DOC, MC, CI for Test 4

Question 1

(Lecture 1)

An anticonvulsant used in Bipolar Disorder, this is the current DOC in most manic indications

Answer 1

Valproic Acid/ Divalproex sodium

Effective as lithium in acute and prophylactic management

PREFERRED FOR RAPID CYCLERS (>4 MANIC EPISODES /YR)

PREGNANCY CAT D

Question 2

(Lecture 1)
This class of drugs is used first line in treating:
-Depression
-OCD
-Panic Disorder
-Social Phobia
-PTSD
-Premenstrual Dysphoric Disorder (PDD)
-Generalized Anxiety Disorder

Answer 2

Selective Serotonin Reuptake Inhibitors (SSRIs)

(EX: Fluoxetine; Fluvoxamine; Paroxetine; Sertraline; Citalopram; Escitalopram; Vilazodone; Vortioxetine

• not as lethal in cases of OD as are TCAs
• ONSET OF ACTION TAKES 3-8 WEEKS (OR LONGER IN SOME CASES)

Question 3

(Lecture 1)

This drug is used as a first line treatment of PTSD along with SSRIs

Answer 3

Venlafaxine (an SNRI)

-WORKS AS AN SSRI AT DOSES ~75mg/day; SNRI AT > 225mg/day

ADE: GI… INCREASE IN BP… ABRUPT DISCONTINUATION can yield withdrawal syndrome similar to SSRI w/d (taper dose)

CI: MAOIs and -triptans (serotonin syndrome)

Question 4

(Lecture 1)

This drug is a 2nd line agent for MDD

Answer 4

Desvenlafaxine (as SNRI)

is an active metabolite of venlafaxine… no advantage over venlafaxine

Question 5

(Lecture 1)
This drug is considered a 2nd or 3rd line agent used for anxious depression or in SSRI use that is too activating/ causing sexual dysfunction

Answer 5

Nefazodone (a Serotonin Receptor Antagonist… inhibits 5HT2 family of receptors)

-BLACK BOX WARNING for risk of liver failure

Question 6

(Lecture 1)

This MAOI, used for atypical depression in patients refractory to other anti-depressants is considered LAST LINE agent

Answer 6

Tranylcypromine

Question 7

(Lecture 1)
This NDRI is contraindicated for PATIENTS AT RISK FOR SEIZURES, those with a hx of eating disorders, and those withdrawing from alcohol or benzos

Answer 7

Bupropion

Question 8

(Lecture 1)

This anti-depressant is “not likely” to cause sexual dysfunction

Answer 8

Bupropion

Question 9

(Lecture 1)

These 2 anti-depressants are “less likely” to cause weight gain

Answer 9

Bupropion
and
Fluoxetine

Question 10

(Lecture 1)

These 3 are good choices for antidepressants which avoid/reduce somnolence

Answer 10

Mirtazapine
Paroxetine
and
Trazodone

Question 11

(Lecture 1)

These anti-depressants can increase energy

Answer 11

• Bupropion or an SNRI

- Fluoxetine and Sertraline are more activating than other SSRIs

Question 12

(Lecture 1)
These anti-depressant classes are recommended if the PT is currently experiencing anxiety; this drug can increase anxiety

Answer 12

• SSRI or SNRIs are recommended in anxiety

- Bupropion can increase anxiety

Question 13

(Lecture 1)

These two anti-depressants can be used in depression plus fibromyalgia or neuropathic pain

Answer 13

Duloxetine
or
Venlafaxine

Question 14

(Lecture 1)

These two anti-depressants have indication for diabetic neuropathy

Answer 14

Amitriptyline
and
Imipramine

Question 15

(Lecture 2)
This class of drugs is DOC for parkinsonism induced by drugs (anti-psychotics and Metoclopromide (Antiemetic))

Answer 15

Anticholinergics

EX: Benztropine (useful for control of EPS other than tardive dyskinesia)
and
Trihexyphenidyl

Question 16

(Lecture 2)

This drug may be the best choice for patients with mild-moderate Parkinson’s

Answer 16

Controlled release Carbidopa/Levodopa
-no measurable effect on “freezing”

(immediate release version for ERRATIC disease)

Question 17

(Lecture 2)
drug class considered first line mono-therapy in most symptomatic Parkinson's Pts because of less dyskinesias and not oxidizing into free radicals

Answer 17

Dopamine Agonists

• may delay need for Levodopa for several years
• can cause daytime sleepiness
• USE WITH CAUTION IN PTS W/ PSYCHOSIS OR DEMENTIA (may worsen sx)

Question 18

(Lecture 2)

IMPROVEMENT OF MOTOR DISABILITY in Parkinson’s is better with which drug?

Answer 18

Levodopa

• greatest effect on bradykinesia and rigidity
• initial therapy for elderly (>70), dementia, and patients with significant cognitive impairment
• wearing-off and on-off phenomena

Question 19

(Lecture 2)
LESSENING OF MOTOR COMPLICATIONS in Parkinson's is better with which class of drugs?

Answer 19

Dopamine agonists

EX: Bromocriptine; Pramipexole; Ropinirole; Apomorphine

Question 20

(Lecture 2)

Treatment strategy for Parkinson’s PT with side effect of Dyskinesia?

Answer 20

• Reduce L-Dopa dose

- Add amantadine (NMDA receptor Inhibitor) or an anticholinergic

Question 21

(Lecture 2)

Treatment strategy for Parkinson’s PT with side effect of severe motor fluctuations despite optimal oral therapy?

Answer 21

consider SQ apomorphine (a short acting D2 selective Dopamine angonist)
- FOR ACUTE, INTERMITTENT TX OF “OFF” EPISODES
- IF NO DOSING >1 WEEK, RESTART AT 0.2 ml INCREASE
or
Duodopa

Question 22

(Lecture 2) 
This class of drug is most useful in Parkinson's PTs with tremors, but side effects and CIs are a concern

Answer 22

Anticholinergics

Question 23

(Lecture 2)

Stimulation of this family of dopamine receptors improves rigidity and bradykinesia

Answer 23

D2

Question 24

(Lecture 2)
These 2 non-ergot D2 and D3 selective dopamine Agonists are used in mild Parkinsons and both have indication for Restless Leg Syndrome

Answer 24

Pramipexole
-POSSIBLE NEURO-PROTECTIVE EFFECT
and
Ropinirole

Question 25

(Lecture 2) This drug is used for prophylaxis of SEVERE N/V with Parkinson's PTS on APOMORPHINE; used 3 days prior to start - first month of tx

Answer 25

TRIMETHOBENZAMIDE

Question 26

``` (Lecture 2) Use of this short-acting D2 selective dopamine agonist in Parkinson is CI'd for -IV use -PTs with Sulfite sensitivity -PTs on 5-HT3 Antagonists ```

Answer 26

Apomorphine

Question 27

(Lecture 2) | This Dopamine analog DOES NOT CROSS THE BBB

Answer 27

Carbidopa

Question 28

(Lecture 2) | This Dopamine analog HAS THE ABILITY TO CROSS THE BBB and is CONVERTED INTO DOPAMINE IN THE PERIPHERY

Answer 28

Levodopa "HONEYMOON" PTs usually respond well for 3-5 years of tx, then effects start to decline

Question 29

(Lecture 2) | Treatment of "WEARING OFF" phenomenon (sx return before the next dose)

Answer 29

``` -INCREASE THE FREQUENCY (SHORTEN THE DOSING INTERVAL) of levodopa or -add a dopamine agonist or -add an MAO-B or COMT inhibitor ```

Question 30

(Lecture 2) Treatment of "ON-OFF" phenomenon (unpredictable return of sx w/o regard to dosing interval with severity ranging from akinesia (off) to periods of mobility with dyskinesias (on))

Answer 30

``` -redistributing dietary protein (high protein diet reduces absorption... keep steady intake) or -add a dopamine agonist or -add an MAO-B or COMT inhibitor ```

Question 31

These drugs carry a risk of SEROTONIN SYNDROME

Answer 31

-MAO-B (Selegiline and Rasagiline) | -

Question 32

SEROTONIN SYNDROME, a potentially life-threatening rxn) looks like this... (clinical triad)

Answer 32

- COGNITIVE EFFECTS - NEUROMUSCULAR DYSFUNCTION - AUTONOMIC DYSFUNCTION

Question 33

This is how you tx SEROTONIN SYNDROME

Answer 33

- W/d offending agents - Supportive care * Benzos for anxiety/seizures * ice/cooling blankets for hyperthermia * cyproheptadine (1st gen antihistamine and 5HT1A and 5HT2 antagonist

Question 34

Compared to Selegiline, Rasagiline is...

Answer 34

- 5X MORE POTENT - NOT METABOLIZED TO AMPHETIMINE derivative - ADDITIONAL TESTING NEEDED to determine HTN CRISIS POTENTIAL - WARNING to avoid tyramine foods

Question 35

(Lecture 2) This NMDA receptor inhibitor was originally designed as an ANTIVIRAL TO TX TYPE A INFLUENZA. It notably carries an ADE of LIVEDO RETICULARIS rashes.

Answer 35

Amantadine

Question 36

(Lecture 2) This COMT Inhibitor used to manage motor fluctuations in Parkinson's ("wearing-off" effect) and is an adjunct to (must be used with) levodopa/carbidopa is known to CAUSE ORANGE DISCOLORED URINE and does not cross the BBB.

Answer 36

Entacapone (STALEVO is a brand combo agent containing Carbidopa, Levodopa, and Entacapone)

Question 37

(Lecture 2) | When tx hallucinations in Parkinsons... what 2 strategies should be used?

Answer 37

- stop meds that may contribute to psychosis beginning with anticholinergics - Avoid typical antipsychotics, risperidone, and olanzapine

Question 38

(Lecture 2) If cognitive D/Os occur with Parkinson's, discontinue/reduce Parkinson's drugs as tolerated. If antipsychotics are needed, treat with these newer neuroleptics:

Answer 38

- Quetiapine | - Clozapine (best option, but bad side effects of agranulocytosis)