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Flashcards in 56. Bipolar Disorder Deck (23):
1

A pharmacist will counsel a patient beginning lamotrigine therapy for bipolar disorder. Which of the following statements regarding lamotrigine are correct? (Select ALL that apply.)

A. When you start this medication, you will need to slowly increase the dose; that's why it comes in a dosing packet.
B. Do not take other medicines or over-the-counter products without discussing them first with your doctor or pharmacist.
C. If you develop a rash that quickly becomes serious; do not take more than prescribed and see your doctor right away if this happens, or if the doctor is not available to consult with you, get emergency medical help.
D. This medicine can cause you to feel somewhat dizzy and tired.
E. The brand name of this medicine is Latuda.

A, B, C, D. The brand name of lamotrigine is Lamictal.

2

A pharmacist will counsel a patient beginning lithium therapy for bipolar disorder. Which of the following statements regarding lithium are correct? (Select ALL that apply.)

A. You should not become pregnant while taking this medicine; it is likely to harm the baby, but if you do, contact your doctor right away.
B. It is helpful to get lots of sun to help improve your mood when using this medicine.
C. This medication can cause a light tremor in your hands; if you notice the tremor looks worse (much more noticable), it can mean the level of drug in your body is too high and you should see the doctor right away.
D. Prepared frozen food, fast food and Chinese food usually contain a lot of salt; the salt in your diet needs to be about the same amount every day, so you need to think about what you are eating.
E. This medication can make your weight go up; it is helpful to get exercise, such as walking, and stay away from sweets and sugary drinks.

A, C, D, E. With lithium, do not change the amount of salt consumed. Do not stay in the sun for long periods.

3

In the past few years, drugs typically used for schizophrenia have been used for bipolar disorder. Which of the following antipsychotics can raise prolactin levels, with increased risk at higher doses? (Select ALL that apply.)

A. Invega
B. Equetro
C. Stavzor
D. Lithobid
E. Risperdal

A, E. Risperidone (Risperdal) and paliperidone (Invega) are associated with increase in prolactin levels. Paliperidone does not have the indication for bipolar but may be used off-label for this condition.

4

A patient received a prescription for asenapine. Choose the correct statement concerning asenapine. (Select ALL that apply.)

A. Formulations of asenapine include an oral solution and tablets.
B. Asenapine can make the mouth numb.
C. Asenapine has little QT risk and can safely be used with cardiovascular conditions.
D. The brand name is Saphire.
E. Patients should be counseled to avoid driving when initiating or titrating therapy.

B, E. Asenapine comes in a sublingual formulation which must be dissolved under the tongue and can cause mouth numbness.

5

A patient has been diagnosed with bipolar II disorder. Which of the following statement concerning bipolar disorder is correct?

A. The mania symptoms are generally worse in bipolar II than in bipolar I.
B. The depressive symptoms are generally worse in bipolar II than in bipolar I.
C. Bipolar II is much less common than bipolar I.
D. Bipolar II is much more common in men.
E. In bipolar I, mania and psychosis can require hospitalization.

E. Bipolar I disorder is the most severe version of the disorder. When patients are in a manic episode or experiencing psychosis, hospitalization may frequently be required. Bipolar II disorder is characterized by hypomanic episodes which are less severe where the patient can still function and does not require hospitalization.

6

A pharmacist will counsel a patient beginning valproic acid therapy for bipolar disorder. Which of the following statements regarding valproic acid are correct? (Select ALL that apply.)

A. In rare cases this drug can cause damage to your liver. If you feel very tired and lose your appetite, or if your stool becomes light in color (or your skin becomes yellowish), you need to be seen by your doctor right away.
B. You should not become pregnant while using this medicine. If you do become pregnant, see the doctor right away.
C. In rare cases this drug can cause damage to your pancreas. If you become nauseated, with a loss of appetite and pain around your abdomen (stomach area), you need to be seen by your doctor right away.
D. This medication can cause the cells that fight infection to become very low. You need to watch for symptoms of having an infection, such as feeling weak and tired, or running a fever. If this happens you should see your doctor as soon as possible.
E. Take this medicine on an empty stomach.

A, B, C. Valproic acid does not cause agranulocytosis. Carbamazepine has this risk. Valproate causes stomach upset and is easier to tolerate if taken with food.

7


A patient gave the pharmacist a prescription for Depakene 150 mg BID #60. Which of the following is an appropriate generic substitution for Depakene?

A. Quetiapine
B. Lithium
C. Carbamazepine
D. Divalproex
E. Valproic acid

E. The generic name of Depakene is valproic acid.

8

Side effects of divalproex sodium may include: (Select ALL that apply.)

A. GI upset
B. Alopecia
C. Sedation
D. Iron overload
E. Weight Loss

A, B, C. Patients should be counseled regarding the possibility of GI upset, alopecia (which is hair loss - may be preventable with selenium and zinc supplementation), sedation, tremor and weight gain. This is one of the drugs with significant weight gain, which can contribute to nonadherence.

9

A pharmacist will counsel a patient beginning lithium therapy for bipolar disorder. Which of the following statements regarding lithium are correct? (Select ALL that apply.)

A. In rare cases this drug can cause damage to your liver. If you feel very tired and lose your appetite, or if your stool becomes light in color (or your skin becomes yellow-ish), you need to be seen by your doctor right away.
B. You should not become pregnant while using this medicine. If you do become pregnant, see the doctor right away.
C. If you feel very nauseated, or if your stools are loose and watery, and if you feel confused (with slurring speech, or trouble walking, it could mean the amount of medicine in your body is too high and you will need to see the doctor right away.
D. This medicine can make you feel thirsty, and then you will need to use the bathroom more often. In order to prevent becoming dehydrated, drink water often and take a water bottle with you when you go out.
E. Take this medicine on an empty stomach one hour before or two hours after meals.

B, C, D. Lithium causes stomach upset and is taken with food; otherwise it can be difficult to tolerate.

10

What is the correct serum trough range for monitoring lithium therapy?

A. 0.1-0.5 mg/L
B. 1-1.2 mEq/L
C. 0.4-1.2 mcg/mL
D. 0.6-1.2 mEq/L
E. 5-10 mg/L

D. Lithium, along with some electrolytes, is measured in milliequivalents (mEq). Most drugs are measured in mg/L, which is the same as mcg/mL. In treating an acutely manic patient, the clinician may go slightly above this level for a short-time period, and then lower the dose to stay within this range.

11

Bipolar disorder can aggravate or cause the following behaviors: (Select ALL that apply.)

A. Tics and other vocal outbursts
B. Excessive gambling
C. Risky sexual behaviors
D. Higher risk of suicide
E. Trouble at work due to poor performance

B, C, D, E. Tics and other vocal outbursts may be present as a comorbid disorder but are not associated with bipolar directly.

12

Choose the correct descriptions concerning lithium, carbamazepine and valproic acid use in pregnancy:

A. They are rated Pregnancy Category B.
B. They are rated Pregnancy Category C.
C. They are rated Pregnancy Category X.
D. These drugs are known to cause birth defects; they should only be used if the benefit clearly outweighs the risk.
E. These drugs are safe to use in pregnancy.

D. These three agents are Pregnancy Category D; they are known teratogens and should only be chosen if the benefit outweighs the risk. Lamotrigine and quetiapine, which are both increasingly used for bipolar disorder, are Pregnancy Category C. Valproate formulations are Pregnancy Category X for migraine (they cannot be used for migraine).

13

JS is a 43 year-old black female with bipolar disorder who has been using lithium for 4 1/2 years. She presents to the clinic to complain about nausea. She says that as she has gotten older, her nausea has worsened and she noticed how bad it was during a recent trip to Disneyland. She couldn't enjoy any of the rides. The nausea is particularly bad when her brother is driving the car because he "jerks."  Her current lithium level is 0.9 mEq/L. She presents with mild tremor and bilateral cogwheel rigidity. Patient reports "good" mood and  states she is "fine" with lithium.  Pharmacy records indicate good adherence.  JS says that she takes Tums for the nausea, but it doesn't help as much as it used to and asks for something stronger.  JS reports that she eats two primary meals per day (lunch and dinner) and rarely has breakfast except some coffee +/-juice.
Medications
Lithium carbonate 300 mg TID, with meals.
B-vitamin "energy" complex
Valerian for "nerves" as-needed
Vitals: BP 118/80, HR 74, Temp: 37.1 C
Height: 5'6", Wt: 72 kg
Which of the following represents a reasonable option for JS at this time?

A. Counsel patient to immediately discontinue the coffee and begin to take Reglan.
B. Change to Symbyax.
C. Change to Seroquel XR.
D. Change to Eskalith CR 450 mg BID, recommend eating some breakfast.
E. Change to valproate for bipolar control; as she ages she should be weaned off lithium.

D. The lithium is working for the patient; she should not be encouraged to switch medications. Her renal function is hopefully being monitored. She can switch to a long-acting formulation and take the doses with food. Even with some toast and water, or ginger ale, can help. Make sure she is consuming adequate fluids; this is required with lithium in all patients. In some patients lower fluid intake will worsen nausea.

14

In the past few years, drugs typically used for schizophrenia have been approved for various states of bipolar. Which of the following drugs can be used for bipolar disorder (various states), according to the FDA-indications? (Select ALL that apply.)

A. Thioridazine
B. Haloperidol
C. Asenapine
D. Quetiapine
E. Aripiprazole

C, D, E. Antipsychotics have various indications and are used for bipolar depression, or for mania, or for mixed episodes, either alone or with other agents in combination. It would have been a good guess that the older agents that cause significant ADRs would not get this approval: thioridazine due to QT prolongation, and haloperidol due to movement disorders.

15

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

A. Treatment of tics due to Tourette's or other conditions
B. Treatment-resistant depression
C. Bipolar depression
D. Antipsychotic-induced metabolic syndrome
E. Fibromyalgia

B, C. Antipsychotics are sometimes used in low doses in addition to antidepressants for treatment-resistant depression (as is seen with this combo drug) and could be useful for depression (which is similar to major depressive disorder) with bipolar disorder.

16

Select the correct name for the resource used to correlate symptoms to a diagnosis in patients with psychiatric illness:

A. The Diagnostic Manual of Psychiatric Disorders, Fourth Edition (DSP-4)
B. The Diagnostic Manual of Psychiatric Disorders, Fifth Edition (DSP-5)
C. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-4)
D. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
E. Joint National Committee on Psychiatric Illness, Eighth Edition (JNC-8)

D. This is an essential resource that is used for diagnostic criteria for psychiatric conditions. In choosing drug treatment other reputable resources will be required.

17

A physician wishes to use an atypical antipsychotic for a patient with early Parkinson's disease. Her medications include ropinirole, metformin, glipizide, and a daily aspirin. He chooses to use quetiapine extended-release. Which of the following benefits would likely be experienced with the use of this agent?

A. Little risk of movement disorders
B. Little risk of metabolic issues, such as elevated blood sugar and lipids
C. Little risk of sedation, orthostasis or dizziness
D. No risk of stroke or worsened mental state
E. No risk of increased appetite or weight

A. Quetiapine (compared to other atypical antipsychotics) has low risk for EPS and is often used for psychosis in Parkinson's disease.

18

Clara is a known patient at the local pharmacy. She states that she is depressed due to her husband’s gambling streaks where he has racked up high credit card debts. She states that he is either engaging in risky behavior or “moping around the house.” Clara says that her husband finally went to see a doctor, who diagnosed her spouse with “bipolar II disorder.” She asks the pharmacist what this means. Pick the most reasonable explanation:

A. This is a disease notable for causing fatigue, muscle weakness and cognitive decline.
B. This is a disease where the person is likely to have psychosis, such as hearing voices.
C. This is a disease where the person has periods of elevated or irritable mood, which alternates with periods of very sad mood.
D. This is a disease where the brain cells become demyelinated.
E. This is a disease where the brain cells lose dopamine, which is replaced with drugs such as Sinemet.

C. In bipolar II, the mania is not as a severe as in bipolar I. It is called "hypomania" in bipolar II. Psychosis is more often seen with bipolar I.

19

Margie has used lithium for many years. Normally, she has a fine hand tremor. Today, her hand is visibly shaking. She is nauseous, and vomited the little she ate this morning. Her speech is slurred and confused. She appears to have difficulty walking into the examination room. Margie is found to have lithium toxicity. Which of the following can contribute to lithium toxicity? (Select ALL that apply.)

A. Increased salt intake
B. Reduced renal function
C. Decreased intake of NaCl
D. Taking the lithium with fatty food
E. Elevated potassium

B, C. Lithium is renally cleared. For this reason, it cannot be used in patients with impaired renal clearance. Salt intake must remain constant. The kidneys do not distinguish between salt and lithium-if the salt intake is increased, the kidneys excrete more lithium and the serum level decreases. Or, vice versa, if the salt intake is decreased, the kidneys retain more lithium and the concentration will increase.

20

Margie has been using lithium for most of her adult life. She cannot afford air conditioning and has been living in an apartment where the temperature has been over 100 degrees for the five days. She succumbed to the heat and has been brought into the hospital with dehydration, acute renal failure and lithium toxicity. The lithium level is taken and found to be 3.2 mEq/L. The following adverse effects may be present when the lithium concentration is at this level: (Select ALL that apply.)

A. Severe CNS sedation
B. Acute (painful) pancreatitis
C. Arrhythmias
D. Seizure
E. Coma, death could occur

A, C, D, E. At this level, the lithium could be fatal. This patient started the lithium when younger. In general, lithium is a "do not use" drug in the elderly due to the risk of toxicity associated with declining renal function.

21

Holly is a 50 year-old female who has been using lithium as a mood stabilizer for bipolar disorder for three years. Holly presents to the clinic for her six-month follow up. She complains of fatigue, constipation, dry skin and mental sluggishness. Which of the following lab tests are most appropriate to find the probable cause of these symptoms?

A. AST and ALT
B. CH and LDL
C. BUN and serum creatinine
D. TSH and FT4
E. CBC

D. Lithium can cause hypothyroidism; patients on lithium therapy need to have their thyroid function monitored. A low FT4 and high TSH would indicate hypothyroidism.

22

A pharmacist is rounding in a lock-down unit. A patient with bipolar I is found to be pregnant. The pharmacist is asked about drug use in pregnancy. Which of the following statements is correct? (Select ALL that apply.)

A. Valproic acid is a dangerous drug to use in pregnancy, and is most dangerous when taken during the first trimester. It can cause neural tube defects in the newborn, and permanent cognitive damage.
B. Lurasidone is a second-generation antipsychotic used for bipolar; it is Pregnancy Category B.
C. Lithium is considered the safest option in pregnancy and is the "drug of choice" for treating bipolar II in pregnant women.
D. Most of the bipolar medications are Pregnancy Category C.
E. Lithium can cause heart damage to the newborn, along with cognitive dysfunction.

A, B, E. Lurasidone is a Pregnancy Category B agent used for bipolar.

23

Lithium must be kept within a “narrow therapeutic range”. What signs and symptoms may be present if the lithium concentration is elevated? (Select ALL that apply.)

A. Diarrhea/Loose stools
B. Aggravation and anxiety
C. Cogwheel rigidity
D. A "drunk-like" uncoordinated walk
E. Coarse hand tremor

A, D, E. Ataxia (lack of coordination and unsteadiness) occurs when many drugs are toxic, including alcohol, many anticonvulsants, many CNS depressants, and lithium. Occasionally, a person suspected of being "drunk" on alcohol is actually toxic on a prescription drug. A patient with ataxia due to a drug would also be significantly mentally confused, or have "cognitive dysfunction." Cogwheel rigidity occurs with chronic use and is not a symptom of toxicity.

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