Block 3 Flashcards
(157 cards)
1
Q
DSM-5 Criteria Bipolar I vs II
Which one has manic episodes?
A
I
2
Q
DSM-5 Criteria Bipolar I vs II
Which one sometimes requires hospitilizations?
A
II
I always requires hospitalization
3
Q
DSM-5 Criteria Bipolar I vs II
Which one must last for 4 consecutive days to be diagnosed?
A
II
4
Q
DSM-5 Criteria Bipolar I vs II
Which one has hypomanic episodes?
A
II
5
Q
DSM-5 Criteria Bipolar I vs II
Which one requires the episode to last for 1 week and being present most of those days?
A
I
6
Q
What must occur for a cyclothymic disorder diagnosis?
A
Fluctuation between subsyndromal depression and hypomanic episodes
2 yrs for adults
1 yr for younger peeps
7
Q
What is a mixed condition for bipolar?
A
Major depressive episode + manic episode almost daily for a week
Requires hospitalization
8
Q
What is a rapid cycling condition for bipolar?
A
> 4 major depressive OR manic episodes in 12 months
Requires hospitalization
9
Q
(T/F)
AD may trigger manic/hypomanic episodes
A
True
10
Q
FDA approved agents for acute mania?
A
LARVA COZ Q
Lithium Aripiprazole Risperidone Valproate Asenapine
Carbamazepine
Olanzapine
Ziprasidone
Quetiapine
11
Q
FDA approved agents for maintenance of bipolar?
A
ALDOL
Aripiprazole Lithium Divalproex Olanzapine Lamotrigine
12
Q
FDA approved agents for bipolar depression?
A
Quetiapine + Lurasidone
13
Q
Labs + Lithium?
A
PT BEER
Pregnancy (teratogenic
Thyroid
Blood (increase WBC)
EKG
Electrolytes (decreases sodium)
Renal (excreted)
14
Q
Serum levels of lithium of acute mania and for maintenance?
A
Acute = 0.8 to 1.2
Maintenance = 0.6-1.0
Draw lvls 12hrs after last dose
15
Q
Lithium + toxicity levels?
A
- 5 to 2.0 = N/V/D, ataxia, , lethargy, drowsiness
- 0 to 2.5 = anorexia, delirium, stubor, ECG changes
> 2.5 = seizures, renal damage, oliguria
16
Q
Which Rx will increase concentration of lithium?
A
Thiazides, NSAIDs and ACE/ARBs
17
Q
How do thiazides increase lithium concentration?
A
Sodium depletion results in increases proximal reabsorption of sodium and lithium
18
Q
How do NSAIDs increase lithium concentration?
A
Enhanced reabsorption of sodium and lithium by inhibition of prostaglandin synthesis
19
Q
How do ACE/ARBs increase lithium concentration?
A
Reduced GFR results in reduced lithium elimination
20
Q
Which genes are associated w/ increased % of ADHD?
A
Dopamine transporters and receptors, SNAP25 and COMT genes
21
Q
Environmental factors of ADHA?
A
FAS, lead poison, meningitis
Obstetric adversity, maternal smoking, adverse parent-child relationships
22
Q
What are the neurotransmitters involved for ADHD?
A
DA and NE
Defect in receptor D4 (DRD4) receptor gene
Overexpression of DAT-1
23
Q
DSM-5 Criteria for ADHD?
A
Must be present for ≥6 months
17+ yo = ≥5 symptoms
16 and below = ≥6 symptoms
Symptoms had to be present prior to age 12
Present in ≥2 settings
24
Q
Most cases of ADHD are found in what age group?
A
School age; 6-11, realized from 6-9
25
Oppositional defiant disorder DSM 5 critera?
4 sx over 6 months (angry, argues, refuses to comply)
<5 yo = most days
>5 yo = once weekly
26
Conduct disorder DSM 5 criteria?
3 sx in the past 12 month but 1 in the past 6 months (bullies, fights, cruel to animals/humans, theft, property destruction)
Childhood onset <10
Adolescent >10yo
27
What are the brain regions involved in ADHD?
Prefrontal cortex + connection to basal ganglia and cerebellum
28
Specific NE receptors involved in ADHD
alpha 2A improves ADHD
alpha 1 impairs
Beta adrenoreceptors impair
29
What are the SNRIs used for ADHD?
Atomoxetine
30
What are the alpha 2 adrenergic agonists used for ADHD?
Clonidine + Guanfacine
31
What are the NDRIs used for ADHD?
Methylphenidate
Dexmethylphenidate
Amphetamines
Dextroamphetamines
Lisdexamfetamine
Bupropion
32
Methylphenidate formulations
Tablets, chewables, liquid = short acting (more flexibility, but can have peak/trough effects that might be uncomfortable)
Wax matrix tablets = intermediate (causes inconsistent release of Rx)
Osmotic release oral system = long-acting
33
Methylphenidate w/ food increases (Cmax/Tmax)
Cmax
34
(d/l) methylphenidate is more bioavailable
D
35
(T/F)
Methylphenidate has extensive first-pass metabolism
True
36
General structure of amphetamine
Ring with a basic carbon skeleton with a methyl group and amine
37
SAR of amphetamines?
Amine = primary is more potent than tertiary except in methamphetamines
Demethylation lowers lipophilicity and increased metabolism (S isomer more potent like in dextroamphetamines)
Adding groups to ring reduces CNS stimulation
38
Metabolism of amphetamines and urine?
Most are excreted unchanged
39
Lisdexamfetamine info?
Prodrug, needs to be hydrolyzed to form d-amphetamine
40
Stimulant AE?
Reduced appetite and weight loss
Insomnia, irritability, psychosis, rebound sx, and even sudden cardiac death
41
Bupropion vs other stimulants
Efficacy
Equal compared to methylphenidate
42
Bupropion vs other stimulants
AE?
Lower prevalence of appetite suppression and weight loss, but risk of seizure exists
43
Atomoxetine vs other stimulants
Efficacy
Less efficacious than methylphenidate OROS and has slower onset (2-4wks) vs stimulants 1-2hrs
44
Atomoxetine AE?
Liver injury and new-onset suicidality
Sexual AE too
More sedation vs stimulants
45
Clonidine vs Guanfacine, which one is more selective for alpha 2?
Guanfacine
Clonidine activates both alpha 1 and 2
46
When starting rx for ADHD, what should adults vs children start off?
Adults = amphetamines
Children = methylphenidates
Swap if they done work
47
Just know that in vyvanse, it doesnt have a dose-dependent effect but rather a dose dependent AE profile
k
48
Stimulant safety issues?
Psychiatric (just decrease dose)
CV risk
Growth
49
DI with atomoxetine?
CYP2D6 inhibitors and increased AUC with PM of CYP2D6
50
Which alpha 2 agonist for ADHD is affected by high fat meals?
Guanfacine (increases concentration)
51
What is pica?
Eat nonfood >1 month
52
What is rumination?
Regurgitation of food >1 month
53
DSM-5 Anorexia nervosa
Cant maintain >85% normal body weight or BMI >17.5
54
Anorexia nervosa types?
Restricting: lasts 3 months, has not engaged in binge eating or purging
Binge-eating/purging type: last 3 months
55
DSM-5 bulimia nervosa
Binges weekly for 3 months
vs binge-eating disorder which just requires once weekly for 3 months
56
What is the most common AE of AN and BN?
Cardiac complications
CV collapse due to refeeding syndrome
57
Prognosis of AN?
Most will reach remission, but 20% will remain chronically ill even if they reach a normal weight
2-4% of those will even die due to cardiac arrest or suicide
58
Considerations for hospitalizations for ppl with eating disorders?
BMI<12
Nonresponsive to outpatient tx after 3-4 months
59
Nonpharm Tx for AN?
Cognitive behavioral therapy for 6 months minimum
SLOW refeeding usually with liquids
Controlled wt gain (2-3lbs/wk)
Add 3500-7000 calories/week
60
Pharm Tx for AN?
No role for antidepressants in acute Tx
If used, SSRIs are preferred due to AE profile; Fluoxetine is the most widely studied one
Smaller study showed Olanzapine with positive results (but not FDA approved)
Works with BN too
61
What rx is used for binge eating disorder?
Lisdexamfetamine 50 and 70mg, NOT 30!!! (only one that is FDA approved)
SSRIs, Atomoxetine, venlafaxine
Topiramate, zonisamide, and orlistat
62
What are the environmental etiologies of alzheimer's disease?
Increased age (#1 factor)
Decreased reserve capacity of brain
Head injury
Increased risk for vascular diseases
63
Which genes can cause early onset familial alzheimer's disease?
Mutations in dominant alleles
Chromo 1 (PSEN 2)
Chromo 14 (PSEN 1)
Chromo 21 (APP)
64
Which genes can cause late onset familial alzheimer's disease?
ApoE
Chromo 19 (specifically epsilon 4 that increases risk)
ApoE4 (both epsilon 4 = most risk, no copies = least risk)
65
What is the amyloid cascade hypothesis?
AD pt have amyloid plaques, which are beta-amyloid proteins
APP is typically cleaved by alpha then gamma secretase, but in AD alpha is replaced by beta
Causes 42 length beta-amyloid fragments which forms plaque
66
What are neurofibrillary tangles?
Found inside AD pt, specially hippocampus and cerebral cortex
NFTs have hyperphosphorylated Tau proteins which fills cytoplasm
67
What role does ApoE have in AD?
May clear beta-amyloids (binds strongest to E2, then E3 and lastly E4)
68
Inflammation and AD?
Believed to be pro-inflammatory mediators such as cytokines
Studies show NSAIDs may reduce AD risk
69
What is the cholinergic hypothesis?
Loss of cholinergic neurons cause decline in memory and cognition
Cell loss is a consequence of AD and doesnt cause AD
70
How is excitotoxicity caused by glutamate?
NMDA and AMPA receptors exist in postsynaptic membranes
AMPA allows sodium influx which allows magnesium to block NMDA receptors
Glutamate binds to NMDA and causes calcium influx to that alone leads to neurotoxicity
71
When can definitive diagnosis be made for dementia?
Autopsy
72
What is unique with Creutzfeldt Jacob Disease in dementia?
No inflammatory response + amyloid plaques are not always observed
73
Which phobias are the most common?
Animals and heights
74
What does the amygdala control?
Fear
75
What does the locus ceruleus control?
NE projections to areas responsible for fear response
76
What does the hippocampus control?
Consolidates traumatic memory and fear conditioning
77
What does the hypothalamus control?
Neuroendocrine + autonomic response to threats
78
Drugs that decrease anxiety and produce sedation target GABA (A/B)
A
Decreases neuronal excitability via chloride channel
79
Drugs that inhibit locus ceruleus such as ______, inhibit LC firing and do what?
EX: BZD, SNRIs, SSRIs
Decrease NE and block anxiogenic drugs
80
How does stress affect the hypothalamus and brainstem?
Hypothalamus affects the pituitary and eventually the adrenal glands which produces cortisol and Epi
Brainstem (which contains locus ceruleus) increases sympathetic outflow which also affects the adrenal glands and autonomic effects
81
How does serotonin activity affect locus ceruleus?
Increases serotonin = decreases locus ceruleus
82
Unlike the other anxiety disorders, OCD involves what?
Serotonin AND dopamine
83
To be diagnosed with generalized anxiety disorder, how long must you have it?
6 months
84
To be diagnosed with panic disorder, how long must you have it?
1 month
85
Which anxiety condition is linked with agoraphobia?
Panic disorders, must have escape routes
86
Social anxiety disorder physical indicator?
Blushing
87
Acute stress disorder occurs when after a trauma?
Within 1 month and lasts 2 days and resolves around 4 wks
88
What are the cholinesterase inhibitors used in dementia? MOA?
Tacrine
Donepezil
Galantamine
Rivastigmine
Binds REVERSIBLY to AchE which accumulates ACh
89
What are the NMDA antagonists used for dementia? MOA?
Memantine
Blocks action of glutamate attaching to NMDA receptors
90
Aducanumab MOA?
Reduces/dissolves beta-amyloid plaques
91
Which drugs for alzheimer's are primarily renally eliminated?
Rivastigmine and memantine
92
Which AD drug has multiple MOA?
Galantamine
Competitively inhibits AChE + modulates pre/postsynaptic nicotinic receptors (can help release ACh? might be neuroprotective?)
93
GABA A receptor info?
Ligand-gated channel
Channel is closed until GABA binds to it which allows chloride to enter
94
BZD bind to which sites?
Allosteric site at alpha and gamma subunits
95
Alpha 1 and alpha 2 sites of GABA, what effects do they lead to?
Alpha 1 = sedation
Alpha 2 = anxiolytic
96
What do BZD require to exert their effects?
GABA because they are positive allosteric modulators
97
What combo with BZD are fatal?
Ethanol and opioids due to them being CNS depressants
98
BZD main structures?
3 rings, but the important ones are the two that are directly touching each other
Side ring = at C7, it enhances anxiolytic activity
Main ring = C3 have comparable potency and are excreted more rapidly
99
Half life and BZD?
BZD are given based off of their half life
Short half life? For hypnotics
Long half life? Anxiolytics
100
Which BZD are inactivated rapidly by non-P450 dependent ways? What the importance?
Lorazepam, Oxazepam, and Temazepam
DDI are less of a concern
101
Buspirone class? Anxiolytic activity is due to what?
Aryl piperazine
5-HT1a partial agonist
102
Buspirone metabolism?
Extensive first pass metabolism (2.5hr half life), gotta be dose 2-3 times/day
103
What are the "Z" drugs?
Non BZD hypnotics
Zaleplon
Zolpidem
Eszopliclone
104
Z drug MOA and use?
Target alpha 1 subunit of GABA
Treats insomnia
105
Zolpidem metabolism? Adjustments?
Absorbed via GI with a 2.5hr half life which should cover a 8hr sleep period
Dose adjustments made for elderly and hepatic impairment
106
Zaleplon metabolism?
Absorbed via GI with a 1hr half life
Metabolized by AO + CYP3A4 with inactive metabolites
107
Eszopiclone metabolism?
Absorbed via GI with a 6hr half life
Only one of the Z drugs that is approved for long-term use
108
AE of Z drugs?
Generally safe vs BZD but amnesic sleep-related behaviors can come up (sleep walking, sleep eating, etc)
109
Ramelteon MOA?
Synthetic analog of melatonin and agonist at GPCR MT1 and 2 with much higher affinity than melatonin
110
Ramelteon AE and metabolism?
Less AE than BZD, no abuse, and can be used chronically
If used with CYP1A2 inhibitors, ramelteon levels will increase
111
Suvorexant MOA?
Orexin receptor antagonist that binds to orexin A and B to OX1 and 2
112
Suvorexant AE and metabolism?
Low potential for abuse and can be used chronically, but next day drowsiness can occur
Metabolised by CYP3A4
113
Lemborexant MOA?
Antagonist of OX1 and 2
114
Lemborexant metabolism?
Via CYP3A4
Caution over 10mg due to impairment
115
Esketamine class and indication?
S-isomer of ketamine (NMDA antagonist)
Used for TRD in certified clinics only
116
Esketamine AE?
Sedation, cognitive impairment, must monitor pt for at least 2 hrs after admin
Similar to phencyclidine aka angel dust which is known to cause episodic hallucinations
117
Brexanolone class and indication?
GABA receptor modulator
Used for postpartum depression over 60hrs of continuous infusion
118
Which antipyschs are generally safe to give to nursing mothers?
Sertraline
Paroxetine
Fluvoxamine
119
Psychotherapy should be used when in depression?
May be used alone in mild to moderate acute MDD
NOT RECOMMENDED ALONE in severe or psychotic MDD
120
When is light therapy used?
For seasonal affective disorders
121
When is ECT useful?
Rapid response is needed
Patient will be under anesthesia
Can be used in severe cases and MDD
122
What is a transcranial magnetic stimulation?
Coil placed on patients head while they are awake (no anesthesia needed)
No cognitive AE
123
What is vagus nerve stimulation?
Approved for epilepsy and TRD
Implanted in left chest wall area attached to left vagus nerve and applies to CN X
Required to be programed
124
Most common AE of vagus nerve stimulation?
Voice modulation during the stimulation
125
Disadvantages to vagus nerve stimulation?
Surgery, cost
126
What is deep brain stimulation?
FDA approved for parkinson's and tremors
127
Statistic to know about homicide and suicide...?
Since 2010, suicide death outnumbered homicide deaths
128
What is the number one drug that is used for suicide?
OTC
129
What are the top mental health conditions of peeps that commit suicide?
Depression (#1), then anxiety and then bipolar
130
Church and suicide?
Church attendance is NOT a factor
Church involvement IS a factor
131
What is a overlooked contributor to "imminent" suicidal risk?
Insomnia
132
DSM-5 Criteria Bipolar I vs II
Which one contains Mixed or Rapid cycling?
Bipolar I and II
133
DSM-5 Criteria Bipolar I vs II
Which one can occur throughout the life cycle with a mean age of onset at 18 yo?
I
II mean age of onset is mid-20s
134
DSM-5 Criteria Bipolar I vs II
Which one has several MDD prior to manic-like states?
II; Several episodes of MDD prior to hypomanic episode
I has mania then depression
135
Bipolar and biological factors
```
Serotonin
NE
Glutamate
GABA
VMAT2
```
Which one affects mania/depression?
Decreased serotonin = depression
NE = linked w/ mania
Glutamate/GABA = affects mania and depression
VMAT2 = higher in bipolar pt
136
How long does Lithium take to work?
7-10 days, but can take up to 6-8wks for full effect
137
Li AE of tremor, how do you treat it?
Propranolol
138
Li AE of polyuria, polydipsia?
Amiloride
139
Valproic acid can treat for (mania/depression)
Both
140
Lamotrigine can treat for (mania/depression)
Just depression
141
Atypical antipsychs are used to prevent relapse of (mania/depression)
Mania
142
AAPPG + Tx for ADHD
Preschool
School age
Adolescents + Adults
Preschool = behavioral therapy + methylphenidate
School age = behavioral therapy AND stimulant, atomoxetine, guanfacine, or clonidine
Adolescents + adults = behavioral therapy AND FDA approved medications
143
Pharmacologic Tx algorithm for ADHD?
>18yo = uses Amphetamines
Dextroamphetamines
Lisdexamfetamine first
then Methylphenidate
Dexmethylphenidate
For Pediatric pt, its swapped
144
Stimulant MOA?
Blocks DA and NE reuptake
Increases catecholamine release
Inhibits monoamine oxidase release
145
Use of lisdexamfetamine and its efficacy?
Not dose dependent for efficacy, but has dose dependent AE profile
146
Methylphenidate AE?
May increase concentration of TCAs
In combo with clonidine, will enhance CV effects
147
DDI of stimulants and MAOIs?
14 day washout period with MAOIs
148
Methylphenidate and psychosis risk?
If they have it, watch them for the first 9 months (especially 3 months)
149
If patient is on stimulant + has reduced appetite or weight loss, what do you do?
Give high calorie meal
150
Alpha 2 agonists for ADHD, MOA?
Inhibits NE and increases blood flow to prefrontal cortex
151
Alpha 2 agonist for ADHD, efficacy?
Not really used as monotherapy, usually in addition to stimulants
152
Weight in anorexia vs bulimia
Weight can be normal in bulimia
153
Prevalence of anorexia, buliimia, and binge-eating
Binge-eating is the most prevalent
154
What is the only FDA approved drug for bulimia?
Fluoxetine
155
In bulimia, is bupropion okay to use?
No, increased seizure risk
156
Fluoxetine is used for (anorexia/bulimia)
Bulimia, no FDA approved meds for anorexia
157
What are some reversible causes of dementia?
B12 and hypothyroidism
