FGAs - Higher affinity for _____ receptor, acts as _______ (agonist/antagonist) - alleviate primarily _____ symptoms - causes an increase in _____, _______, and _____ ________ - inexpensive

- D2, antagonist - positive - EPS, prolactin, tardive dyskinesia (TD)

SGAs - ↑ _________ vs. ________ receptor affinity - Thought to treat negative/cognitive symptoms??? - ↓ ___, ↓ _______, ↓ ______ _______ - ↑ ______ _______ - More expensive

- ↑ Serotonin (5HT2) vs. dopamine (D2) receptor affinity - ↓ EPS, ↓ prolactin, ↓ TD - ↑ Metabolic effects

Exam 2 practice questions Flashcards by Dette Ang

DSM-5 TR® Criteria: Schizophrenia

A.) 2 or more of the following symptoms, each persisting for a significant portion of time during a 1 month period, one symptom must include (1), (2), or (3):

DELUSIONS
HALLUCINATIONS
DISORGANIZED SPEECH
GROSSLY DISORGANIZED/CATATONIC BEHAVIOR
NEGATIVE SYMPTOMS

B.) Social/Occupational Dysfunction
> 1 area of functioning below level prior to onset of illness
- WORK
- INTERPERSONAL RELATIONSHIPS
- SELF-CARE

C.) Duration
- Continuous signs of disturbance for > 6 months

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1st Generation/Typical Antipsychotics

chlorpromazine (Thorazine)

* haloperidol (Haldol)

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2nd Generation/Atypical Antipsychotics

aripiprazole (Abilify)
asenapine (Saphris)
clozapine (Clozaril)
olanzapine (Zyprexa)
quetiapine (Seroquel)
risperidone (Risperidal)
iloperidone (Fanapt)
paliperidone (Invega)
lurasidone (Latuda)
ziprasidone (Geodon)

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Treatment Goals
• Acute phase
o Initiate pharmacotherapy ASAP
o Titrate to ___________(maximum/lowest) therapeutic dose based on tolerability

lowest

only need lowest effective dose
–> higher the dose = more side effects

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FGAs

Higher affinity for _____ receptor, acts as _______ (agonist/antagonist)
alleviate primarily _____ symptoms
causes an increase in _____, _______, and _____ ________
inexpensive

D2, antagonist
positive
EPS, prolactin, tardive dyskinesia (TD)

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SGAs

↑ _________ vs. ________ receptor affinity
Thought to treat negative/cognitive symptoms???
↓ ___, ↓ _______, ↓ ______ _______
↑ ______ _______
More expensive

↑ Serotonin (5HT2) vs. dopamine (D2) receptor affinity
↓ EPS, ↓ prolactin, ↓ TD
↑ Metabolic effects

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Which of these is not a sx of schizophrenia?

a. Positive sx (hallucinations, delusions)
b. Negative sx (loss of motivation, asocial
c. Mania
d. Lack of Salience
e. Cognitive sx (d1R mediated)-inability learn

c. Mania

mania is a sx of bipolar; salience means knowing what’s important when you are getting a lot of input into your brain

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Matching: DA projects from VTA and substantia nigra; what do they mediate?

a. VTA to frontal cortex 1. movement
b. Sub. Nigra to striatum 2. Motivations, emotions
c. VTA to nucleus accumbens 3. ADRs/prolactin release
d. Hypothalamus projection 4. Rewards/psychosis

a. VTA to frontal cortex - Motivations, emotions
b. Sub. Nigra to striatum - movement
c. VTA to nucleus accumbens - Rewards/psychosis
d. Hypothalamus projection - ADRs/prolactin release

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True or False?

According to dopamine hypothesis, high levels of DA to the frontal cortex is what causes the cognitive side effects

False.
It is low levels of DA from the VTA to the cortex that cause cognitive side effects. High levels of DA in mesolimbic pathway that cause the psychosis and positive sx

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According to the glutaminergic hypothesis, which NT is there a deficiency of in the cortex to cause an increase in DA upstream?

a. Glutamate
b. GABA
c. serotonin
d. Dopamine

GABA
NMDA receptors on the GABA receptor are not working properly according to this hypothesis causing less GABA to be released. This doesn’t allow for inhibition of the glutamate neuron that releases glutamate and allows for DA to increase on a dopaminergic neuron (excitatory) in the limbic neuron. It is a PROBLEM from the NMDA receptor though, which causes the deficiency in GABA. This explains positive, negative, cognitive sx; it can also explain the DA hypothesis

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Which receptor antagonism causes the tremors in chlorpromazine (Thorazine)

a. 5ht2
b. D1R
c. D2R
d. D5R

D2R

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Which of these are reasons why it takes a few weeks for a typical antipsychotic to decrease DA levels?

a. Remodeling
b. Action on autoreceptors
c. Increasing breakdown of DA

Remodeling.

If it acts on autoreceptors it is increasing DA levels in the synapse which wouldn’t help what we want since we want antagonism

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Which of these is a partial D2R agonist?

a. Chlorpromazine
b. Loxapine
c. Thiothixene
d. Aripiprazole

Aripiprazole

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Which drugs are more likely to cause EPS? Select all

a. Geodon
b. Perphenazine
c. Haldol
d. Abilify

Perphenazine
Haldol

the typicals are more likely to cause it; abilify has partial agonism so it would be less likely to cause EPS

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Which of these is more likely to cause metabolic syndrome?

a. Clozapine
b. Haldol
c. Chlorpromazine
d. Loxapine

Clozapine

more of a concern in atypicals; mostly clozapine and olanzapine

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Which atypical antipsychotic has an active metabolite that inhibits NET?

a. Olanzapine
b. Abilify
c. Quetiapine
d. Ziprasidone

Quetiapine

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What are the anticonvulsants used in bipolar disorder?

Lamotrigine, Tegretol, Depakote, Oxcarbazepine

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Which of the following is NOT a usual hallmark sx of schizophrenia & psychosis?

a. Depression
b. Cognitive impairment
c. Negative sx
d. Positive sx

depression

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Which of the following neurotransmitters was mentioned in the video as being related to schizophrenia?

a. Acetylcholine
b. Norepinephrine
c. Serotonin
d. Dopamine
e. GABA

dopamine

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Cognitive sx of schizophrenia are primarily due to dysfunction of the dopamine projections to the cortex.

a. True
b. False

True

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Schizophrenia is possibly due to:

a. Genetics (only)
b. Physical stressor on mom during pregnancy (only)
c. All of the factors above
d. None of the above

All of the factors above

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Imaging & post-mortem studies on schizophrenic patients have shown an enlargement of the brain mass and shrinking of the ventricles compared to non SCZ patients.

a. True
b. False

False

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Which of these drugs should not be used with CBZ (carbamazepine) due to it’s inhibition of epoxide hydroxylase?

a. VPA - valproic acid
b. OXC - oxcarbazepine
c. LTG - lamotrigine
d. Seroquel

VPA

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Which of these induces its own metabolism? Select all

a. VPA
b. Lithium
c. oxcarbazepine
d. CBZ

c. oxcarbazepine
d. CBZ

It induces 3a4 which causes slow therapeutic levels

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Which drug has its major activity in its metabolite? a. VPA b. Lithium c. Carbazepine d. Oxcarbazepine

d. Oxcarbazepine Answer: MHD is the active metabolite that has a half life of 9 while OXC has a half life of 2h. Abilify also has an active metabolite that has a longer half life than the main drug

Which drug has 20 metabolites via 3a4 from the first pass effect? a. Quetiapine b. Olanzapine c. Oxcarbazepine d. Haloperidol e. Lithium

a. Quetiapine

Which of these drugs undergoes stereoselective metabolism to give an active metabolite that is sold in the market? a. Quetiapine b. Olanzapine c. Oxcarbazepine d. Haloperidol e. Risperidone

e. Risperidone Answer: 3a4/2d6 gives it stereoselective metabolism into paliperidone (Invega)

Which drug undergoes osmotic pressure to release its contents and makes it longer acting? a. Olanzapine b. Oxcarbazepine c. Paliperidone d. Haloperidol e. Lithium

c. Paliperidone

Which are the IM depot antipsychotics? SELECT ALL a. Invega Sustenna b. haloperidol c. Fluphenazine d. Perphenazine e. Thiothixene f. Abilify Maintena

a. Invega Sustenna b. haloperidol (DECANOATE) c. Fluphenazine (DECANOATE) f. Abilify Maintena These are long acting and help with compliance and relapse issues; haloperidol decanoate & fluphenazine decanoate = IM depots

``` SGA Dosing: risperidone paliperidone iloperidone aripiprazole asenapine olanzepine quetiapine clozapine lurasidone ziprasidone ```

``` Usual Target Dose (mg/day) risperidone 2 – 8 paliperidone 3 – 12 iloperidone 12 – 24 aripiprazole 10 – 15 asenapine 10 – 20 olanzapine 10 – 20 quetiapine 150 – 800 clozapine 300 – 450 lurasidone 40 – 80 ziprasidone 40 – 100 ```

What drugs are metabolized by 1A2? Select all a. Abilify b. Saphris c. Latuda d. Geodon e. Fanapt f. Clozaril g. Zyprexa

Saphris / asenapine Clozaril / clozapine Zyprexa / olanzapine

What drugs are metabolized by 2D6? Select all a. Abilify b. Saphris c. Latuda d. Geodon e. Fanapt f. Clozaril g. Zyprexa h. Risperdal

Fanapt Abilify Risperdal "FAR"

What drugs are metabolized by 3A4? Select all a. Abilify b. Saphris c. Latuda d. Geodon e. Fanapt f. Clozaril g. Zyprexa h. Seroquel

``` Fanapt / iloperidone Latuda / lurasidone Abilify / aripiprazole Geodon / ziprasidone Seroquel / quetiapine ``` "FLAGS"

Which drug is the only one to go through non-CYP metabolism? a. Latuda b. Geodon c. Invega d. Fanapt e. Clozaril

Invega

Which drug that is metabolized by 3A4 is contraindicated with a strong 3a4 inhibitors and inducers? a. Latuda b. Abilify c. Fanapt d. Seroquel

Latuda

If you are giving fluvoxamine with olanzapine, you would have to: a. Increase the dose of olanzapine b. Increase the dose of fluvoxamine c. Decrease the dose of olanzapine d. Decrease the dose of fluvoxamine

c. Decrease the dose of olanzapine olanzapine is metabolized by 1A2 and fluvoxamine is a 1A2 inhibitor

Which drug can you not give along with short acting IM olanzapine? a. IV lorazepam b. IV carbazepine c. IV fluvoxamine d. Sertraline

IV lorazepam IM olanzapine is not to be given concomitantly with parenteral BZDs. Wait an hour first

Which of these BBWs of clozapine are dose related? Select all a. Myocarditis b. Agranulocytosis c. CV/respiratory effects d. Elderly mortality increase e. Seizures

c. CV / respiratory effects e. Seizures Seizures are dose related, and the CV effects may occur with rapid dose escalation

You have a patient that needs to be started on Clozaril. They have failed most other therapy. They have an ANC of 2500/mm3 and WBC of 3500/mm3. What dose of Clozaril would you start? a. Clozapine 300 mg b. Clozapine 12.5 mg c. Don’t start Clozapine d. Clozapine 400 mg

b. Clozapine 12.5 mg Clozapine must be titrated up and the WBC values are okay to start clozapine. Start over titration if missed >/= 2 days

The patient comes back in a week and has an ANC of 500 and WBC of 1500. Do you adjust the dose of Clozaril? a. Keep patient at current dose b. Increase dose to normal titration c. Discontinue Clozaril d. Decrease dose of Clozaril

c. Discontinue Clozaril D/c clozaril when ANC

Which SGA antipsychotics are NOT approved in acute manic episodes? a. Latuda b. Asenapine c. Olanzapine d. Quetiapine e. Clozaril f. Fanapt g. Risperidone h. Geodon i. Abilify j. Invega

Clozaril Latuda Invega Fanapt "CLIF"

Which SGA antipsychotics are approved for acute depressive episodes?

Clozaril / clozapine (treatment refractory) Latuda / lurasidone Seroquel / quetiapine Symbyax / olanzapine-fluoxetine "CLSS"

Which pain killer is recommended to be avoided with the use of Lithium? a. APAP b. Aspirin c. Sulindac d. Ibuprofen

d. ibuprofen NSAIDs should generally be avoided with Li, but the 3 pain killers listed above are okay to use. Lithium increases with concomitant use

Which of these increases Lithium concentrations when used in combo? a. Caffeine b. Pregnancy c. ACE inhibitors d. Theophylline

ACE Inhibitors the other 3 decrease Li concentration. ACEis, NSAIDs, and diuretics increase Li concentration

With Depakote DR you must wait ____ days and ____ hours post dose to check a level. a. 5 days, 12 hours b. 3 days, 12 hours c. 5 days, 18 hours d. 3 days, 18 hours

3 days, 12 hours 5 days wait is with lithium; 18 hours is for the ER Depakote

Due to the risk of thrombocytopenia, we always want to check ____ while a patient is on Depakote a. Platelets b. WBC c. ANC d. Blood glucose

platelets

With which side effect of VPA do you not have to discontinue the drug? a. Hyperammonia b. Tremor c. significant hepatic dysfunction d. Pancreatitis

tremor the other 3 are rare but serious and must not retry VPA after discontinuing; BBWs of VPA are hepatotoxicity, pancreatitis, and teratogenicity

Carbamazepine can decrease levels of all these drugs EXCEPT: a. Lamotrigine b. Phenytoin c. Oral contraceptives d. Protease inhibitors

phenytoin

MN is a 24 year-old female recently diagnosed with BPAD. Her physician is going to place her on a mood stabilizer. Which of the following mood stabilizers will not decrease the effectiveness of her birth control, Alesse® (ethinyl estradiol and levonorgestrel)? Select all that apply. a. Carbamazepine b. Lithium c. Oxcarbazepine d. Divalproex

Lithium | Divalproex

GG presents to the inpatient psych unit in a bipolar depressive episode. He had been stabilized on divalproex 1500 mg/day as an outpatient until this recent episode. You and the medical team decide to increase the dose of divalproex to 2000 mg/day and add lamotrigine. What is the target dose of lamotrigine? A. 200 mg/day B. 100 mg/day C. 400 mg/day D. Lamotrigine should not be given with divalproex

100 mg/day

``` MG presents to your inpatient psych unit in a current manic episode. Her lithium trough level is 0.7 mEq/L at a dose of 900 mg PO QHS. To adequately treat mania, trough levels should typically be around: a. 0.6-0.8 mEq/L b. 1.0-1.2 mEq/L c. >1.5 mEq/L d. ```

b. 1.0-1.2 mEq/L

HH was initiated on carbamazepine during his inpatient hospitalization. A trough level is drawn 5 days after increasing the dose to 400 mg/600 mg and returns at 9 mcg/mL. A month later, at his outpatient appointment, another trough level is drawn and returns at 5 mcg/mL. The physician suspects that HH has not been compliant with his carbamazepine. Another reason his trough may be low is due to: a. Autoinduction of metabolism by CYP2D6 b. Drug interaction with alcohol c. Use of interacting OTC medications (NSAIDs) d. Autoinduction of metabolism by CYP3A4

d. Autoinduction of metabolism by CYP3A4 Due to autoinduction of metabolism by CYP3A4; autoinduction takes several weeks to occur, that’s why it is higher at first

A patient newly started on lithium carbonate IR tablets (300 mg/600 mg)comes to your pharmacy complaining of diarrhea. He would like to know what can be done to stop to his diarrhea. What do you recommend to his physician? a. Switch to Lithobid b. Switch to lithium citrate c. Discontinue lithium d. Consolidate dose to bedtime

lithobid would make it worse, d/c is not helpful, and bedtime is for the sedation ADR

Of the mood stabilizers listed below, which plasma level correlates with efficacy in BPAD? a. Lithium b. Divalproex c. Carbamazepine d. Lamotrigine

Lithium We check levels of VPA and CBZ but they don’t correlate and LTG we don’t take levels

When to check trough level a. Lithium b. VPA c. CBZ

Valproic acid (divalproex) - 3 days Tegretol (carbamazepine) - 4 days Lithium - 5 days "Very True Level"

``` All of the following are FDA-approved as monotherapy for bipolar maintenance EXCEPT: A. Quetiapine B. Aripiprazole C. Olanzapine D. Risperidone long-acting injectable ```

quetiapine

``` All of the following will increase lithium levels EXCEPT: A. Ibuprofen B. Lisinopril C. Caffeine D. Furosemide ```

caffeine

``` HH comes to your pharmacy complaining of frequent bruising, hair loss, and GI upset. She said she recently started a mood stabilizer but cannot remember its name. These side effects most likely result from which mood stabilizer? A. Lithium B. Divalproex C. Carbamazepine D. Lamotrigine ```

divalproex Divalproex causes alopecia and thrombocytopenia

FP was recently started on oxcarbazepine and would like to know what her options are for birth control. She may receive treatment with all of the following EXCEPT: A. Progestin-only pill B. Medroxyprogesterone depot injection- Depo Provera® C. Hormone-releasing intrauterine system (levonorgesterel- releasing intrauterine system)- Mirena ® D. Copper IUD

A. Progestin-only pill

True or False. All drugs of abuse increase dopamine levels

True

True or False. If you are dependent on a drug, you are addicted

False. Opioid users may not be addicted, but their body is dependent and may go into withdrawal if they are chronic users

Alcohol _______ GABA causing sedation, and ______ glutamate. a. decreases, decreases b. increases, increases c. decreases, increases d. increases, decreases

d. increases, decreases

Which drug is not to be used while ingesting alcohol or being a chronic alcoholic? a. ibuprofen b. APAP c. Sulindac d. ASA

APAP APAP forms toxic NAPQI. Glutathione metabolizes NAPQI into inactive metabolites and clears it from the body. Toxic NAPQI levels increase due to alcohol depleting glutathione levels. Risk of hepatotoxicity

True or False. If you have alcoholism dependence and stop drinking immediately, your brain decreases GABA and increases glutamate causing an excitatory effect in the brain which may lead to seizures.

True

What is acamprosate? a. an NMDA antagonist b. anticonvulsant c. antidepressant d. anxiolytic

a. an NMDA antagonist

Why is naltrexone an appropriate agent to use in alcoholism? a) it is an opioid antagonist b) it is a gaba antagonist c) it is a glutamate agonist d) it is a serotonin agonist

a) it is an opioid antagonist | - which will prevent alcohol from binding to opioid receptors

True or False. Nicotine has its main effects in the VTA

True. It has little effect on the nucleus accumbens; mostly in VTA-SHARPE

How does Chantix work to help smoking cessation? A. it is a n. ach receptor antagonist b. it is an n. ach receptor partial agonist c. it is a DAT and NET inhibitor d. It is used as replacement therapy

b. it is a nicotinic ACh receptor partial agonist - this blocks the euphoric effects given from smoking by inhibiting nicotine to bind to it’s receptor but still giving some of the feeling

True or false. Cocaine has 2 MOAs. It is a competitive substrate for DAT, blocking DAT. Once it is taken up, it blocks VMAT from taking up DA causing a higher concentration of DA to build up in the presynaptic terminal, ultimately moving it into the synapse.

False. Amphetamine and methamphetamine do this. Cocaine just blocks DAT

True or false. There is FDA approved pharmacologic therapy to treat meth addiction.

False. | Only behavioral therapy is approved

True or false: Opioids are depressants

True. | not stimulants, hint: alcohol also agonizes opioid receptor, alcohol depresses

Methadone has the same activity as heroin. Why is it used as a pharmacological agent? a. It has a faster onset and a steady level b. It has a slower onset and a steady level c. It isn’t used as an agent d. It is just as euphoric and addictive as heroin so it helps the patient

b. It has a slower onset and a steady level it does cause addiction still but usually when it is abused such as being crushed and injected IV

Which of these causes mu opioid receptor ANTAGONISM? a. naltrexone b. buprenorphine c. methadone d. acamprosate

a. naltrexone b and c cause agonism/partial agonism, and acamprosate is an NMDA antagonist

Mu opioid receptor causes (select all) a. aversion b. sedation c. respiratory depression d. reward (reinforcement)

a. aversion kappa causes aversion

Which THC derivative is an antagonist? a. Dronabinol b. Nabilone c. Rimonabant

c. Rimonabant The others are agonists

Which of these drugs has its MAJOR effects through 5ht (select all) a. Methamphetamine b. Nicotine c. Alcohol d. Ecstasy e. Heroin f. LSD

d. Ecstasy f. LSD still has effects at DA but major effect through 5ht according to SHARPE

Which of these is not a stimulant given in ADHD? Select all a. Adderall b. Vayarin c. Ritalin d. Intuniv e. Straterra

b. Vayarin d. Intuniv e. Straterra

Alcohol-containing products, such as hand sanitizer and mouth wash, cannot be used until 2 weeks after discontinuing which agent? a. Disulfiram b. Naltrexone c. Buprenorphine d. Acamprosate

a. disulfiram bc they can cause the reaction to occur with a build up of acetylaldehyde; don’t use with Flagyl either

Which agent, used for opioid detoxification and maintenance therapy, has the potential to prolong the QT interval? a. Naltrexone b. Buprenorphine c. Methadone d. Acamprosate

c. Methadone

Which agent produces a “ceiling-effect” around doses of 16-20 mg/day, making it less effective for use in patients requiring higher opioid maintenance therapy doses? a. Naloxone b. Naltrexone c. Methadone d. Buprenorphine

d. Buprenorphine

All of the following are known risk factors for substance use disorders EXCEPT: a. Widowed, divorced, or separated b. Male c. Old age d. Lower socioeconomic status

c. Old age

What is the treatment of choice for alcohol withdrawal syndrome and delirium tremens? a. Carbamazepine b. Diazepam c. Alprazolam d. Acamprosate

b. Diazepam

True or False. | The presence of liver disease does not influence GGT levels but does effect CDT levels.

False

What does RIPS in the DSM5 for substance abuse stand for?

Risky use, impaired control, pharmacological criteria (dependence/withdrawal), social impairment

Which BZDs are approved in treating seizures in alcohol withdrawal pts that are elderly or have hepatic dysfunction? Select all a. diazepam b. Lorazepam c. chlordiazepoxide d. oxazepam

b. Lorazepam d. oxazepam The others are approved in treating seizures in younger pts; the others have a long half life and fewer rebound withdrawal sx

True or False | If pts have a CIWA score of <10 then we could give them a sx triggered regimen of BZDs.

False Should be >10

Wernicke’s is caused by what deficiency? a. sodium b. thiamine c. potassium d. magnesium

b. thiamine give it prophylactically and with glucose. Korsakoff’s is the permanent version characterized by memory impairment; doesn’t respond to thymine

Which drug should not be used concommitently with opioids or if pt is experiencing opioid withdrawal? a. Disulfiram b. Revia c. Buprenorphine d. Acamprosate

b. Revia it is an mu opioid antagonist that will make the withdrawal worse or the opioid not work; also not in liver failure: BBW-hepatotoxicity. Vivitrol is used in opioid dependence

True or false. | You could have ADHD as an adult if you didn’t have sx of ADHD as a child.

False | you don’t need to be diagnosed as a child, but you need to have the sx

If a 4 y/o child is diagnosed with ADHD. What is the best tx for them? a. behavioral therapy b. antidepressants c. methylphenidate d. Adderall

a. behavioral therapy 4-6 yo only get behavioral therapy, <4 don’t diagnose, 6-11- drug therapy but prefer to start with behavioral 12-18 yo- drug therapy

First line drug in adult adhd? a. bupropion b. STratera c. Adderall d. methylphenidate

d. methylphenidate b and c are second line and a is third; most stimulants are effective; usually BID and don’t give at night

True or False. | Stimulant therapy is weight dependent.

False use lowest dose possible, only take weight and height to check baseline for adrs. Increase dose until target sx resolvement; switch to ER if having sx before next dose in BID dosing

True or False. | You see an immediate effect with stimulants in ADHD.

False titrate q 1-3 weeks, you can see doctor after 1 week if it isn’t working. Monitor BP and HR, height and weight q3 month and q 6 months

Stimulants for ADHD are CI in all these pts except: a. Anxiety pt b. Psychosis pt c. those with HTN d. Pre existing tics

c. those with HTN only use caution

True or false. | Patients who were treated for ADHD were more likely to abuse substances

False less likely

Select all. Weight based dosing for which of these in ADHD? a. Ritalin b. Intuniv c. Straterra d. Adderall

b. Intuniv | c. Straterra

Which drug among these can be used in monotherapy for ADHD and comorbid conditions? a. venlafaxine b. bupropion c. Modafinil

b. bupropion

``` Which of the following is NOT a usual hallmark symptom of schizophrenia and psychosis? A. Depression B. Cognitive impairment C. Negative symptoms D. Positive symptoms ```

depression

``` Which of the following neurotransmitter was mentioned in the video as being related to schizophrenia? A. Acetylcholine B. Norepinephrine C. Serotonin D. Dopamine E. GABA ```

dopamine

True or false | The cognitive symptoms of schizophrenia are primarily due to dysfunction of the dopamine projections to the cortex.

True

``` Schizophrenia is possibly due to: A. Genetics (only) B. Physical stressor on mom during pregnancy (only) C. Psychosocial factors (only) D. All of the above E. None of the above ```

all of the above

True or false Imaging and post-mortem studies on schizophrenic patients have shown an enlargement of the brain mass and shrinking of the ventricles compared to non-SCZ patients.

False shrinking of the brain mass and enlargement of the ventricles

Provide a rationale for Valproic acid’s high PO bioavailability of higher than 80%.

Carboxylic acid FG → environment is acidic (stomach), ionization is minimal therefore can cross into systemic circulation

Low potency first-generation antipsychotics (FGA) differ from high potency FGAs because (select 2 answers): A. High potency FGA have higher binding affinity to D2 receptors B. High potency FGA have higher binding affinity to histamine (H1) muscarinic (M1), and alpha-1 receptors C. Low potency agents have higher binding affinity to D2 receptors D. Low potency agents have higher binding affinity to H1, M1 and alpha-1 receptors

A. High potency FGA have higher binding affinity to D2 receptors D. Low potency agents have higher binding affinity to H1, M1 and alpha-1 receptors

Risk factors for tardive dyskinesia include all of the following EXCEPT: A. Older age B. Long duration of antipsychotic treatment C. African-American D. Female gender

C. African-American

``` MN is a 24-year-old female recently diagnosed with BPAD. Her physician is going to place her on a mood stabilizer. Which of the following mood stabilizers will not decrease the effectiveness of her birth control, Alesse (ethinyl estradiol and levonogestrel)? Select all that apply. A. Carbamazepine B. Lithium C. Oxcarbazepine D. Divalproex ```

B. Lithium D. Divalproex

GG presents to the inpatient psych unit in a bipolar depressive episode. He has been stabilized on divalproex 1500 mg/day as an outpatient until this recent episode. You and the medical team decide to increase the dose of divalproex to 2000 mg/day and add lamotrigine. What is the target dose of lamotrigine? A. 200 mg/day B. 100 mg/day C. 400 mg/day D. Lamotrigine should not be given with divalproex.

B. 100 mg/day Lamotrigine usual target dose is 200 mg/day but since divalproex increases the concentration of lamotrigine 2-fold, it's dose should be decreased by half.

``` MG presents to your inpatient psych unit in a current manic episode. Her lithium trough level is 0.7 mEq/L at a dose of 900 mg PO QHS. To adequately treat mania, trough levels should typically be around: A. 0.6-0.8 mEg/L B. 1.0-1.2 mEq/L C. >1.5 mEq/L D. ```

B. 1.0-1.2 mEq/L

HH was initiated on carbamazepine during his inpatient hospitalization. A trough level is drawn 5 days after increasing the dose to 400 mg/600 mg and returns at 9 mcg/mL. A month later, at his outpatient appointment, another trough level is drawn and returns at 5 mcg/mL. The physician suspects that HH has not been compliant with his carbamazepine. Another reason his trough may be low is due to: A. Autoinduction of metabolism by CYP2D6 B. Drug interaction with alcohol C. Use of interacting OTC medications (NSAIDs) D. Autoinduction of metabolism by CYP3A4

D. Autoinduction of metabolism by CYP3A4

``` A patient newly started on lithium carbonate IR tablets (300 mg/600 mg) cones to your pharmacy complaining of diarrhea. He would like to know what can be done to stop to his diarrhea. What do you recommend to his physician? A. Switch to Lithobid B. Switch to lithium citrate C. Discontinue lithium D. Consolidate dose to bedtime ```

B. Switch to lithium citrate

``` Of the mood stabilizers listed, which plasma level correlates with efficacy in BPAD? A. Lithium B. Divalproex C. Carbamazepine D. Lamotrigine ```

Lihium

``` All of the following are FDA-approved as monotherapy for bipolar maintenance EXCEPT: A. Quetiapine B. Aripiprazole C. Olanzapine D. Risperidone long-acting injectable ```

Quetiapine

``` All of the following will increase lithium level EXCEPT: A. Ibuprofen B. Lisinopril C. Caffeine D. Furosemide ```

caffeine

``` AA comes to your pharmacy complaining of frequent bruising, hair loss, and GI upset. She said she recently started a mood stabilizer but cannot remember its name. These side effects most likely result from which mood stabilizer? A. Lithium B. Divalproex C. Carbamazepine D. Lamotrigine ```

divalproex

FP was recently started on oxcarbazepine and would like to know what her options are for birth control. She may receive treatment with all of the following EXCEPT: A. Progestin-only B. Medroxyprogesterone depot injection – Depo Provera C. Hormone-releasing intrauterine system (levonorgestrel-releasing intrauterine system) – Mirena D. Copper IUD

A. Progestin-only

True or false. | A drug that is injected or smoked is more likely to be abused than the same drug taken orally.

True

``` All drugs of abuse have in common that they cause: A. An increase in dopamine in the brain B. A decrease in dopamine in the brain C. An increase in serotonin in the brain D. A decrease in serotonin in the brain ```

A. An increase in dopamine in the brain

``` Withdrawal is a hallmark sign of: A. Drug addiction B. Drug abuse C. Tolerance D. Sensitization E. Dependence ```

E. Dependence

``` Which of the following drugs is NOT approved for use to help keep an alcoholic abstinent from alcohol use? A. Naloxone B. Buprenorphine C. Disulfiram D. Acamprosate ```

B. Buprenorphine

``` Which of the following drugs is NOT approved for use in helping someone quit tobacco use? A. Buproprion B. Acamprosate C. Varenicline D. Nicotine patch ```

B. Acamprosate

True or false | Acamprosate can be used to treat the seizures that occur in alcohol withdrawals.

False

Ephedrine and pseudophedrine are good for beginning synthesis of: A. Cocaine B. Methamphetamine

B. Methamphetamine

True or false | Physical dependence to opiates can happen in absence of addiction.

True

True or false | It is possible to become physically dependent on marijuana.

True

Why is withdrawal less common with marijuana and THC? A. They are less potent drugs than others B. They are smoked or ingested, not injected C. THC is stored in fat D. They are quickly metabolized and eliminated

C. THC is stored in fat

``` Which of the following is NOT a hallmark symptom of ADHD? A. Hyperactivity B. Impulsivity C. Inattention D. Mania ```

Mania

``` ADHD is linked to deficits of which of the following neurotransmitters? A. Serotonin B. GABA C. Glutamate D. Dopamine E. Histamine ```

dopamine

True or false | Guanfacine is a stimulant used to treat ADHD.

False

JP is a 21 yo male who presents to his PCP for difficulty maintaining focus in his college courses. Symptoms include:  difficulty sustaining attention  forgetfulness  frequently losing things  being easily distracted  depressed mood  difficulty sleeping JP denies a history of childhood ADHD. He reports these symptoms began several months ago after the loss of his grandfather. He also works evenings on the weekends at a local fast food establishment. He does not notice the symptoms while working. The majority of JP’s symptoms per DSM V ADHD criteria: A. Inattentive B. Hyperactive/impulse C. Combined

Inattentive

JP is a 21 yo male who presents to his PCP for difficulty maintaining focus in his college courses. Symptoms include:  difficulty sustaining attention  forgetfulness  frequently losing things  being easily distracted  depressed mood  difficulty sleeping JP denies a history of childhood ADHD. He reports these symptoms began several months ago after the loss of his grandfather. He also works evenings on the weekends at a local fast food establishment. He does not notice the symptoms while working. JP meets the DSM V criteria for a diagnosis of adult ADHD. A. True B. False

False

``` Choose a contraindication to methylphenidate use? A. History of substance abuse B. Severe anxiety disorder C. Mild hypertension D. Controlled seizures ```

B. Severe anxiety disorder

If a patient is abusing illicit drugs, which ADHD medication should be initially prescribed? A. Methylphenidate B. Atomoxetine

B. Atomoxetine

 CC: CB is a six year old boy brought into clinic by his mother after she was told by a teacher that her son was having difficulty adjusting to first grade.  PMH: Asthma since age 2; Fam Hx: Single parent family; one sister, aged 9  Social HX: enrolled in first grade at public school. Hobbies: bike riding, exploring. Diet: no veggies, candy, ice cream; Very active and talkative; good hygiene.  Won’t sit for more than 5 – 10 seconds, pulls books from shelves after being reprimanded by mother.  Friendly, demands attention.  Since age 4, in preschool, in kindergarten and now first grade, teachers complain that he is disruptive and impulsive, displaying little consideration for other children.  Medication history: Albuterol inhaler 1 – 2 puffs PRN breathing difficulty  Wt 25 kg (90th percentile) Ht 3’10”(75th percentile)  HEENT: runny nose ``` What non-pharmacological treatment would be best to start? A. EEG biofeedback B. Behavior modification C. Chelation therapy D. High Vitamin B dosing ```

B. Behavior modification

``` Which medication should be started if parents agree? A. Buproprion B. Venlafaxine C. Methylphenidate D. Modafinil ```

C. Methylphenidate

``` Depending on the medication chosen, what baseline medical evaluation should be done? A. EKG B. EEG C. Diet history D. Hepatic function ```

EKG (minimum HR & BP, also height and weight)

``` After starting this medication, how long until would you need to see the patient for monitoring? A. 1 week B. 4 weeks C. 6 months D. 1 year ```

1 week

``` What is the treatment of choice for alcohol withdrawal syndrome and delirium tremens? A. Carbamazepine B. Diazepam C. Alprazolam D. Acamprosate ```

B. Diazepam

True or False. | The presence of liver disease does not influence GGT levels but does effect CDT levels.

False

``` All of the following are known risk factors for substance use disorders EXCEPT: A. Widowed, divorced, or separated B. Male C. Old age D. Lower socioeconomic status ```

old age

``` Which agent produces a “ceiling-effect” around doses of 16-20 mg/day, making it less effective for use in patients requiring higher opioid maintenance therapy doses? A. Naloxone B. Naltrexone C. Methadone D. Buprenorphine ```

D. Buprenorphine

``` Which agent, used for opioid detoxification and maintenance therapy, has the potential to prolong the QT interval? A. Naltrexone B. Buprenorphine C. Methadone D. Acamprosate ```

C. Methadone

``` Alcohol-containing products, such as hand sanitizer and mouth wash, cannot be used until 2 weeks after discontinuing which agent? A. Disulfiram B. Naltrexone C. Buprenorphine D. Acamprosate ```

A. Disulfiram

This medication can be used for the treatment of both alcohol and opioid dependence and carries a black box warning for hepatotoxicity.

Naltrexone | ReVia, Vivitrol

This type of receptor down-regulates, while this other type of receptor up-regulates secondary to chronic alcohol use, which increases the risk of _____upon alcohol cessation

GABA receptors down-regulate; | NMDA receptors up-regulate; seizures

List 2 benefits of using symptom-triggered administration of benzodiazepines for alcohol withdrawal symptoms vs. fixed-dose scheduling.

1. Shorter duration of treatment required | 2. Less total medication administered

List 4 biomarkers of heavy drinking.

1. GGT 2. CDT 3. AST/ALT 4. MCV

If ≥ ___ consecutive days of methadone are missed, the patient may be at risk of overdose due to loss of tolerance. Also, methadone’s peak ______ effects occur later and persist longer than its peak analgesic effects, thereby increasing the risk of overdose.

3 days Respiratory Depressant Effects

Bupropion, fluoxetine, and paroxetine can increase the concentration of ______, an ADHD medication, due to inhibitory effects on the CYP___ enzyme.

Atomoxetine (Strattera); CYP2D6

Divalproex can increase levels of this medication, thereby increasing the risk of Stevens Johnson Syndrome.

Lamotrigine (Lamictal)

_______, a CYP1A2 inducer, decreases clozapine levels while _______ , a CYP1A2 inhibitor, increases clozapine levels.

Decrease clozapine levels: cigarette smoke, rifampin, carbamazepine, phenytoin, phenobarbital Increase clozapine levels: ciprofloxacin, fluvoxamine

_________, an antihypertensive agent, increases lithium concentrations while ______, the active ingredient in a Starbucks latte, decreases lithium concentrations.

Increase Lithium concentrations: ACEIs/ARBs, Thiazides, Furosemide Decrease Lithium concentrations: caffeine

______, a mood stabilizer, decreases the effectiveness of oral contraceptives through inducing the metabolism of estrogen and progesterone, while estrogen decreases the concentration of _____, a different mood stabilizer.

Decreases Effectiveness of oral contraceptives: carbamazepine (Tegretol) and Oxcarbazepine (Trileptal) Estrogen: Increases lamotrigine (Lamictal) clearance

Patients missing greater than _____ days of clozapine therapy must be retitrated back-up to their previous dose due to the risk of ______.

2 Days; dose-related seizures

YR is being initiated on Risperdal Consta. He must continue to take oral therapy for a minimum of ______ after the first injection.

3 weeks

RY is a 20 y/o male who was initiated on haloperidol 20 mg BID within the past week. He is now febrile, displaying muscular rigidity and an altered mental status, and is hypertensive. RY most likely is displaying symptoms of ______. Haloperidol is discontinued and the team would like to know how long they must wait until they can initiate a different antipsychotic.

NMS; 2 weeks after symptom resolution

RY is stabilized on haloperidol 10 mg PO BID. The team would like to initiate him on haloperidol decanoate. Please recommend a loading dosing and injection interval for this patient.

200 mg IM on day 1 followed by 200 mg IM 3-7 days later; | maintenance dose: 300 mg IM month 2 then 225 mg IM month 3

To initiate clozapine, WBCs must be greater than ____ /mm3 and the ANC must be greater than ____/mm3 due to the risk of ______.

WBC> 3.5/mm3 ANC > 2.0/mm3 Agranulocytosis

TY is a 32 y/o female who presents to your pharmacy complaining of headaches. She is currently being treated with lithium 300 mg PO BID and divalproex 1000 mg PO QHS. She would like to know which OTC pain reliever will not interact with her current medication regimen.

Aspirin, Acetaminophen

Its important to educate patients on the risk of suicidality associated with these two classes of medications.

Antidepressants and Antiepileptic Drugs

___ and ___, both atypical antipsychotics, should be taken with food to enhance absorption.

Ziprasidone (Geodon) and Lurasidone (Latuda)

Patients may notice an empty capsule-shaped tablet in their stool when taking _____, an antidepressant, or ____, an antipsychotic, or ______, a stimulant, due to their osmotic drug release technology.

Desvenlafaxine (Pristiq), Paliperidone (Invega), Long-acting methylphenidate (Concerta)

Patients should be instructed that if they miss ≥ ______ days of therapy, they need to retitrate iloperidone due to the risk of __________.

Orthostatic Hypotension

Name 6 monitoring parameters for stimulants that are assessed at baseline and every 3 months.

Height/weight Eating/sleeping pattern Blood pressure/HR

RG’s mother would like his Daytrana patch to be effective by 8 AM, when he starts school. When should she apply the patch and how long can she leave the patch on RG?

Apply patch 2 hours (6 AM) before desired effect and total wear time of patch should not exceed 9 hours (3 PM).

Name 3 medications that can be used as first-line agents for the treatment of acute manic episodes in bipolar disorder.

Lithium, Divalproex, Atypical Antipsychotics* or Haloperidol *clozapine use reserved for treatment refractory cases; No evidence yet for lurasidone or iloperidone

This medication is a good option for ADHD in adults with a history of substance abuse or in those who are unable to tolerate stimulants; however, it takes ____ amount of time for its effects to be seen.

Atomoxetine (Strattera): Onset- 2 to 4 weeks (adequate trial: 6 weeks at max dose) Bupropion (Wellbutrin): Onset- 4 to 6 weeks (adequate trial: 6 weeks at max dose)

Drowsiness, slurred speech, ataxia, confusion, n/v/d, polyuria/polydipsia, cardiac conduction abnormalities

Lithium Toxicity

CD is stabilized on carbamazepine 400 mg PO BID for treatment of bipolar disorder. She would like to know which forms of contraception she can use. What are her options.

1. Medroxyprogesterone depot injection (Depo-Provera) 2. Copper IUD 3. Levonorgesterel-releasing intrauterine system (Mirena) 4. Barrier methods

Exam 2 practice questions Flashcards

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