Multiple Choice
Which class of antidepressants are the first line of treatment for mild-moderate depression, panic disorder, and OCD
A. MAOI
B. SSRI
C. SNRI
D. Serotonin Multimodal drugs
B. SSRIs
relatively safe with overdose (no anticholinergic effects)
Does contain a black box warning of increased suicidal ideation in children
What is the therapeutic maintenance dose fo Lithium in mEq/L?
A. 1.0-1.2
B. 0.6-0.8
C. 1.6-2.5
D. 1.0-1.5
A. 1.0-1.2 (used for acute mania)
B. 0.6-0.8 (correct)
C. 1.6-2.5 (is associated with moderate toxic effect)
D. 1.0-1.5 (associated with mild toxic effects)
MAIO inhibit monoamine oxidase which is responsible for breaking down which neurotransmitters (Select all that apply)?
A. epinephrine
B. Dopamine
C. Norepinephrine
D. Serotonin
E. Tyrosine
A, B, C, D
tyrosine is the precursor to L-DOPA which is the precursor to Dopamine
True or Flase: Tricyclic antidepressants have a narrow therapeutic window putting patients at risk for overdose which causes cholinergic symptoms
Flase!!!
It does have a narrow TI but...
it causes ANTICHOLINERGIC symptoms, intractable myocardial depression, hypotension, seizures, and coma
Tx: Physostigmine (a cholinesterase inhibitor that crosses BBB)
State whether these drugs increase or decrease Lithium concentrations:
A. NSAIDS
B. ACE inhibitors
C. aminophylline
D. potassium-sparing diuretics
E. Thiazide diuretics
A. NSAIDS: increase (change renal BF to increase lithium reabsoption)
B. ACE inhibitors: increase
C. aminophylline: decrease
D. potassium-sparing diuretics: decrease
E. Thiazide diuretics: increased (increased excretion of sodium causes more lithium to be reabsorbed)
Which MAOI do you not have to restrict dietary tyramine?
A. Selegiline
B. Phenelzine
C. Tranylcypromine
D. Isocarboxazid
Bonus if you know what happens with too much Tyramine
A. Selegiline
It is a selective MOA-B inhibitor used to treat Parkinson's. MOA-A breaks down tyramine, and all the other drugs are MOA-A and B inhibitors. By inhibiting MOA-B only the breakdown of tyramine can continue and will not accumulate
Too much tyramine causes a hypertensive crisis
How many criteria of the Hunter Serotonin Toxicity Criteria must be met in order to diagnose it?
A. 3 or more
B. 1 or more
C. 5 or more
D. 2 or more
B. 1 or more
the criteria:
1. spontaneous clonus
2. inducible clonus and agitation or diaphoresis
3. ocular clonus and agitation or diaphoresis
4. tremor and hyperreflexia
5. hypertonia and temp >38, and ocular clonus or inducible clonus
(Select all that apply) Which of the following are uses for Tricyclic antidepressants?
A. moderate/severe depression
B. mood disorders
C. chronic pain
D. anxiolysis
A. moderate/severe depression
B. mood disorders
C. chronic pain (at lower doses)
D. anxiolysis
True or Flase: Adderal is a pro-drug where Lisdexamfetamine is hydrolyzed to d-amphetamine
Flase: this is Vyvanse used to treat ADHD and binge eating disorder
Adderall is levoamphetamine and dextroamphetamine and is used to treat ADHD
Match the over dose to its treatment:
A. lithium
B. MAOI
C. Trycyclic
1. hemodialysis, osmotic diuretics, IV sodium bicard
2. Physostigmine, benzos, IV bicarb, gastric lavage, lido for arrhythmia
3. supportive measures, gastric lavage, and dantrolene for skeletal muscle rigidity
A --> 1
B --> 3
C --> 2
Which of these statements if false:
A. Modafinil is a dopamine reuptake inhibitor used to treat narcolepsy
B. Benztropine is a dopamine reuptake inhibitor used to treat Parkinson's symptoms
C. Methylphenidate (Ritalin) is a multimodal dopamine and NE reuptake blocker used to treat ADHD
D. Droperidol is a dopamine antagonist used to treat PONV and Parkinson's disease
D. Droperidol is a dopamine antagonist used to treat PONV and Parkinson's disease
had anti-dopamine effects and will worsen symptoms
Your patient presents for their second debridement surgery today. They have been admitted for treatment of cellulitis with Erythromycin, which they received last night. During your preop interview, you notice the patient is tachycardic, has dilated pupils, and increased saliva. You also notice myoclonus and a tremor. The SRNA knows that this is most likely the cause
A. Anticholinergic syndrome from a scopolamine patch
B. Neuroleptic malignant syndrome from metoclopramide
C. Serotonin syndrome from Setraline
D. Malignant hyperthermia from VA used in the first surgery
Bonus if you know the treatment!!
C. serotonin syndrome from Sertraline
all other syndromes are mistaken diagnoses. Clonus is the key, for it is strongly associated with serotonin syndrome. Also the mixture of an SSRI (sertraline) and the Erythromycin could have precipitated the serotonin syndrome
Tx is Cyproheptadine 12mg initial dose then 2mg q2hr (MAX 32mg)
Select all of the side effects of MAOIs:
A. weight loss
B. sexual dysfunction
C. orthostatic hypotension
D. paresthesia
A. weight loss (its actually weight gain)
B. sexual dysfunction
C. orthostatic hypotension (this one is tricky because it can also caused a hypertensive crisis due to unmetabolized tyramine)
D. paresthesia
most psych meds will cause hypotension, sexual dysfunction, and weight gain
FALSE!!
although SSRIs have antiplatelet activity it is better to hold the Asprin, since discontinuation of the SSRI risks a major depression episode. (As a rule of thumb most psych meds should always be continued for Sx)
Match the antipsychotic drug to its class:
a. Phenothiazines
b. thiozanthenes
c. dibenzodiazepines
d. butyrophenones
e. Benzisoxazole
1. respiridone
2. clozapine
3. haloperidol
4. droperidol
5. chlorpromazine
6. Chlorprothixene
7. Perphenazine
a. Phenothiazines: Chloropromazine, Perphenazine
b. thiozanthenes: Chloroprothixene
c. dibenzodiazepines: Clozapine
d. butyrophenones: droperidol, haloperidol
e. Benzisoxazole: Respiridone
Which of the following is not a side effect of lithium?
A. nephrogenic DI
B. tall peaked T waves
C. hypothyroidism
D. acne
A. nephrogenic DI: (polyuria and polydipsia)
B. tall peaked T waves (actually causes flattened inverted T waves and SA node dysfunction)
C. hypothyroidism (q 6 mo checks and levothyroxine)
D. acne (also causes psoriasis and hair loss)
What condition is associated with Myonecrosis, renal failure, fever, autonomic disturbances, lead-pipe rigidity, and flaccid paralysis from NDMRs?
A. serotonin syndrome
B. anticholinergic syndrome
C. neuroleptic malignant syndrome
D. Malignant hyperthermia?
Bonus: What is the treatment?
C. neuroleptic malignant syndrome
rare but has a 20-30% mortality rate. Very similar to MH but has lead-pipe rigidity instead of total body
Bonus: dantrolene, bromocriptine, amantadine
Select all of the side effects from first generation antipsychotics:
A. Extrapyramidal effects
B. increased seizure threshold
C. sedation
D. increased prolactin
E. weight gain
F. impaired glucose tolerance
G. skeletal muscle relaxation
H. antiemetic
A. Extrapyramidal effects (tardive dyskinesia, acute dystonia, akathisia)
B. increased seizure threshold (its decreased)
C. sedation
D. increased prolactin (gynecomastia, galactorrhea)
E. weight gain (from hypothalamic effects)
F. impaired glucose tolerance
G. skeletal muscle relaxation
H. antiemetic
True or False: Buspirone is a partial serotonin agonist that is used to treat anxiety disorders.
True!!
Its a 1st generation in new a new class of anxiolytics called azaprieones
Match the second generation antipsychotic with each definition (Clozapine, Olanzapine, Risperidone, aripiprazole, Quetiapine, Ziprasidone, Lurasidone, Amisulpride)
A. reduced metabolic risks, frequently causes akathisia
B. prolong QT but minimal metabolic effects, moderately effective
C. low risk of sedation, weight gain, or QT prolongation, but is associated with emergence of compulsive behaviors
D. POTENT dopamine antagonist. Increased prolactin and extrapyramidal symptoms, also A receptor antagonist
E. most effective antipsychotic with no extrapyramidal effects. Can cause agranulocytosis, excessive salvation, and anticholinergic symptoms
F. highest risk with eight gain, metabolic syndrome, thermoregulation disruption. Is heavily sedating
G. serotonin antagonism > dopamine. very sedating and causes hypotension. Low incidence of extrapyramidal symptoms
A. reduced metabolic risks, frequently causes akathisia (Lurasidone)
B. prolong QT but minimal metabolic effects, moderately effective (Ziprasidone)
C. low risk of sedation, weight gain, or QT prolongation, but is associated with emergence of compulsive behaviors (aripiprazole)
D. POTENT dopamine antagonist. Increased prolactin and extrapyramidal symptoms, also A receptor antagonist (Clozapine)
E. most effective antipsychotic with no extrapyramidal effects. Can cause agranulocytosis, excessive salvation, and anticholinergic symptoms (Risperidone)
F. highest risk with weight gain, metabolic syndrome, thermoregulation disruption. Is heavily sedating (Olanzapine)
G. serotonin antagonism > dopamine. very sedating and causes hypotension. Low incidence of extrapyramidal symptoms (Quetiapine)
H. treatment of PONV but only in US. used as antipsychotic abroad (Amisulpride)
Which pathway does D2 receptor blockade cause extrapyramidal effects
A. Mesolimbic
B. Mesocortical
C. Nigrostiratal
D. Tuberoinfundibular
A. Mesolimbic (dopamine modulation)
B. Mesocortical (dopamine blockade)
C. Nigrostiratal
D. Tuberoinfundibular (endocrine effect)
Choose the incorrect statement:
A. Phenelzine is an MAOI used to treat depression in manic-depressive psychosis. It causes anticholinergic effects.
B. Paroxetine should be used in caution in patients taking warfarin since it potentiates warfarin
C. Tranylcyprimine is an MAOI used for severe depression and is a mild stimulant with anticholinergic side effects
D. Both fluoxetine and nefazodone interfere with CYP450
E. Anticholinergic toxicity is associated with brain zap, nausea and vomiting, and flu-like symptoms
E. Anticholinergic toxicity is associated with brain zap, nausea and vomiting, and flu-like symptoms
This is serotonin reuptake inhibitor discontinuation syndrome. Anticholinergic is dry mouth, blurred vision, tachycardia, hot red skin, delirium
Which of the following drugs are not recommended to use with MAOI (Select all that apply)?
A. Meperidine
B. Phenylephrine
C. Fluoxetine
D. Buporin
C. Trazedone
All but B.
Phenylephrine is preferred for hypotension since it is a direct-acting vasoconstrictor. Avoid indirect-acting drugs like ephedrine since an exaggerated response can occur.
All the others can either cause serotonin syndrome (ie. fluoxetine, meperidine) or have a synergistic effect (Bupropion(SNRI), Trazodone(serotonin multimodal)
True or False: Second-generation antipsychotics are preferred over First generation due to their decreased risk of tardive dyskinesia and Neuroleptic syndrome.
Can you name the other extrapyramidal effects of 1st generation antipsychotics?
TRUE!!
tardive dyskinesia is caused by a compensatory increase in Dopamine levels in the basal ganglia. IT IS PERMANENT
acute dystonia: of neck, tongue, face and back (responds to benadryl)
Akathisia: restlessness