NURS-6630F-4/NURS-6630N-4/NURS-6630C-4-Approaches to Treatment....QUESTIONS,,,

Close-ended questions will help identify when patients are taking medications incorrectly. What is the therapeutic plasma level of carbamazepine? Which of the following statements below is NOT considered an appropriate treatment strategy for treatment-resistant depression? Response Feedback: “Combination of an SSRI OR an SNRI with a norepinephrine-dopamine re-uptake inhibitor (bupropion) or a serotonin-norepinephrine antagonist (mirtazapine or mianserin) is a commonly used combination” Which of the following medications used for treatment of bipolar disorder may increase stroke risk among older patients, particularly those with dementia? Response Feedback: “Notably, pharmacovigilance studies suggest that atypical antipsychotics may increase stroke risk among older patients, particularly those with dementia, so use of SGA requires more caution in this group.” Which antiepileptic drugs should we avoid in pregnant women in the treatment of bipolar disorder? i. Depakote ii. Lamotrigine iii. Topiramate iv. Carbamazepine v. Gabapentin Response Feedback: All the others listed except for lamotrigine are not used in treatment of bipolar disorder. Which neurotransmitter is considered the major inhibitory neurotransmitter? Choose the appropriate statement regarding lamotrigine dosing. Response Feedback: Carbamazepine induced metabolism of lamotrigine – increase dose of lamotrigine; Valproate may inhibit clearance of lamotrigine, so dose reduction of lamotrigine is needed Of the following antipsychotic medications listed below, which one has a Black Box Warning for seizure, agranulocytosis, and seizures? Response Feedback: Box 7-5 * indicated clozapine-specific black box warnings K. T. is a 35-year-old woman who was diagnosed with Generalized Anxiety Disorder about 4 weeks ago. She was prescribed Clonazepam 2 mg at bedtime but was referred to you to determine chronic treatment. K. T. states the new medication has been helping a lot but worries about all the side effects that come with it. She wants to discontinue the medication. What is the appropriate next step to help K. T.? Response Feedback: “The regular use of benzodiazepines for more than 2 to 3 weeks may be associated with physiological dependence and the potential for significant withdrawal symptoms with discontinuation. Discontinuation of benzodiazepines is best done with a gradual taper to minimize withdrawal symptoms.” - Answer choice A: Honor the patient’s request of discontinuing the medication. - Answer Choice C: An abrupt stop of a benzodiazepine will likely send the patient into having withdrawal symptoms. - Answer D: Patient will likely experience withdrawal symptoms due to how often the patient uses it OR patient will experience withdrawal symptoms after missing one dose, thus the therapy wouldn’t have changed at all from how she has been taking it. Which atypical antipsychotic(s) require a meal for better absorption? i. Quetiapine ii. Ziprasidone iii. Asenapine iv. Olanzapine v. Lurasidone Response Feedback: - Ziprasidone – best with a fatty meal - Lurasidone – best with a meal of at least 350 calories (no effect of fat composition) Which of the following are NOT primary target(s) symptom for antipsychotic agents in schizophrenia? i. Depression, anxiety, demoralization, suicidality, excitability, and agitation ii. Delusions, hallucinations, disorganized thoughts iii. Affective flattening, alogia, avolition, anhedonia, social withdrawal iv. Attention, memory, and executive functions Response Feedback: “For schizophrenia, the primary target symptoms for antipsychotic agents fall into three categories: psychotic symptoms (e.g., hallucinations, delusions, disorganization); agitation (e.g., distractibility, affective lability, tension, increased motor activity); and negative symptoms (e.g. apathy, diminished affect, social withdrawal, poverty of speech.” AND “Although cognitive deficits are an important contributor to disability in schizophrenia, cognitive deficits usually are not considered a target for antipsychotic agents because they are not very responsible to current agents.” How do you manage a patient who develops neuroleptic malignant syndrome while on an atypical antipsychotic? M. M. is 27-year-old female student pharmacist who presents to the ER after experiencing extreme lightheadedness during her fourth-year seminar presentation. Her vitals are as follows: BP (107/65) and HR of 45. What medication below is likely the cause of these symptoms? Response Feedback: “The use of beta-blockers may be associated with orthostatic hypotension, lightheadedness, bradycardia, and nausea.” K. B. never felt relief from his depressive symptoms, even after appropriate time and dose titration of Venlafaxine. He was switched to Bupropion 150 mg about 2 months ago and is following up with you today. He reported feeling “great” and that his relationship with his girlfriend is “better than ever now.” Because he is feeling so well at this time, he is wondering when he can stop taking Bupropion. How long must the patient be symptom-free before he may begin a trial to taper off the antidepressant therapy? Response Feedback: “Therefore, in treatment-responders, most experts favor a continuation of antidepressant therapy for a minimum of 6 months following the achievement of remission.” What is the strongest established risk factor for bipolar disorder? Response Feedback: “The strongest established risk factor for BPD is a family history of BPD.” With second-generation antipsychotics, what is the main side effect that requires frequent monitoring? Response Feedback: table 7-6 & page 80, table 7-7; Page 78: “However, attention over the past decade has focused on effect of second-generation antipsychotics on glucose metabolism and lipids and associated metabolic syndrome.” The following patient case is considered an example of treatment-resistant depression. B. B. is a 26-year old-female at your clinic today with the diagnosis, “treatment-resistant depression.” She is currently on Bupropion 300 mg daily and has been at this dose for 6 weeks with no alleviation in depressive symptoms. She has trialed the following medications in the past with treatment duration listed: - Paroxetine 40 mg daily for 4 weeks - Citalopram 20 mg daily for 2 weeks Response Feedback: “At least one trial with an antidepressant with established efficacy in MDD (with sufficient duration and doses) is considered to be adequate antidepressant treatment.” Which of the following symptoms is NOT part of the diagnostic features for bipolar disorder? Response Feedback: “Psychosis is not represented in the diagnostic features for BPD.” - “Psychosis typically resolves along with the mood symptoms, though diagnostic criteria acknowledge that psychotic symptoms may linger beyond the end of the episode.” A 25-year-old female comes into your clinic today informing you she is ready to have a baby and wishes to discontinue her birth control at this time. After reviewing her chart, you notice she has a history of bipolar disorder and was previously prescribed valproic acid by another doctor. What is your concern with this medication in this specific patient? Response Feedback: “Valproic acid may produce teratogenic effects.” Glia cells play a supportive role in the neuron. A few of the functions of the glial cells include providing nutrition, maintaining homeostasis, stabilizing synapses, and myelinating axons. The glial cells are categorized as microglia or macroglia. Of the macroglia cells, which one plays a role in myelinating axons, which may contribute to mood disorders if altered? Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY. Response Feedback: under pharmacokinetics and pharmacodynamics subtitle - “NSAIDs or other COX-2 inhibitors may decrease renal blood flow and thereby increase lithium levels by up to 25%.” - “Therefore, thiazide diuretics, which act distally, will tend to increase lithium levels by up to 50% while those that act more proximally generally have less of an effect on lithium levels.” An 81-year-old male comes to your clinic today complaining of dry mouth, blurred vision, and constipation. He has a past medical history significant for hypertension, heart failure, and depression. Of the following medications, which one is likely contributing to these side effects? Response Feedback: Only TCA is listed with most anticholinergic effects; Page 39 for TCA side effect profile: “dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia, memory difficulties, and ejaculatory difficulties” Which of the following medications are known as selective serotonin re-uptake inhibitors (SSRIs)? i. Nortriptyline ii. Citalopram iii. Duloxetine iv. Fluoxetine v. Venlafaxine Which of the following receptors below would likely result in extra-pyramidal symptoms, tardive dyskinesia, and hyperprolactinemia? Response Feedback: first generation antipsychotics all share the common property of D2 blockade, which can produce EPS, TD, and hyperprolactinemia Patient is a 72-year-old male with a past medical history significant for atrial fibrillation and COPD with a new diagnosis of major depression disorder. Based on his comorbid conditions, what antidepressant would you recommend as first-line? Response Feedback: (Options C & D are both TCA antidepressants and, based on the patient’s age and comorbid conditions, a TCA would likely result in more side effects, such as increased fall risk due to potential for orthostatic hypotension and anticholinergic-related side effects. In addition, patient has a history for cardiac abnormalities due to A. fib diagnosis - TCAs result in electrocardiographic changes in susceptible individuals, therefore, would likely avoid. Choice B is used more for ADHD purposes than as an antidepressant) Page numbers used: Page 39 for TCA side-effect profile Which of the following medications is best to AVOID in maintenance treatment of bipolar disorder and why? Response Feedback: “As noted previously, antidepressants may contribute to an increase in mood episode frequency.” Which anticonvulsant below induces its own metabolism over time? Choose the appropriate pair regarding acetylcholine receptors. Response Feedback: “There are two classes of ACh receptors: muscarinic and nicotinic. While muscarinic receptors are G-protein-coupled, nicotinic receptors are ion channels, which allows for rapid influx of NA+ and Ca2+ into the post- synaptic neuron.” A 23-year-old female was just diagnosed with major depressive disorder and is being started on escitalopram 10 mg daily. The patient should be counseled about which Black Box warning? Response Feedback: “In 2004, the FDA asked manufacturers of almost all the new antidepressant drugs to include in their labeling a warning statement that recommends close observation of adult and pediatric patients treated with these drugs for worsening depression or the emergence of suicidality." Which disease state of a non-adherent patient is at greater risk for substance use, violence, and victimization as well as worse overall quality of life? Response Feedback: “Moreover, non-adherent patients with schizophrenia are at greater risk for substance use, violence, and victimization as well as worse overall quality of life.” Which drug below has an interaction with cigarette smoking and should be adjusted based on patient’s tobacco use/non-use? Response Feedback: “Clozapine blood levels are significantly lowered by cigarette smoking and by other hepatic enzyme-inducers.” Which drug below diff