Antipsychotics/Lithium- 2

Question 1

ADEs of Clozapine or Haloperidol?

• Sedation: +
• EPS: ++++
• Anticholinergic: +
• Orthostasis: +
• Weight gain: +
• Prolactin: +++

Answer 1

Haloperidol

(opposite effects as Clozapine)

Question 2

ADEs of Clozapine or Haloperidol?

• Sedation: ++++
• EPS: +
• Anticholinergic: ++++
• Orthostasis: ++++
• Weight gain: ++++
• Prolactin: +

Answer 2

Clozapine

(opposite effects as Haloperidol)

Question 3

What is the main thing Risperidone causes an increase in?

B/c of this, what might you see on physical exam?

Answer 3

Increase in Prolactin

Galactorrhea

Question 4

T/F: the following side effects are for ALL antipsychotic medicaitons:

Akathisia, Anticholinergic, Glucose intolerance, Hyperlipidemia, Orthostatic hypotension, Hyperprolactinemia, Sedation, Sexual dysfunction, Tardive dyskinesia, Weight gain

Answer 4

True

Question 5

Which antipsychotic has agranulocytosis?

Answer 5

Clozapine

Question 6

Which medication has Sialorrhea (excess drooling) as a side effect?

Answer 6

Clozapine

Question 7

Which antipsychotic has the following adverse effects:

1. Bronchospasm
2. Respiratory distress
3. Respiratory depression

4. Respiratory arrest

Answer 7

Inhaled loxapine

(Can only be administered in approved healthcare facilities registered in REMS program)

Question 8

Which antipsychotic has post injection sedation/delerium syndrome?

Answer 8

Long-acting olanzapine pamoate monohydrate

Question 9

What are 5 examples of dose-dependent extrapyramidal effects caused by antipsychotics?

Answer 9

Parkinson like syndrome:

• Bradykinesia, rigidity, tremor
• Akathsia, dystonias

Question 10

What are the 5 treatment options for dose-dependent extrapyramidal effects (parkinson-like syndrome) caused by antipsychotics?

(“BAD AB”)

Answer 10

1. Antimuscarinics (Benztropine, Trihexyphenidyl)
2. Antihistaminic (Diphenhydramine)
3. Dopamine Agonist (Amantadine)
4. Benzos (Lorazepam, Diazepam, Clonazepam)
5. B-blockers (Propanolol)

Question 11

What are the two toxicities of antipsychotics?

Answer 11

1. Dose-dependent extrapyramidal effects
2. Tardive dyskinesias (may appear as early as 6mo, usually years)

Question 12

What is the treatment goal for schizophrenia in the first 7 days?

Answer 12

Decreased agitation, hostility, anxiety and aggression

Normalization of sleep and eating

Question 13

What is the treatment goal for schizophrenia during weeks 2 and 3?

Answer 13

Improve socialization, self-care and mood

Question 14

What is the goal of maintenance therapy for Schizophrenia?

Answer 14

Avoidance of relapses

Question 15

Schizophrenia maintenance therapy:

How long should you continue medication after remission of the first psychotic episode?

Answer 15

at least 12 months

(many experts recommend tx for at least 5 years)

Question 16

Schizophrenia maintenace therapy:

Which group of meds should be tapered slowly before discontinuation to avoid cholinergic rebound?

Answer 16

Antipsychotics (especially FGAs and clozapine)

Question 17

Schizophrenia maintenance therapy:

What should you do when switching from one antipsychotic to another?

Answer 17

the first should be tapered and discontinued over at least 1 to 2 weeks while the second antipsychotic is initiated and tapered upward

Question 18

The following meds are used for what?

• Lithium
• Valproate
• Carbamazepine
• Aripiprazole
• etc

Answer 18

Acute mania treatment in Bipolar disorder

Question 19

What are the 4 meds used as maintenance treatment for Bipolar disorder?

Answer 19

1. Lithium
2. Aripirazole
3. Olanzepine
4. Lamotrigine

(LOLA has bipolar disorder)

Question 20

What 2 meds are used to tx bipolar depression?

Answer 20

1. Quetiapine
2. Lurasidone

Question 21

Bipolar Disorder treatment:

Which two groups of meds may need to be included during initiation because of the slow onset of lithium or valproic acid?

Answer 21

Antipsychotics and benzos

Question 22

What can precipitate mania in bipolar patients?

(KNOW)

Answer 22

Monotherapy with antidepressants

Question 23

______ appears to preserve or increase the volume of brain structures involved in emotional regulation such as the prefrontal cortex, hippocampus and amygdala, possibly reflecting its neuroprotective effects.

Answer 23

Lithium

Question 24

At a neuronal level, lithium reduces ______ but increases _______

Answer 24

At a neuronal level, lithium reduces excitatory (dopamine and glutamate)** but increases **inhibitory (GABA) neurotransmission

Question 25

T/F: Lithium has a narrow margin of safety

Answer 25

True

Question 26

Lithium is excreted virtually entirely how?

Answer 26

in the urine

Question 27

Toxicities associated with lithium are seen when there is too low of what?

Answer 27

sodium

Question 28

What needs to be closely controlled when prescribing lithium?

Answer 28

sodium

Question 29

Does therapy with Lithium make sense in a high performing atheletes?

Answer 29

No because can't maintain the sodium

Question 30

Does litihium cause sedation?

Answer 30

no

Question 31

Clearance of Lithium is decreased by taking what 2 medications?

Answer 31

Thiazides and NSAIDs

Question 32

What is the first sign of lithium toxicity?

Answer 32

tremor

Question 33

What are the 4 toxicities of Lithium?

Answer 33

1. Tremor (1st sign of toxicity) 2. Edema 3. **Hypothyroidism** 4. Renal dysfunction

Question 34

Lithium is a pregnancy category \_\_\_\_\_

Answer 34

D

Question 35

Where can Lithium substitute for sodium?

Answer 35

In proximal tubule cells and principal cells of the collecting duct in kidney cells

Question 36

* Lithium inhibits GSK-3 leading to increased \_\_\_\_\_\_expression and PGE2 synthesis. * This results in diminished _______ activity and decreased AQP2 levels on apical membrane of principal cells, which leads to increased \_\_\_\_\_\_\_.

Answer 36

* Lithium inhibits GSK-3 leading to increased **_COX-2_** expression and PGE2 synthesis. * This results in diminished **_Vasopressin_** activity and decreased AQP2 levels on apical membrane of principal cells, which leads to increased **_Urination_** (This is Lithium induced nephrogenic diabetes insipidis)

Question 37

How do you treat an acute hypomania episode in a patient with bipolar disorder?

Answer 37

1. optimize current mood stabilizer or initiate one (**Lithium, Valproate, Carbamazepine or SGAs**) 2. +/- Benzos for short term tx of agitation or insomnia

Question 38

How do you treat an acute manic episode in a person with bipolar disorder? (3)

Answer 38

2-3 drug combo (Lithium, valproate, or SGA) + Benzo (Lorazepam or clonazepam) +/- antipsychotic (short term for agitation/insomnia)x

Question 39

What are the 5 general guidelines for treatment of **acute manic or mixed episodes** in a patient with bipolar I disorder?

Answer 39

1. Assess for secondary cuases of mania or mixed states (ex: alcohol, drugs) 2. Discontinue antidepressants 3. Taper off stimulants and caffeine if possible 4. Treat substance abuse 5. Encourage good nutrition, exercise, sleep, stress reduction, etc

Question 40

What are the 4 general guidelines for treatment of an **acute depressive episode** in a patient with bipolar I disorder?

Answer 40

1. Assess for secondary causes of depression (ex: alcohol, drugs) 2. Taper off antipsychotics, benzos or sedative hypnotic agents if possible 3. Treat substance abuse 4. Encourage good nurtition, exercise, sleep, etc

Question 41

How do you treat a severe depressive episode in a patient with Bipolar I disorder

Answer 41

* Optimize current mood stabilizer or initiate mood-stabilizing med (lithium or quetiapine or lurasidone) * If psychosis: initiate antispychotic \*do not combine antipsychotics\*