E. The generic name for Zoloft is sertraline.

4

A patient gave the pharmacist a prescription for Viibrid. Which of the following is the correct generic name for Viibrid?

A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Vortioxetine
E. Vilazodone

E. The generic name of Viibrid is vilazodone.

5

Briana has suffered with depression for years, which she describes as "coming on every year, once or twice, lasting a few months, and making me miserable. I don't want to live when I'm that low." Her medications are listed below. Which medications could be contributing to her depressive symptoms? (Select ALL that apply.)

A. Pegasys, for hepatitis C
B. Sulfamethoxazole-trimethoprim, taken daily for UTI prophylaxis
C. Methadone, used off-label for chronic pain
D. Varenicline, for smoking cessation
E. Lisinopril-HCT, for hypertension

A, C, D. Pegasys and PEG-Intron are common agents (interferon alpha-2a) used for hepatitis. A common side effect is depression (about 20%), along with many others. Varenicline is likely. Methadone is possible; this would be patient-specific.

6

A patient has been treated at the community hospital for osteomyelitis in the lower left extremity. The other medications that the patient uses chronically include Levitra, Oleptro, Symbyax, Novolin N, DiaBeta, Fortamet and Cozaar. The hospital infectious disease team has discharged the patient with a prescription for Zyvox 600 mg PO BID, to continue as an outpatient for 4 weeks.  Zyvox cannot be filled in this patient due to the concurrent use of the following medications:

A. Levitra, Oleptro, Fortamet, DiaBeta, Insulin
B. Oleptro, Symbyax
C. Levitra, Oleptro, Fortamet, Cozaar
D. Levitra, Oleptro, Symbyax
E. Levitra, Oleptro

B. The SSRIs are contraindicated with linezolid, methylene blue, pimozide (and some other strong QT prolongers), and the use of MAO Is. The SNRIs and related compounds, the tricyclics, trazodone (Oleptro) and bupropion are contraindicated with linezolid and methylene blue.

7

A patient is using Wellbutrin 100 mg TID for depression. He told his doctor that he feels better, but not quite good enough. The prescriber calls the pharmacy to increase the prescription to Wellbutrin SR 200 mg TID. The pharmacist should relay the following information to the prescriber: (Select ALL that apply.)

A. The prescription cannot be filled; the dose is too high.
B. The maximum dose/day is 450 mg (Wellbutrin and generics) or 522 mg maximum daily dose if using Aplenzin.
C. The correct thing to do would have been to reduce the dose of bupropion and add on phenelzine.
D. Doses of bupropion above 300 mg daily put the patient at risk for seizures.
E. He can use only up to 200 mg of bupropion daily.

A, B. Do not use this agent in patients at risk for seizures, which includes having a past history of seizures, or having current seizures. If phenytoin is in the patient profile it indicates seizure presence or risk. Phenytoin is not used for other indications.

8

Sean has been prescribed doxepin 200 mg daily for depression. He should be counseled on the following possible side effects:

A. Orthostasis/dizziness
B. Dry mouth
C. Blurry vision
D. Urinary retention
E. Diarrhea

A, B, C, D. The tricyclics cause "cardiac" side effects, such as QT prolongation and orthostasis, and "anticholinergic" side effects, such as dry mouth, constipation and urinary retention. They can also cause vivid dreams, particularly with therapy initiation or during up-titration.

9

Which of the following items are contraindicated with monoamine oxidase inhibitors? (Select ALL that apply.)

A. Tricyclic antidepressants
B. Foods rich in tyramine, including many foods that are smoked, aged, pickled or fermented
C. Guaifenesin
D. Venlafaxine and desvenlafaxine
E. Fluoxetine and paroxetine

A, B, D, E. MAOIs cannot be used with many other drugs-the drugs will not be broken down and the interaction could be fatal. MAOIs cannot be used with tyramine-rich foods, including aged cheese, pickled herring, yeast extract, air-dried meats, sauerkraut, soy sauce and some red wines and beers. Foods can become high in tyramine when they have been aged, fermented, pickled or smoked.

10

What is the mechanism of action of venlafaxine and duloxetine?

A. Serotonin and norepinephrine reuptake inhibitor
B. Selective serotonin reuptake inhibitor
C. Monoamine oxidase inhibitor
D. Tricyclic antidepressant
E. Dopamine and norepinephrine reuptake inhibitor

A.

11

A patient will begin therapy with bupropion. The pharmacist should check that the patient does not have any contraindications to the use of this medication. Which of the following are contraindications to the use of bupropion? (Select ALL that apply.)

A. Seizure disorder
B. Narcolepsy
C. Bulimia
D. Schizophrenia
E. Anorexia nervosa

A, C, E. Bupropion is activating and has contraindications that are unique to this antidepressant. Commonly, a patient seeking help for depression will initially be given an SSRI or SNR unless a specific reason exists to use this agent (such as smoking concurrently) or another alternative agent (for example, if the patient is cachectic and is having difficulty with sleep, mirtazapine may be chosen).

12

A patient gave the pharmacist a prescription for Sarafem 20 mg PO QAM 14 days prior to the anticipated onset of menstruation. Which of the following is an appropriate generic substitution for Sarafem?

A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Paroxetine
E. Sertraline

A. The generic name of Sarafem is fluoxetine.

13

A patient gave the pharmacist a prescription for Brintellex. Which of the following is the correct generic name for Brintellex?

A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Vortioxetine
E. Vilazodone

D. The generic name of Brintellex is vortioxetine.

14

A patient has treatment-resistant depression. He has failed reasonable doses, with reasonable trial periods of doxepin, escitalopram, fluoxetine and venlafaxine. Which of the following statements apply to treatment-resistant depression? (Select ALL that apply.)

A. Abilify can be used as an augmentation agent, in addition to the antidepressant.
B. The use of Abilify may cause the patient to become sedated during the day and increase the appetite.
C. Symbyax is a combination of fluoxetine and aripiprazole.
D. Olanzapine carries high risk of weight gain, and metabolic issues, such as elevated blood glucose.
E. Olanzapine is sedating and fluoxetine is stimulating; when used together they are dosed QHS.

A, D, E. Aripiprazole causes insomnia and anxiety, but does not contribute to weight gain. Symbyax is a combination of fluoxetine and olanzapine.

15

Moe has been using tranylcypromine for depression for thirty years. He was recently admitted to the hospital for coronary artery bypass surgery. During his first day as an inpatient the tranylcypromine was stopped and he was switched to duloxetine. The physician thought it was a better choice because it might also treat his neuropathic pain and would have less troublesome interactions. Choose the correct statement:

A. Replace duloxetine with citalopram.
B. Replace duloxetine with escitalopram.
C. Stop the duloxetine immediately.
D. Replace duloxetine with venlafaxine.
E. Replace duloxetine with desvenlafaxine.

C. There must be a two week wash-out period between monoamine oxidase inhibitors (MAOIs) and many other classes of drugs. If going from fluoxetine to an MAOI, a longer wash-out period is required.

16

Mary is admitted to a skilled nursing facility after experiencing a stroke. She is clinically depressed and cannot get to sleep at night due to excessive worry. Mary is not eating much at all and does not like the food at the facility. She has a BMI of 12.8. Her blood pressure is 88/60 mmHg. Her potassium is 3.4 mEq/L. The physician has started mirtazapine 15 mg QHS. Choose benefits that this medication may provide to the patient. (Select ALL that apply.)

A. Increased appetite and weight gain
B. Improvement in bone density
C. Improvement in potassium level
D. Help with sleeping at night
E. Positive benefit in mood

A, D, E. Mirtazapine increases appetite and can increase weight. It is given at night because it is highly sedating and helps the patient sleep.

17

Mike is using citalopram. Choose possible side effects from the use of citalopram. (Select ALL that apply.)

A. Decreased libido
B. Inability to have an erection.
C. Risk of prolongation of the QT interval.
D. Decreased INR, if taking warfarin concurrently
E. Dizziness

A, C, E. Sexual side effects of the SSRIs and SNRIs include decreased libido and ejaculation difficulties, including anorgasmia. The ability to have an erection is not typical; rather the patient may not wish to have sex, or may have difficulty with orgasm or controlling ejaculation.

18

A pharmacist will counsel a patient beginning therapy on Emsam. Which of the following statements are correct regardingEmsam? (Select ALL that apply.)

A. Wash hands with soap after patch application.
B. Pick a time of day that you can remember.
C. This patch contains the prescription drug tranylcypromine, that is used to treat depression.
D. Change once weekly.
E. Apply to the same general area on the upper part of the arm or upper part of the thigh.

A, B. Change daily. Medication patches are always rotated so the application site does not become irritated, with the exception of some of the topical pain patches, such as the lidocaine and diclofenac patches. The Emsam patch is applied to the upper chest, or on the back (below the neck and above the waistline).

19

A 51 year-old female gave the pharmacist a prescription for doxepin 75 mg daily #30. The other medications she takes chronically are irbesartan for hypertension, cetirizine for nasal allergies, Silenor for insomnia and occasional use of diphenhydramine. The patient has two complaints for the pharmacist: the Silenor causes her to be very sleepy the following morning, and the cetirizine is not enough when her allergies "get really bad." The pharmacist notes that the patient has an active prescription for Veramyst, which was not picked up and was returned to the shelf. She states that her nose runs all day and her eyes are red and itchy. Select the correct statement:

A. The prescriber should be called due to a serious drug interaction that could cause reduced levels of the antidepressant.
B. The prescriber should be called due to a heightened risk of worsening depression.
C. The prescriber should be called to recommend a less expensive antidepressant option.
D. The prescriber should be called regarding a potential side effect with the new medication that may be intolerable in this patient.
E. The prescriber should be called to recommend occasional use of oral steroids to control worsening allergy symptoms.

D. Doxepin is the tricyclic agent that is still commonly used for depression. This patient is using doxepin as a hypnotic (Silenor) and is tired the next day. It would not be advisable to add on more doxepin in the morning. The pharmacist should counsel the patient to use the steroid nasal spray for better symptom control.

20

Mabel has been using Pristiq for a few days. She returns to the pharmacy to report that the medicine is not getting into her body. Her other medications include Prilosec OTC and occasional Advil PM. She saw it in the toilet after she had a bowel movement. Mabel should be provided with the following information:

A. She should return to the physician for a medicine that is absorbed faster.
B. She should not use acid-suppressing medicines while taking this medicine since they prevent the drug from being absorbed.
C. She should be informed that the drug has entered her body.
D. She needs to take this medicine with food or it is not absorbed.
E. She needs to take this medicine with one tablet of buffered aspirin.

C. Pristiq is taken at the same time each day, with or without food. Most people take 50 mg daily. It has become popular because (unlike venlafaxine) no dose titration is required and so it is simpler for prescribers. What she saw in her stool was a "ghost" shell; the drug has leached out of the shell. She saw an empty shell.

21

Many of the antidepressants increase serotonin and avoidance of excessive serotonin is required. Methylene blue, which is used in diagnostic procedures and to treat a few medical conditions has monoamine oxidase properties. Linezolid is a weak monoamine oxidase inhibitor. The use of either will generally require temporary discontinuation of the antidepressant medication. In addition, other drugs increase serotonin and can cause risk with concurrent antidepressant use. Which of the following drugs will contribute to additive serotonergic risk? (Select ALL that apply.)

A. Demerol
B. Lithobid
C. Ultram
D. St. John's wort
E. Chantix

A, B, C, D. Most serotonergic psychiatric drugs should be stopped at least 2 weeks in advance of methylene blue or linezolid treatment. Fluoxetine (Prozac), which has a longer half-life compared to similar drugs, should be stopped at least 5 weeks in advance. As in most issues with pharmacy, this is a dose-dependent concern; higher doses are higher risk.

22

A 23 year old male has been using venlafaxine 150 mg taken once daily for the past year. He complains that the drug makes him nauseated. The following recommendation may be helpful:

A. Change to the ODT formulation.
B. Change to the immediate-release formulation.
C. Change to the venlafaxine patch.
D. Take with food.
E. Take with one cup of coffee upon first awakening.

D. Venlafaxine does not come in a patch or an ODT. The only ODT antidepressant is mirtazapine and the only antidepressant patch formulation is selegiline. Extended-release formulations contribute less to nausea than IR formulations; it would not make sense to switch, and if the patient was switched, twice daily dosing would be required.

23

Camden is hepatitis C positive and has mildly elevated liver enzymes. Which antidepressant would be the least acceptable choice in this patient?

A. Fluoxetine
B. Venlafaxine
C. Mirtazapine
D. Nefazodone
E. Citalopram

D. Nefazodone is rarely used due to hepatotoxicity. Liver enzymes must be monitored and the patient must be counseled on symptoms of liver damage.

24

Forfivo XL is a newer formulation of bupropion 450 mg, taken once daily. It is available only in this dose. Forfivo is not approved for smoking cessation. It has the same suicidality warning as all other antidepressants. Which of the following contraindications would rule out the use of Forfivo in a patient being treated for depression?

A. Seizure disorder, using other forms of bupropion, bulimia, anorexia, or alcohol use within the past 72 hours
B. Concurrent post-traumatic stress disorder, bulimia, anorexia, seizure history
C. Concurrent bipolar disorder, bulimia, anorexia, seizure history
D. Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO I use within the past 14 days
E. Seizure disorder, using other forms of bupropion, bulimia, anorexia, or MAO I use within the past 4-5 weeks

D. Do not dispense Forfivo to anyone discontinuing alcohol or sedatives (primarily benzodiazepines); they are at risk of seizures and the dose of bupropion is the maximum.

25

BL is a 39 y/o female who comes into the outpatient clinic visibly upset and anxious. She is a single mother who works as a paralegal and takes care of her 14-year-old daughter. BL complains that over the past month or two she has had more frequent fights with her daughter, and has been having difficulty concentrating at work, trouble staying asleep at night, bouts of crying spells, and has gained ten pounds. She has been on an antidepressant the last six months which she reports taking every other day or "when she feels like it" because it makes her have trouble urinating and makes her feel more tired.  She says it did help her mood when she used to use it regularly which is why she takes it every now and then.  Another complaint she adds is that when she was using the antidepressant daily she had trouble reaching orgasm and complained that this is not something she wants to deal with "on top of everything else."  Which recommendation would best address BL's issues with her therapy for depression?
Current Medications:
Cyclessa 1 PO daily
Rhinocort Aqua 1 spray to each nostril daily
Inderal LA 80 mg PO daily
Sertraline 200 mg PO daily
Pepcid AC 10 mg PO PRN
Cetirizine 10 mg PO PRN
Past Medical History:
Allergic rhinitis
Anxiety
Depression
GERD
Hypothyroidism
Migraines
Psoriasis
Substance abuse (marijuana)
EtOH: 2-3 drinks/week
Vitals:
Height: 5'5"                    Weight: 138 lbs
BP: 129/80 mmHG        HR: 85 BPM            RR: 20 BPM
Temp: 98.6

A. Change to fluoxetine 10 mg daily
B. Switch to venlafaxine
C. Switch to phenelzine
D. Switch to bupropion
E. Discontinue fluoxetine and re-trial sertraline at 50 mg daily

D. Bupropion targets norepinephrine and dopamine reuptake inhibition. Due to its lack of activity on serotonin, it is an reasonable option for patients experiencing sexual dysfunction from SSRIs or SNRIs.

26

Select the correct indication for Brisdelle:

A. Depression
B. Fibromyalgia complicated with pain and depression
C. Vasomotor symptoms of menopause
D. Obsessive Compulsive Disorder
E. Generalized Anxiety Disorder

C. The dosing for this indication is 7.5 mg, taken at bedtime. This is a version of the SSRI paroxetine.

27

Which of the following medications can cause low sodium to appear on a lab report? (Select ALL that apply.)

A. Tegretol
B. Trileptal
C. Citalopram
D. Linezolid
E. Fluoxetine

A, B, C, E. There are several drugs that can cause SIADH, including SSRIs and SNRIs. With oxcarbazepine sodium levels must be monitored due to hyponatremia risk.

28

Select the correct primary mechanism of action for Elavil:

A. Serotonin and dopamine reuptake inhibitor.
B. 5HT-1a (serotonin-1a) reuptake inhibitor and norepinephrine antagonist.
C. Norepinephrine and serotonin (5-HT) reuptake inhibitor.
D. Selective serotonin reuptake inhibitor.
E. SSRI and 5-HT1a (serotonin-1a) partial agonist.

C. Elavil is the brand name for amitriptyline. In addition to the mechanism listed, the tricyclics block acetylcholine and histamine receptors, which contributes to the side effect profile.

29

BL is a 39 y/o female who comes into the outpatient clinic visibly upset and anxious. She is a single mother who works as a paralegal and takes care of her 14-year-old daughter. BL complains that over the past month or two she has had more frequent fights with her daughter, and has been having difficulty concentrating at work, trouble staying asleep at night, bouts of crying spells, and has gained ten pounds. She has been on an antidepressant the last six months which she reports taking every other day or "when she feels like it" because it makes her have trouble urinating and makes her feel more tired.  Of the following conditions below, which is most likely to contribute to a depressed state? 
Current Medications:
Cyclessa 1 PO daily
Rhinocort Aqua 1 spray to each nostril daily
Inderal LA 80 mg PO daily
Sertraline 200 mg PO daily
Pepcid AC 10 mg PO PRN
Cetirizine 10 mg PO PRN
Past Medical History:
Allergic rhinitis
Anxiety
Depression
GERD
Hypothyroidism
Migraines
Psoriasis
Substance abuse (marijuana)
EtOH: 2-3 drinks/week
Vitals:
Height: 5'5"                    Weight: 138 lbs
BP: 129/80 mmHG        HR: 85 BPM            RR: 20 BPM
Temp: 98.6

A. Hypertesnion
B. Allergic rhinitis
C. Migraine
D. Hypothyroidism
E. Occasional urinary tract infections

D. The patient is currently not on any medications to manage the hypothyroidism, which contributes to depression.

30

Seroquel XR has been prescribed as adjunctive treatment for a patient receiving drug treatment for depression who has not had a satisfactory response to several antidepressant medications. The Seroquel XR is being added to his current medication regimen. Which of the following represent boxed warnings for this use of Seroquel XR and will necessitate counseling by the pharmacist? (Select ALL that apply.)

A. Neuroleptic malignant syndrome
B. Bipolar episodes
C. Increased mortality in elderly patients with dementia-related psychosis
D. Suicidal thoughts and behavior
E. Aggravation of psychosis

C, D. These two boxed warnings apply to all of the antipsychotics used in the treatment of treatment-resistant depression.

31

A patient is using the selegiline patch at 12 mg/day. The patient asks the pharmacist: "I was told to avoid foods rich in tyramine, but I don't know what foods I should stop eating. Do you?" The pharmacist should counsel the patient to avoid the following foods: (Select ALL that apply.)

A. Sauerkraut
B. Peppermints, spearmints
C. Milk and any lactose-containing products
D. Soy sauce
E. Aged cheese, air-dried meats

A, D, E.

32

What are likely rationales behind using Remeron SolTab when given to thin, elderly patients in skilled nursing facilities, or in patients receiving chemotherapy? (Select ALL that apply.)

A. The patient will not be able to "cheek" the medicine and spit it in the toilet.
B. Patients using mirtazapine may have dysphagia.
C. Patients using mirtazapine may have nausea.
D. Many patients using mirtazapine have tremor.
E. Patients using mirtazapine may have lost all their teeth.

A, B, C. This drug is used commonly in older, frail nursing home or assisted living facility patients, and in patients receiving chemotherapy for cancer. Some of the atypical antipsychotics come in ODTs to help prevent "cheeking" and improve medication adherence. Patients taking mirtazapine are unlikely to wish to spit out the medicine.

33

Select the side effects common to the class of drugs that includes venlafaxine, duloxetine and desvenlafaxine. (Select ALLthat apply.)

A. Elevated blood pressure and heart rate
B. Tremor, seizures in prone patients
C. Generalized anxiety disorder
D. Sexual dysfunction
E. Diaphoresis

A, D, E. Sexual side effects are similar to the SSRIs, since the SNRIs block serotonin reuptake. SNRIs also block the reuptake of norepinephrine, causing risk of elevated blood pressure, heart rate and sweating. Diaphoresis is sweating, and this side effect will cause some patients to discontinue the use of SNRIs if it happens to them.

34

A pharmacist will counsel a male patient beginning therapy with trazodone to help treat the patient's depressed mood. Which of the following statements concerning trazodone are correct? (Select ALL that apply.)

A. If this makes you too sleepy, ask your doctor about a newer formulation of trazodone that is taken at night called Oleptro, which may have less daytime sleepiness.
B. The primary side effect of trazodone is priapism.
C. If you have an erection that lasts 2 hours or longer, and is painful, you need to get emergency medical help.
D. The use of trazodone can put a frail patient at risk for falls and injury.
E. Trazodone is likely to cause insomnia.

A, D. If an erection lasts four hours or longer, and is painful, emergency medical attention is required. The penis will be drained and a vasoconstrictor administered. Although priapism can occur, the common side effect is sedation.

35

A pharmacist will make a recommendation to a medical team on treatment considerations for depression during pregnancy and lactation. Which of the following statements are correct? (Select ALL that apply.)

A. It is always important to treat depression with medications during pregnancy; low mood may cause the mother not to eat well, which could harm the baby.
B. Of all the SSRIs, sertraline is considered most dangerous in pregnancy and should be avoided.
C. The FDA has issued a warning concerning the risks of persistent pulmonary hypertension (PPHN) in children born to women who were using SSRIs during pregnancy; prior to recent years the use of SSRIs in pregnancy were largely considered safe.
D. Breastfeeding can be helpful for the mother's physical and emotional symptoms.
E. SSRIs and tricyclics are generally preferred in women who are breastfeeding their baby, with the exception of doxepin, per the ACOG recommendations.

C, D, E. If the depression is mild, psychotherapy should be tried prior to the initiation of medications. It is best to avoid medication use in pregnancy, if possible. The long-term health of the baby must be considered. Of all the SSRIs, paroxetine is considered most dangerous in pregnancy and should be avoided.

36

What is the mechanism of action of paroxetine?

A. Selective serotonin reuptake inhibitor
B. Monoamine oxidase inhibitor
C. Norepinephrine reuptake inhibitor
D. Dopamine and norepinephrine reuptake inhibitor
E. Serotonin and norepinephrine reuptake inhibitor

A. The selective serotonin reuptake inhibitors (SSRIs) include fluoxetine, paroxetine, sertraline, citalopram and escitalopram.

37

Eleanor is using fluoxetine 20 mg QHS. She is having difficulty sleeping and has asked her pharmacist for advice. Choose the most reasonable initial response:

A. Ask the doctor for a prescription for zolpidem.
B. Move the fluoxetine to the morning.
C. Ask the doctor for a prescription for temazepam.
D. Discontinue the fluoxetine and replace with bupropion.
E. Discontinue the fluoxetine and replace with atomoxetine.

B. Of all the SSRIs, fluoxetine is the most activating and is taken in the morning. However, a minority of patients may find it sedating. All of the SSRIs can be either activating or sedating or neutral; in general, they are started in the morning but if the patient has daytime somnolence they can be taken at night. The SSRIs are once-daily medications.

38

What are the indications for Cymbalta? (Select ALL that apply.)

A. Post-Traumatic Stress Disorder (PTSD)
B. Generalized Anxiety Disorder (GAD)
C. Diabetic Neuropathic Pain
D. Fibromyalgia
E. Depression

B, C, D, E. This has become a popular agent as many patients have more than one condition that may be able to be treated with the same drug. It is also indicated for chronic musculoskeletal pain.

39

Margaret is using warfarin. She is given a prescription for citalopram 40 mg daily. Choose the correct counseling point:

A. You should start to feel better within a few days; if the medication does not work by then, you should stop taking it.
B. This medication is unsafe to take if you have Crohn's disease or "irritable bowel syndrome."
C. This medication can be unsafe to take with medications such as warfarin; the risk for bleeding will be higher.
D. Take on an empty stomach 1/2 hour before eating breakfast.
E. Do not consume dairy products while using this medicine.

C. SSRIs and SNRIs increase bleeding risk in patients using other drugs with bleeding risk.

40

A patient is using the following medications daily: amlodipine 10 mg and chlorthalidone 25 mg for hypertension, atorvastatin 40 mg and fenofibrate 130 mg for cholesterol, Wellbutrin 100 mg TID for depression. He also uses lorazepam 1 mg as-needed for anxiety. The patient is a smoker and has been unable to quit. The prescriber calls in a prescription for Zyban 150 mg BID to the pharmacy. Select the correct statement:

A. The prescription for Zyban should be filled as-written.
B. Zyban cannot be used with high cholesterol.
C. Zyban cannot be used with anxiety.
D. Zyban cannot be used with hypertension.
E. The patient is already using the component in Zyban; the prescription cannot be filled.

E. Do not use Zyban and Wellbutrin together; they are the same drug (bupropion).

41

A patient gave the pharmacist a prescription for Cymbalta 20 mg PO BID #60. Which of the following is an appropriate generic substitution for Cymbalta?

A. Fluoxetine
B. Venlafaxine
C. Duloxetine
D. Desvenlafaxine
E. Milnacipran

C. The generic name of Cymbalta is duloxetine.

42

Which of the following are brand formulations of buproprion? (Select ALL that apply.)

A. Wellbutrin
B. Aplenzin
C. Betapace
D. Buproban
E. Zyban

A, B, D, E. Betapace is sotalol. Do not use different formulations of the same drug concurrently and, with this drug, it could get dangerously close to or above the safe maximum dose.

43

Alandra is a 38 year-old female who has stopped enjoying her normal activities. She is easily tearful. Alandra is hesitant to ask for help as she feels worthless and does not wish to burden her family or friends. In addition to extreme sadness, she is worried about most things in her life, including finances and job security. Alandra has not slept well in months. This is affecting her ability to think clearly. Her current medications include Inderal for migraine prophylaxis, sumatriptan for acute migraines, Catapres, Dyazide, amlodipine, alendronate, calcium plus vitamin D and fish oil supplements. Which medication/s could be contributing to her depressive symptoms? (Select ALL that apply.)

A. Catapres
B. Inderal
C. Alendronate
D. Amlodipine
E. Dyazide

A, B. Medications that can contribute to depression include lipophilic beta blockers, clonidine, certain types of hormones, indomethacin, interferons, isotretinoin, stimulants, along with some others. Inderal is propranolol.

44

A patient gave the pharmacist a prescription for Luvox 100 mg daily #30. Which of the following is an appropriate generic substitution for Luvox?

A. Fluvoxamine
B. Fluoxetine
C. Citalopram
D. Vilazodone
E. Vortioxetine

A. The generic name of Luvox is fluvoxamine.

45

A mother brought in a prescription for fluoxetine for her teenage son. The boy has not been participating in his usual sports, is eating poorly and is having difficulty getting to sleep at bedtime. She tells the pharmacist that the boy was found trying to slit his wrists. After a directed intervention, he is better but is still high-risk for suicide. The following counseling must be relayed to the parent:

A. The medication will help improve his sleep; take prior to bedtime.
B. His mood will improve before his energy.
C. His appetite should increase with this medication.
D. His sexual interest will increase due to a known side effect of this medication.
E. Initially, he will be at heightened risk for suicide.

E. Antidepressants increase the risk (compared to placebo) of suicidal thinking and behavior in children, adolescents, and young adults in short term studies of major depressive disorder (MDD) and other psychiatric disorders.

46

A patient is using Wellbutrin XL for seasonal affective disorder. The prescriber instructed the patient to start early in the spring at 150 mg BID and continue indefinitely. He said that the best treatment for SAD is to take it all year since depression can be debilitating. He said that the pharmacist would instruct the patient how to use the drug. Which statement below is correct? 

A. The dose is correct; the timing (when to use the drug) is incorrect.
B. The dose is incorrect; the timing (when to use the drug) is correct.
C. The dose and the timing (when to use the drug) are both incorrect.
D. This drug is not indicated for this condition.
E. The patient is contraindicated for this drug due to her concurrent conditions.

C. The dose should not start this high; it should start at 150 mg once daily and then should be increased to 300 mg once daily. For SAD the drug is started in early fall and titrated off in the spring, but if the condition warrants it could be continued indefinitely.

47

Which antidepressant below has the highest risk of causing liver damage?

A. Oleptro
B. Remeron
C. Fortivo XL
D. Nefazodone
E. Zyban

D. Forfivo XL is a newer formulation of bupropion 450 mg, taken once daily.

48

BL is a 39 y/o female who comes into the outpatient clinic visibly upset and anxious. She is a single mother who works as a paralegal and takes care of her 14-year-old daughter. BL complains that over the past month or two she has had more frequent fights with her daughter, and has been having difficulty concentrating at work, trouble staying asleep at night, bouts of crying spells, and has gained ten pounds. She has been on an antidepressant the last six months which she reports taking every other day or "when she feels like it". Of the following medications BL is using chronically, which can contribute to a depressed mood? (Select ALL that apply.)
Current Medications:
Cyclessa 1 PO daily
Rhinocort Aqua 1 spray to each nostril daily
Inderal LA 80 mg PO daily
Sertraline 200 mg PO daily
Pepcid AC 10 mg PO PRN
Cetirizine 10 mg PO PRN
Past Medical History:
Allergic rhinitis
Anxiety
Depression
GERD
Hypothyroidism
Migraines
Psoriasis
Substance abuse (marijuana)
EtOH: 2-3 drinks/week
Vitals:
Height: 5'5"                    Weight: 138 lbs
BP: 129/80 mmHG        HR: 85 BPM            RR: 20 BPM
Temp: 98.6

A. Cyclessa
B. Ativan
C. Cetirizine
D. Inderal LA
E. Pepcid AC

A, D. Oral contraceptives and beta-blockers (especially propranolol) can worsen depression symptoms. It is unlikely that the lower-dose oral contraceptives used currently will cause low mood, but they can, and may be an issue for individual patients. Propranolol taken PRN for stage-fright is not likely to contribute to a mood disorder; this patient is taking propranolol daily.

49

A patient has treatment-resistant depression. He has failed reasonable doses, with reasonable trial periods of doxepin, escitalopram, fluoxetine and venlafaxine. Which of the following statements apply to treatment-resistant depression? (Select ALL that apply.)

A. In some patients, a dosage increase is all that is required if the dose remains reasonable for the particular agent.
B. Lithium is occasionally used for antidepressant augmentation.
C. It has become very popular to add-on an antipsychotic to the antidepressant for treatment-resistant depression; this use must be done very cautiously as an additional agent is being used with a whole array of possible side effects and complications. This is being done commonly in children, where the long-term safety effects are unknown.
D. It is never appropriate to combine different antidepressants.
E. Buspirone is not used as an augmentation agent; it is only used in patients who present with anxiety as a sole symptom.

A, B, C. It is often not appropriate to combine different antidepressants, but it has benefit for some patients. The pharmacist must always consider additive side effects due to the combination, and any unsafe considerations. Buspirone is a reasonable augmentation agent if residual anxiety remains an issue. It is used by itself if anxiety is the primary complaint.

50

Margo wishes to begin therapy with an antidepressant. The physician is considering either desvenlafaxine or sertraline. Which of the following statements are correct? (Select ALL that apply.)

A. It takes 1-2 weeks to have the maximum benefit from this medicine; it does not help much on an immediate basis.
B. Antidepressants hardly ever offer any benefit and should not be used.
C. There is a large placebo response in antidepressant trials; however, in some patients they provide benefit and the pharmacist should help a patient feel positive about using the medication. Hopefully, it will provide some help.
D. Physical symptoms, such as energy and sleep, usually improve prior to an improvement in emotional symptoms, such as feeling better.
E. SSRIs and SNRIs can cause hyponatremia.

C, D, E. It is important to counsel patients about the "lag" time before the mood lifts. The common experience is to take a pain pill or cough suppressant-and it works in about an hour. If the patient is not informed these medicines take time to work, they may give up and stop using it.

51

A patient gave the pharmacist a prescription for Effexor 37.5 mg 1 capsule BID #60. Which of the following is an appropriate generic substitution for Effexor?

A. Fluoxetine
B. Venlafaxine
C. Duloxetine
D. Desvenlafaxine
E. Milnacipran

B. The generic name of Effexor is venlafaxine.

52

Select the correct mechanism of action for vilazodone:

A. Serotonin and norepinephrine reuptake inhibitor.
B. 5-HT1a (serotonin-1a) reuptake inhibitor and norepinephrine antagonist.
C. Norepinephrine and dopamine reuptake inhibitor.
D. Selective serotonin reuptake inhibitor.
E. SSRI and 5-HT1a (serotonin-1a) partial agonist.

E.

53

A pharmacist receives a prescription for Brintellix. Select the appropriate generic name for this antidepressant medication:

A. Vilazodone
B. Vortioxetine
C. Bupropion
D. Desvenlafaxine
E. Levomilnacipran

B. Vortioxetine (Brintellix) is an SSRI antagonist and serotonin 5-HT1A agonist.

54

A female patient suffers from severe depression prior to the onset of menses. After the period begins, her mood appears brighter and the depression dissipates. This pattern occurs monthly and causes significant distress to her routine functioning. She has been diagnosed with pre-menstrual dysphoric disorder (PMDD). Which medication/s are indicated for this condition? (Select ALL that apply.)

A. Yasmin
B. Sarafem
C. Lexapro
D. Yaz
E. Zoloft

B, D, E. When an antidepressant is taken for PMDD, it is taken for the two weeks prior to menses and through the first full day of bleeding. Alternatively, the antidepressant can be taken daily. This is the only medical condition in which antidepressants are not always taken continuously.

55

A patient gave the pharmacist a prescription for Prozac 10 mg PO QAM #30. Which of the following is an appropriate generic substitution for Prozac?

A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Paroxetine
E. Sertraline

A. The generic name of Prozac is fluoxetine.

56

Hai is an 82 year-old male with end stage renal disease who has been using venlafaxine. Recently, he had a hematoma that put him in the hospital and was nearly fatal. His daily medications are venlafaxine, warfarin, metoprolol and PhosLo. Choose the risky problem present with this combination:

A. Bleeding risk due to combination of a phosphate binder with a beta blocker.
B. Bleeding risk due to combination of warfarin and a beta blocker.
C. Bleeding risk due to combination of warfarin and an SNRI.
D. Fall risk due to venlafaxine use in end stage renal disease.
E. Fall risk due to phosphate binder use in end stage renal disease.

C. SSRIs and SNRIs carry bleeding risk when combined with anticoagulants such as warfarin. This patient should have been recognized as high-risk and the combination should have been avoided. It is not contraindicated at present, but is considered unsafe. Perhaps an alternative agent could be chosen.

57

Everette is using paroxetine for depression and experiences significant sexual problems. He states it could ruin his relationship. The physician must consider an alternative agent. Which option below would provide the lowest risk of sexual problems?

A. Escitalopram
B. Duloxetine
C. Desvenlafaxine
D. Fluvoxamine
E. Bupropion

E. Unlike the SSRIs and SNRIs, bupropion does not cause or worsen sexual dysfunction.

58

A pharmacist receives a prescription for Viibryd. Select the appropriate generic name for this antidepressant medication:

A. Vilazodone
B. Vortioxetine
C. Bupropion
D. Desvenlafaxine
E. Levomilnacipran

A. Vilazodone (Viibryd) is an SSRI agonist and serotonin 5-HT1A partial agonist. Counseling should include to take with food. Administration without food causes inadequate absorption and could cause subtherapeutic levels.

59

A patient gave the pharmacist a prescription for Celexa 20 mg PO daily #30. Which of the following is an appropriate generic substitution for Celexa?

A. Fluoxetine
B. Citalopram
C. Escitalopram
D. Paroxetine
E. Sertraline

B. The generic name of Celexa is citalopram.

60

A patient gave the pharmacist a prescription for Lexapro 10 mg daily #30. Which of the following statements concerningLexapro are correct? (Select ALL that apply.)

A. The usual daily dose is 10 milligrams, taken once daily.
B. Escitalopram is the s-enantiomer (active form) of citalopram.
C. Lexapro has more significant drug interactions than the other SSRIs.
D. Lexapro does not cause sexual concerns which can be present with other SSRIs.
E. Doses above 20 mg/day would cause unsafe risk due to QT prolongation.

A, B, E.

61

An increased risk of teratogenic effects, including cardiovascular defects, are linked to the mother using SSRIs during pregnancy. Choose a specific type of problem identified with the newborn that is linked with SSRI use during pregnancy:

A. Floppy baby syndrome
B. Persistent pulmonary hypertension of the newborn (PPHN)
C. Spina bifida
D. Cleft lip and cleft palate
E. Patent ductus arteriosus (PDA)

B. Persistent pulmonary hypertension of the newborn (PPHN) can occur with in utero SSRI exposure.

62

Alandra is a 34 year-old female who has stopped enjoying her normal activities. She is easily tearful. One thing that her family finds annoying about her is that she leaves messes around the house and has done this since childhood. Alandra is hesitant to ask for help as she feels worthless and does not wish to burden her family or friends. In addition to extreme sadness, she is worried about most things in her life, including finances and job security. Alandra has not slept well in months. This is affecting her ability to think clearly. She has stopped consuming her normal food and has lost weight. What symptoms of depression, according to the DSM criteria, are present in this patient? (Select ALL that apply.)

A. Feelings of worthlessness or inappropriate guilt
B. Sloppiness, leaving messes
C. Changes in sleep pattern
D. Changes in appetite
E. Anhedonia

A, C, D, E. Other symptoms are psychomotor agitation or retardation, diminished ability to think or concentrate, or indecisiveness (either by subjective account or as observed by others), recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Leaving messes is not helpful when living with others, but is not a symptom of depression (unless a lack of energy and motivation is present; in this case, she has always had similar behavior).

63

A patient’s chronic pain has been controlled on methadone. The patient has obsessive compulsive disorder (OCD) and has been given a prescription for fluvoxamine. What effect would be caused by this drug interaction?

A. Elevated fluvoxamine and increased risk of sexual dysfunction.
B. Decreased fluvoxamine level and poor control of OCD.
C. No drug interaction is present.
D. Elevated methadone level and risk of methadone overdose.
E. Decreased methadone level and poor pain control.

D. Methadone is pro-arrhythmic at higher doses; missing this interaction could be a fatal mistake. Fluvoxamine is an enzyme inhibitor of most isoenzymes, including the most common drug-metabolizing enzyme, CYP 450 3A4.

64

A patient gave the pharmacist a prescription for Pristiq 50 mg PO once daily #30. Which of the following is an appropriate generic substitution for Pristiq?

A. Fluoxetine
B. Venlafaxine
C. Duloxetine
D. Desvenlafaxine
E. Milnacipran

D. The generic name of Pristiq is desvenlafaxine.

65

A 25 year-old female pharmacy student went to the school’s health clinic complaining of depression and excessive worry. She felt tired all the time because she cannot get a good night’s sleep due to the anxiety. She is worried that she will make a mistake dispensing a medication. The medical resident prescribed trazodone 150 mg twice daily. This is a poor choice for the following reason:

A. Trazodone is contraindicated in females.
B. She is at high risk for priapism.
C. This medication is contraindicated in pharmacists due to their unusual physiology.
D. She will be sedated more than she is already and may make a prescription error.
E. This is a fine choice; she can safely use trazodone.

D. Trazodone is too sedating to be used routinely as an antidepressant. If this medication is dispensed for any reason (including off-label for sleep) counseling on the risk of priapism is required: emergency treatment is required for a sustained, painful erection lasting longer than 4 hours.

66

In 2011 the FDA issued a warning not to presribe citalopram above this maximum daily dose, due to the risk of QT prolongation:

A. 5 mg daily
B. 10 mg daily
C. 20 mg daily
D. 40 mg daily
E. 60 mg daily

D. In addition to QT risk, it is important to look at the total use of agents that increase serotonin that the patient is using in order to reduce the risk of serotonin syndrome. Escitalopram should not be dosed above 20 mg daily.

67

Which of the following are side effects/possible adverse reactions of bupropion? (Select ALL that apply.)

A. Decreased bone density
B. Dry mouth
C. Sedation
D. Insomnia
E. Tremors/risk of seizures

B, D, E. Bupropion is not used in patients with a seizure history.

68

Sean has been prescribed doxepin 200 mg daily for depression. He has failed trials with other agents. Sean suffers from severe depression and has tried to kill himself in the past. His other medications include furosemide, potassium extended-release, carvedilol and fosinopril. Which of the following safety concerns should the pharmacist relay to the physician? (Select ALL that apply.)

A. Suicide risk with tricyclic antidepressants
B. Additive bradycardia due to the combination of fosinopril and carvedilol
C. Additive potassium accumulation due to doxepin and potassium supplements
D. Additive potassium lowering due to the combination of furosemide and an ACE inhibitor
E. QT prolongation risk

A, E. Tricyclics are QT-prolongating agents. If a month's supply is taken they could induce a fatal arrhythmia. It may be prudent to use a drug that is not as risky in this patient. In addition his medications indicate heart failure. Cardiac conditions put patients at risk for arrhythmia.

69

John has had depression most of his adult life. He used doxepin when he was a teenager and stopped taking this medicine during his twenties. He had a recurrence of the depression later that year and began using paroxetine. He has been successfully treated with paroxetine for five years. He is asking the pharmacist if it is safe to stop the paroxetine. Which of the following statements concerning paroxetine and doxepin are correct? (Select ALL that apply.)

A. Doxepin also comes in formulations used for itching (as a cream) and in an oral formulation taken at night for insomnia.
B. If he wishes to try and stop the paroxetine, he can stop using the medicine at any time.
C. If he wishes to try and stop the paroxetine, he will need to have it discontinued with a slow, gradual taper.
D. Paroxetine is not a preferred agent in pregnancy; it is unsafe for the health of the baby.
E. Brisdelle is Pregnancy Category C.

A, C, D. Paroxetine is short-acting and thus causes significant withdrawal symptoms. In contrast, fluoxetine self-tapers due to the long half-life. Abrupt withdrawal of SSRIs can cause nightmares, confusion, anxiety, depressed mood, flu-like symptoms, weakness and nausea.

70

Several of the antidepressants, including all the SSRIs and SNRIs, have warnings not to initiate in patients being treated with the following agents: (Select ALL that apply.)

A. Fortaz
B. Zyvox
C. Methylene blue
D. Linezolid
E. Invanz

B, C, D.

71

SR is a 34 y/o male lawyer who has been recently diagnosed with major depression.  He feels unmotivated to go to work, complains of lack of energy and feelings of guilt that constantly plague him, and has noticed he sleeps much more than he normally does. He has tried Lexapro 10 mg daily in the past for several months but without much success or improvement in symptoms. "Many years ago I tried Zoloft too and that did nothing except make me feel worse!" Which medication might be a reasonable option in this patient at this time?
Current Medications:
Ambien 5 mg
Alprazolam 0.5 mg BID
Glucophage 1000 mg BID
Sildenafil 50 mg PRN
Past Medical History:
Anxiety
Diabetes mellitus (type 2) 
Erectile dysfunction
Insomnia
Major depression
Smoking
Vitals:
Height: 5'8"                   Weight: 200 lbs
BP: 135/89 mmHG        HR: 82 BPM            RR: 17 BPM
Temp: 98.3

A. Fluvoxamine
B. Celexa
C. Mirtazapine
D. Trazodone
E. Wellbutrin

E. SSRIs or SNRIs are used first-line for treatment of major depressive disorder in most patients. When choosing an antidepressant, look back at the patient's history. Consider if previous drugs were used at a therapeutic dose and for a reasonable trial period. Bupropion has more contraindications than SSRIs or SNRIs and cannot be used if any of the contraindications is present.

Decks in Pharmacy Class (61):