Podcast
Questions and Answers
A patient with bipolar I disorder experiencing an acute manic episode presents with rapid cycling. Considering the interplay between mood stabilization and minimizing adverse effects, which of the following treatment strategies requires the MOST vigilant monitoring for potential iatrogenic complications, specifically focusing on endocrine and metabolic disturbances?
A patient with bipolar I disorder experiencing an acute manic episode presents with rapid cycling. Considering the interplay between mood stabilization and minimizing adverse effects, which of the following treatment strategies requires the MOST vigilant monitoring for potential iatrogenic complications, specifically focusing on endocrine and metabolic disturbances?
- Initiating monotherapy with lamotrigine, titrating slowly to minimize the risk of Stevens-Johnson syndrome while observing for emergent depressive symptoms due to its limited efficacy in acute mania.
- Prescribing valproic acid, accompanied by frequent monitoring of liver function tests (LFTs), complete blood count (CBC) to detect thrombocytopenia, and assessing for signs of polycystic ovary syndrome (PCOS) in female patients.
- Administering lithium carbonate, while diligently monitoring serum creatinine, thyroid-stimulating hormone (TSH), and lithium levels to prevent nephrogenic diabetes insipidus and hypothyroidism. (correct)
- Commencing aripiprazole, carefully monitoring for extrapyramidal symptoms and akathisia, while concurrently measuring baseline prolactin levels to mitigate potential hyperprolactinemia.
A 35-year-old patient with bipolar II disorder presents with persistent depressive symptoms despite being on a stable dose of lamotrigine for six months. The patient reports significant cognitive slowing and anhedonia. Which of the following augmentation strategies necessitates the MOST careful consideration of potential adverse cognitive and metabolic effects, requiring comprehensive baseline and ongoing monitoring?
A 35-year-old patient with bipolar II disorder presents with persistent depressive symptoms despite being on a stable dose of lamotrigine for six months. The patient reports significant cognitive slowing and anhedonia. Which of the following augmentation strategies necessitates the MOST careful consideration of potential adverse cognitive and metabolic effects, requiring comprehensive baseline and ongoing monitoring?
- Introducing low-dose quetiapine, with careful monitoring for weight gain, metabolic syndrome, and extrapyramidal symptoms (EPS). (correct)
- Adding omega-3 fatty acid supplementation and encouraging increased physical activity, monitoring for potential gastrointestinal side effects.
- Initiating light therapy, monitoring for signs of overstimulation or hypomania.
- Supplementing with L-methylfolate, while observing for potential interactions with other medications and monitoring mood changes.
A 28-year-old female with bipolar I disorder, well-managed on lithium for several years, expresses a desire to become pregnant. Considering the teratogenic potential of lithium and the complexities of managing bipolar disorder during pregnancy, which of the following strategies represents the MOST judicious approach, balancing fetal safety with the patient's psychiatric stability, and requiring close collaboration with both a psychiatrist and an obstetrician specializing in high-risk pregnancies?
A 28-year-old female with bipolar I disorder, well-managed on lithium for several years, expresses a desire to become pregnant. Considering the teratogenic potential of lithium and the complexities of managing bipolar disorder during pregnancy, which of the following strategies represents the MOST judicious approach, balancing fetal safety with the patient's psychiatric stability, and requiring close collaboration with both a psychiatrist and an obstetrician specializing in high-risk pregnancies?
- Switching to lamotrigine, while acknowledging the potential risk of decreased lamotrigine levels during pregnancy due to increased metabolism, necessitating frequent monitoring of serum levels and potential dose adjustments. (correct)
- Switching to electroconvulsive therapy (ECT) throughout the pregnancy to avoid any medication exposure, ensuring proper anesthesia and monitoring for cognitive side effects in the mother.
- Maintaining the patient on a reduced dose of lithium, with frequent monitoring of lithium levels and fetal echocardiograms to assess for Ebstein's anomaly, while educating the patient on the risks and benefits.
- Abruptly discontinuing lithium to eliminate any risk of fetal exposure, while closely monitoring for relapse of mood symptoms and implementing crisis management strategies as needed.
A patient with cyclothymic disorder reports experiencing significant social and occupational impairment due to unpredictable mood swings, despite not meeting the full criteria for bipolar I or II disorder. Considering the nuances of treating subsyndromal bipolar presentations, which of the following interventions should be implemented FIRST, prior to initiating pharmacological treatment, to optimize long-term outcomes and minimize unnecessary medication exposure?
A patient with cyclothymic disorder reports experiencing significant social and occupational impairment due to unpredictable mood swings, despite not meeting the full criteria for bipolar I or II disorder. Considering the nuances of treating subsyndromal bipolar presentations, which of the following interventions should be implemented FIRST, prior to initiating pharmacological treatment, to optimize long-term outcomes and minimize unnecessary medication exposure?
A 45-year-old male with bipolar I disorder presents to the emergency department in a catatonic state, unresponsive to verbal stimuli and exhibiting rigidity. He has a history of non-adherence to his medication regimen of lithium and quetiapine. Which of the following represents the MOST appropriate initial management strategy, considering the potential life-threatening complications associated with catatonia and the need for rapid intervention?
A 45-year-old male with bipolar I disorder presents to the emergency department in a catatonic state, unresponsive to verbal stimuli and exhibiting rigidity. He has a history of non-adherence to his medication regimen of lithium and quetiapine. Which of the following represents the MOST appropriate initial management strategy, considering the potential life-threatening complications associated with catatonia and the need for rapid intervention?
A patient exhibiting acute psychosis and a known hypersensitivity to serotonin reuptake inhibitors requires immediate pharmacological intervention. Considering the receptor binding profiles, which of the following antipsychotics would be LEAST appropriate due to the highest potential for cross-reactivity and adverse events?
A patient exhibiting acute psychosis and a known hypersensitivity to serotonin reuptake inhibitors requires immediate pharmacological intervention. Considering the receptor binding profiles, which of the following antipsychotics would be LEAST appropriate due to the highest potential for cross-reactivity and adverse events?
A patient stabilized on clozapine for treatment-resistant schizophrenia develops a constellation of symptoms including pyrexia, muscular rigidity, altered mental status, and autonomic dysfunction. Which of the following management strategies should be prioritized, considering the potential underlying etiology?
A patient stabilized on clozapine for treatment-resistant schizophrenia develops a constellation of symptoms including pyrexia, muscular rigidity, altered mental status, and autonomic dysfunction. Which of the following management strategies should be prioritized, considering the potential underlying etiology?
In a patient with a pre-existing diagnosis of Parkinson's disease who requires urgent antipsychotic treatment, which agent is most likely to exacerbate their motor symptoms due to its specific mechanism of action?
In a patient with a pre-existing diagnosis of Parkinson's disease who requires urgent antipsychotic treatment, which agent is most likely to exacerbate their motor symptoms due to its specific mechanism of action?
A patient on chronic lithium therapy presents with new-onset nephrogenic diabetes insipidus. Which of the following interventions is the MOST appropriate initial step in managing this adverse effect, considering the patient's ongoing need for mood stabilization?
A patient on chronic lithium therapy presents with new-onset nephrogenic diabetes insipidus. Which of the following interventions is the MOST appropriate initial step in managing this adverse effect, considering the patient's ongoing need for mood stabilization?
A patient maintained on carbamazepine for bipolar disorder develops signs of syndrome of inappropriate antidiuretic hormone secretion (SIADH). What is the most likely mechanism by which carbamazepine induces this electrolyte imbalance?
A patient maintained on carbamazepine for bipolar disorder develops signs of syndrome of inappropriate antidiuretic hormone secretion (SIADH). What is the most likely mechanism by which carbamazepine induces this electrolyte imbalance?
A 28-year-old female with bipolar I disorder, currently managed with lamotrigine, desires to conceive. What is the MOST critical consideration regarding lamotrigine's pharmacokinetics during pregnancy that needs to be addressed in her management plan?
A 28-year-old female with bipolar I disorder, currently managed with lamotrigine, desires to conceive. What is the MOST critical consideration regarding lamotrigine's pharmacokinetics during pregnancy that needs to be addressed in her management plan?
A patient on valproic acid presents with acute pancreatitis. Which of the following mechanisms is MOST likely responsible for this adverse effect?
A patient on valproic acid presents with acute pancreatitis. Which of the following mechanisms is MOST likely responsible for this adverse effect?
A patient, who has been on risperidone for schizophrenia, reports persistent constipation and bloating. Upon further investigation, decreased gastric motility is noted. Given risperidone's receptor binding profile, which receptor antagonism is MOST likely contributing to this gastrointestinal adverse effect?
A patient, who has been on risperidone for schizophrenia, reports persistent constipation and bloating. Upon further investigation, decreased gastric motility is noted. Given risperidone's receptor binding profile, which receptor antagonism is MOST likely contributing to this gastrointestinal adverse effect?
A patient with a known history of schizophrenia and schizoaffective disorder presents with acute agitation and aggression. Considering the patient's history and the need for rapid tranquilization, which of the following antipsychotics would be LEAST appropriate to administer, given its potential for significant anticholinergic adverse effects?
A patient with a known history of schizophrenia and schizoaffective disorder presents with acute agitation and aggression. Considering the patient's history and the need for rapid tranquilization, which of the following antipsychotics would be LEAST appropriate to administer, given its potential for significant anticholinergic adverse effects?
A 32-year-old female with bipolar I disorder, currently managed with lamotrigine, reports persistent depressive symptoms despite therapeutic adherence. Given lamotrigine's mechanism of action, what is the MOST probable explanation for its limited efficacy in treating her depressive episode?
A 32-year-old female with bipolar I disorder, currently managed with lamotrigine, reports persistent depressive symptoms despite therapeutic adherence. Given lamotrigine's mechanism of action, what is the MOST probable explanation for its limited efficacy in treating her depressive episode?
A patient stabilized on carbamazepine for bipolar disorder develops a concurrent HIV infection and requires initiation of antiretroviral therapy. Given the known interactions of carbamazepine, which antiretroviral agent would necessitate the MOST careful monitoring and potential dosage adjustments of both medications to avoid subtherapeutic levels and potential breakthrough symptoms?
A patient stabilized on carbamazepine for bipolar disorder develops a concurrent HIV infection and requires initiation of antiretroviral therapy. Given the known interactions of carbamazepine, which antiretroviral agent would necessitate the MOST careful monitoring and potential dosage adjustments of both medications to avoid subtherapeutic levels and potential breakthrough symptoms?
A 68-year-old patient with dementia-related psychosis is prescribed risperidone. Three weeks later, the patient exhibits fever, rigidity, altered mental status, and autonomic instability. Which immediate intervention(s) is/are MOST appropriate, considering the likely adverse effect?
A 68-year-old patient with dementia-related psychosis is prescribed risperidone. Three weeks later, the patient exhibits fever, rigidity, altered mental status, and autonomic instability. Which immediate intervention(s) is/are MOST appropriate, considering the likely adverse effect?
A patient being treated with lithium for bipolar disorder presents with new-onset polyuria, polydipsia, and an elevated serum creatinine. Which of the following mechanisms BEST explains the MOST likely cause of these findings?
A patient being treated with lithium for bipolar disorder presents with new-onset polyuria, polydipsia, and an elevated serum creatinine. Which of the following mechanisms BEST explains the MOST likely cause of these findings?
A 28-year-old female of Han Chinese descent is newly diagnosed with bipolar I disorder and is being considered for carbamazepine therapy. What is the MOST critical pre-initiation screening test, and what potential adverse effect is it intended to mitigate?
A 28-year-old female of Han Chinese descent is newly diagnosed with bipolar I disorder and is being considered for carbamazepine therapy. What is the MOST critical pre-initiation screening test, and what potential adverse effect is it intended to mitigate?
A patient on valproic acid for bipolar disorder presents with fatigue, abdominal pain, and jaundice. Laboratory findings reveal elevated liver transaminases and hyperammonemia. Which of the following underlying conditions would MOST significantly increase the risk of valproic acid-induced hepatotoxicity in this patient?
A patient on valproic acid for bipolar disorder presents with fatigue, abdominal pain, and jaundice. Laboratory findings reveal elevated liver transaminases and hyperammonemia. Which of the following underlying conditions would MOST significantly increase the risk of valproic acid-induced hepatotoxicity in this patient?
A 45-year-old patient with schizophrenia, well-managed on aripiprazole, reports persistent akathisia that is refractory to typical treatments. Given aripiprazole's unique mechanism of action, which of the following strategies would be the MOST MECHANISTICALLY PLAUSIBLE to alleviate this side effect??
A 45-year-old patient with schizophrenia, well-managed on aripiprazole, reports persistent akathisia that is refractory to typical treatments. Given aripiprazole's unique mechanism of action, which of the following strategies would be the MOST MECHANISTICALLY PLAUSIBLE to alleviate this side effect??
A 52-year-old patient with treatment-resistant schizophrenia is being considered for clozapine therapy. Beyond the typical monitoring for agranulocytosis, what specific risk assessment should be undertaken BEFORE initiating treatment, considering clozapine's potential cardiovascular effects?
A 52-year-old patient with treatment-resistant schizophrenia is being considered for clozapine therapy. Beyond the typical monitoring for agranulocytosis, what specific risk assessment should be undertaken BEFORE initiating treatment, considering clozapine's potential cardiovascular effects?
A patient on quetiapine for bipolar disorder has gained a significant amount of weight and developed dyslipidemia. What is the MOST appropriate initial intervention, considering the metabolic adverse effects of quetiapine?
A patient on quetiapine for bipolar disorder has gained a significant amount of weight and developed dyslipidemia. What is the MOST appropriate initial intervention, considering the metabolic adverse effects of quetiapine?
A patient with schizophrenia experiences significant improvement in positive symptoms with haloperidol but develops severe parkinsonism. Which of the following mechanisms underlies the observed motor effects, and how does it relate to haloperidol's primary antipsychotic action?
A patient with schizophrenia experiences significant improvement in positive symptoms with haloperidol but develops severe parkinsonism. Which of the following mechanisms underlies the observed motor effects, and how does it relate to haloperidol's primary antipsychotic action?
A patient on clozapine develops persistent tachycardia and ECG changes suggestive of myocarditis. Considering clozapine's pharmacology, which mechanism is most likely contributing to this potentially fatal adverse effect?
A patient on clozapine develops persistent tachycardia and ECG changes suggestive of myocarditis. Considering clozapine's pharmacology, which mechanism is most likely contributing to this potentially fatal adverse effect?
A patient stabilized on lithium for bipolar disorder presents with new-onset nephrogenic diabetes insipidus. Which of the following mechanisms accounts for this adverse effect, and how does it influence therapeutic decision-making?
A patient stabilized on lithium for bipolar disorder presents with new-onset nephrogenic diabetes insipidus. Which of the following mechanisms accounts for this adverse effect, and how does it influence therapeutic decision-making?
A patient with bipolar disorder is being treated with lamotrigine. They concurrently develop a skin rash that rapidly progresses to Stevens-Johnson syndrome (SJS). Which of the following best describes the mechanism by which lamotrigine induces SJS, and what genetic factors might predispose individuals to this reaction?
A patient with bipolar disorder is being treated with lamotrigine. They concurrently develop a skin rash that rapidly progresses to Stevens-Johnson syndrome (SJS). Which of the following best describes the mechanism by which lamotrigine induces SJS, and what genetic factors might predispose individuals to this reaction?
A patient on long-term risperidone treatment develops galactorrhea and amenorrhea. Which of the following mechanisms is primarily responsible for these endocrine side effects, and how does risperidone's receptor-binding profile contribute to this issue compared to other atypical antipsychotics?
A patient on long-term risperidone treatment develops galactorrhea and amenorrhea. Which of the following mechanisms is primarily responsible for these endocrine side effects, and how does risperidone's receptor-binding profile contribute to this issue compared to other atypical antipsychotics?
A patient with a history of non-adherence to oral medication is prescribed fluphenazine decanoate, a long-acting injectable antipsychotic. Six weeks after the initial injection, the patient develops akathisia. What is the most appropriate strategy for managing this side effect while minimizing the risk of relapse, considering the pharmacokinetic properties of fluphenazine decanoate?
A patient with a history of non-adherence to oral medication is prescribed fluphenazine decanoate, a long-acting injectable antipsychotic. Six weeks after the initial injection, the patient develops akathisia. What is the most appropriate strategy for managing this side effect while minimizing the risk of relapse, considering the pharmacokinetic properties of fluphenazine decanoate?
A patient on carbamazepine for bipolar disorder presents with nausea, vomiting, and confusion. Lab results show hyponatremia (serum sodium of 120 mEq/L). By what mechanism does carbamazepine induce hyponatremia, and what other drug interaction could exacerbate this electrolyte imbalance?
A patient on carbamazepine for bipolar disorder presents with nausea, vomiting, and confusion. Lab results show hyponatremia (serum sodium of 120 mEq/L). By what mechanism does carbamazepine induce hyponatremia, and what other drug interaction could exacerbate this electrolyte imbalance?
A patient with schizoaffective disorder is treated with a combination of olanzapine and valproic acid. Which of the following pharmacokinetic interactions is most likely to occur, and how should the dosages of these medications be adjusted to maintain therapeutic efficacy?
A patient with schizoaffective disorder is treated with a combination of olanzapine and valproic acid. Which of the following pharmacokinetic interactions is most likely to occur, and how should the dosages of these medications be adjusted to maintain therapeutic efficacy?
A patient being treated for bipolar disorder with lithium carbonate develops hypothyroidism. Elucidate the most probable mechanism by which lithium induces hypothyroidism, and discuss how thyroid hormone levels should be monitored to guide clinical management.
A patient being treated for bipolar disorder with lithium carbonate develops hypothyroidism. Elucidate the most probable mechanism by which lithium induces hypothyroidism, and discuss how thyroid hormone levels should be monitored to guide clinical management.
A patient with schizophrenia, who has been stable on aripiprazole for several years, reports a significant worsening of negative symptoms, including blunted affect and avolition. Assuming adherence to the medication regimen, which of the following mechanisms could explain this paradoxical worsening, considering aripiprazole's unique pharmacology?
A patient with schizophrenia, who has been stable on aripiprazole for several years, reports a significant worsening of negative symptoms, including blunted affect and avolition. Assuming adherence to the medication regimen, which of the following mechanisms could explain this paradoxical worsening, considering aripiprazole's unique pharmacology?
A patient with a known genetic predisposition to schizophrenia presents with early, sub-clinical symptoms that are not significantly impairing daily function. Considering the limitations of current antipsychotic interventions, which of the following preemptive strategies best balances minimizing potential adverse effects while addressing the patient's concerns?
A patient with a known genetic predisposition to schizophrenia presents with early, sub-clinical symptoms that are not significantly impairing daily function. Considering the limitations of current antipsychotic interventions, which of the following preemptive strategies best balances minimizing potential adverse effects while addressing the patient's concerns?
A 30-year-old patient presents to the emergency department exhibiting acute agitation, paranoid delusions, and disorganized speech. Following initial stabilization with intramuscular haloperidol, the patient develops severe muscle rigidity, hyperthermia, and altered mental status. Which of the following is the MOST critical next step in managing this patient’s condition?
A 30-year-old patient presents to the emergency department exhibiting acute agitation, paranoid delusions, and disorganized speech. Following initial stabilization with intramuscular haloperidol, the patient develops severe muscle rigidity, hyperthermia, and altered mental status. Which of the following is the MOST critical next step in managing this patient’s condition?
A patient stabilized on clozapine for treatment-resistant schizophrenia develops persistent sialorrhea, leading to significant psychosocial distress and non-adherence. Which of the following pharmacological interventions is LEAST likely to exacerbate clozapine's adverse effect profile while effectively mitigating the sialorrhea?
A patient stabilized on clozapine for treatment-resistant schizophrenia develops persistent sialorrhea, leading to significant psychosocial distress and non-adherence. Which of the following pharmacological interventions is LEAST likely to exacerbate clozapine's adverse effect profile while effectively mitigating the sialorrhea?
A 25-year-old female with a history of schizophrenia treated with long-acting injectable paliperidone presents with galactorrhea and amenorrhea. Endocrine evaluation reveals hyperprolactinemia. Beyond medication adjustment, which of the following interventions carries the HIGHEST evidence-based likelihood of ameliorating these specific adverse effects while minimizing potential disruptions to her psychiatric stability?
A 25-year-old female with a history of schizophrenia treated with long-acting injectable paliperidone presents with galactorrhea and amenorrhea. Endocrine evaluation reveals hyperprolactinemia. Beyond medication adjustment, which of the following interventions carries the HIGHEST evidence-based likelihood of ameliorating these specific adverse effects while minimizing potential disruptions to her psychiatric stability?
A patient with chronic schizophrenia, maintained on a stable dose of risperidone, reports experiencing new-onset motor tics and akathisia. After ruling out other potential etiologies, which of the following pharmacological strategies is MOST judicious for managing these emergent movement disorders while minimizing the risk of precipitating psychotic decompensation?
A patient with chronic schizophrenia, maintained on a stable dose of risperidone, reports experiencing new-onset motor tics and akathisia. After ruling out other potential etiologies, which of the following pharmacological strategies is MOST judicious for managing these emergent movement disorders while minimizing the risk of precipitating psychotic decompensation?
A patient with schizoaffective disorder currently managed with aripiprazole presents with persistent depressive symptoms despite adequate control of psychotic symptoms. The patient has a history of poor adherence with multiple previous antidepressant trials due to intolerable side effects. Which of the following augmentation strategies is MOST likely to target both the depressive symptoms and improve overall adherence, while also accounting for potential pharmacokinetic interactions?
A patient with schizoaffective disorder currently managed with aripiprazole presents with persistent depressive symptoms despite adequate control of psychotic symptoms. The patient has a history of poor adherence with multiple previous antidepressant trials due to intolerable side effects. Which of the following augmentation strategies is MOST likely to target both the depressive symptoms and improve overall adherence, while also accounting for potential pharmacokinetic interactions?
A 60-year-old patient with a 30-year history of schizophrenia treated with haloperidol develops persistent, involuntary choreoathetoid movements affecting the face and extremities. These movements significantly impair the patient's ability to perform basic daily activities. Which of the following interventions is MOST appropriate as an initial management strategy for this presentation of tardive dyskinesia?
A 60-year-old patient with a 30-year history of schizophrenia treated with haloperidol develops persistent, involuntary choreoathetoid movements affecting the face and extremities. These movements significantly impair the patient's ability to perform basic daily activities. Which of the following interventions is MOST appropriate as an initial management strategy for this presentation of tardive dyskinesia?
A patient with schizophrenia on quetiapine develops significant weight gain, metabolic syndrome, and complains of excessive daytime sedation. Despite dose adjustments and behavioral interventions, these side effects persist and severely impact the patient's quality of life. Which of the following strategies represents the MOST evidence-based approach to mitigate these adverse effects while preserving antipsychotic efficacy?
A patient with schizophrenia on quetiapine develops significant weight gain, metabolic syndrome, and complains of excessive daytime sedation. Despite dose adjustments and behavioral interventions, these side effects persist and severely impact the patient's quality of life. Which of the following strategies represents the MOST evidence-based approach to mitigate these adverse effects while preserving antipsychotic efficacy?
A 40-year-old male with a diagnosis of treatment-resistant schizophrenia, currently maintained on clozapine, develops neutropenia (ANC <1000/μL) but remains clinically stable from a psychiatric standpoint. Considering the absolute necessity of clozapine for this patient's mental health, which of the following management strategies is MOST appropriate?
A 40-year-old male with a diagnosis of treatment-resistant schizophrenia, currently maintained on clozapine, develops neutropenia (ANC <1000/μL) but remains clinically stable from a psychiatric standpoint. Considering the absolute necessity of clozapine for this patient's mental health, which of the following management strategies is MOST appropriate?
A patient with chronic schizophrenia treated with haloperidol presents to the emergency department with complaints of sustained, painful muscle contractions in the neck and back. Upon examination, the patient exhibits marked torticollis and opisthotonos. Which of the following interventions is BOTH the MOST appropriate and the MOST rapid-acting initial treatment for this acute dystonic reaction?
A patient with chronic schizophrenia treated with haloperidol presents to the emergency department with complaints of sustained, painful muscle contractions in the neck and back. Upon examination, the patient exhibits marked torticollis and opisthotonos. Which of the following interventions is BOTH the MOST appropriate and the MOST rapid-acting initial treatment for this acute dystonic reaction?
What are the three types of Bipolar Disorder?
What are the three types of Bipolar Disorder?
Which of the following medications are commonly used to treat acute mania? (Select all that apply)
Which of the following medications are commonly used to treat acute mania? (Select all that apply)
Which of the following medications are used for depressive episodes in bipolar disorder? (Select all that apply)
Which of the following medications are used for depressive episodes in bipolar disorder? (Select all that apply)
Which of the following antipsychotic medications is commonly used to treat bipolar disorder?
Which of the following antipsychotic medications is commonly used to treat bipolar disorder?
Flashcards
Clozapine MOA
Clozapine MOA
Antipsychotic that blocks dopamine and serotonin receptors; also affects alpha-adrenergic, histamine, and cholinergic receptors.
Clozapine Indications
Clozapine Indications
Schizophrenia, treatment-resistant bipolar disorder, and treatment-resistant schizophrenia.
Clozapine Adverse Effects
Clozapine Adverse Effects
Severe neutropenia, seizures, bradycardia, myocarditis, and small bowel obstruction.
Clozapine Contraindications
Clozapine Contraindications
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Clozapine Black Box Warnings
Clozapine Black Box Warnings
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Haloperidol MOA
Haloperidol MOA
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Haloperidol Indications
Haloperidol Indications
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Haloperidol Adverse Effects
Haloperidol Adverse Effects
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Aripiprazole MOA
Aripiprazole MOA
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Olanzapine MOA
Olanzapine MOA
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Lithium MOA
Lithium MOA
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Carbamazepine MOA
Carbamazepine MOA
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Lamotrigine MOA
Lamotrigine MOA
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Valproic Acid MOA
Valproic Acid MOA
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Schizophrenia: Positive Symptoms
Schizophrenia: Positive Symptoms
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Schizophrenia: Negative Symptoms
Schizophrenia: Negative Symptoms
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Extrapyramidal Symptoms (EPS)
Extrapyramidal Symptoms (EPS)
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Antipsychotic: Key Prescribing
Antipsychotic: Key Prescribing
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Bipolar Disorder
Bipolar Disorder
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Mania
Mania
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Hypomania
Hypomania
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Bipolar Disorder Meds
Bipolar Disorder Meds
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Lithium Monitoring
Lithium Monitoring
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Schizophrenia Treatment Objectives
Schizophrenia Treatment Objectives
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Aripiprazole Advantage
Aripiprazole Advantage
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Rapid Symptom Control
Rapid Symptom Control
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Maintenance Therapy Goal
Maintenance Therapy Goal
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Non-Drug Schizophrenia Treatments
Non-Drug Schizophrenia Treatments
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Medication Adherence Issues
Medication Adherence Issues
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Causes of Non-Adherence
Causes of Non-Adherence
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QTc Prolongation Risk
QTc Prolongation Risk
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Torsades de Pointes
Torsades de Pointes
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Symptoms of Schizophrenia
Symptoms of Schizophrenia
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Schizophrenia
Schizophrenia
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Positive Symptoms of Schizophrenia
Positive Symptoms of Schizophrenia
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Negative Symptoms of Schizophrenia
Negative Symptoms of Schizophrenia
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Potency of 1st Generation Antipsychotics
Potency of 1st Generation Antipsychotics
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Extrapyramidal Side Effects (EPS)
Extrapyramidal Side Effects (EPS)
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Tardive Dyskinesia
Tardive Dyskinesia
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Neuroleptic Malignant Syndrome (NMS)
Neuroleptic Malignant Syndrome (NMS)
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Major Drug Classes for Bipolar Disorder
Major Drug Classes for Bipolar Disorder
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Lithium
Lithium
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Study Notes
Schizophrenia
- Clinical presentation and etiology should be reviewed.
- Differentiate between positive and negative symptoms
1st and 2nd Generation Antipsychotics
- Classify by potency and incidence of extrapyramidal side effects.
- Define early and late extrapyramidal side effects, features and management, including tardive dyskinesia.
- Discuss the approach to other adverse effects of antipsychotics which include:
- NMS
- Anticholinergic effects
- Hypotension
- Agranulocytosis
- Dysrhythmias
- Know the black box warnings and lab monitoring requirements for clozapine.
- Summarize the key prescribing considerations and patient education when treating with 1st and 2nd generation antipsychotics.
- Discuss benefits and risks for the use of depot antipsychotic preparations.
- There are 3 major objectives of drug therapy for schizophrenia.
- Outline the general approach to drug selection, dosing, routes, initial therapy, maintenance therapy, adherence, and non-drug therapy.
- Schizophrenia is a neurodevelopmental disorder that has neuropathological changes that begin in utero.
- Schizophrenia is a syndrome that has positive and negative symptoms, cognitive impairments, and mood/anxiety disorders.
- Positive symptoms of Schizophrenia:
- Hallucinations
- Delusions
- Disorganization
- Negative symptoms of Schizophrenia:
- Typically presents first
- Resistant to treatment
- Blunted affect
- Apathy
- Asociality
- Alogia (thought blocking)
- Cognitive impairment includes issues with:
- Processing speed
- Attention
- Working memory
- Learning (verbal/visual)
- Reasoning
- Social interaction
- Mood/Anxiety has Higher rates:
- 1st Generation antipsychotics include Haloperidol and Chlorpromazine
- 2nd Generation antipsychotics include:
- Aripiprazole
- Quetiapine
- Olanzapine
- Clozapine
- Risperidone
- 1st Generation antipsychotics have a Higher risk of EPS and Higher sedation.
- Common AEs of antipsychotics include weight gain.
- 2nd Generation antipsychotics have a higher risk of metabolic syndrome and QT prolongation.
- Early Extrapyramidal Side Effects include:
- Acute dystonia
- Neuroleptic Malignant Syndrome
- Akathisia
- Late Extrapyramidal Side Effects include:
- Pseudoparkinsonism
- Tardive Dyskinesia
- Pseudoparkinsonism
- Benztropine, Dantrolene + Benzos, and Propranolol is management for early side effects
- Amantadine, Discontinuing offending agent, and Benzos is management for late side effects
- Management of Anticholinergic AEs includes the following:
- Limit dose
- Frequent water intake
- Oral-balance products
- Management of Dysrhythmias includes:
- QT monitoring
- IV Magnesium
- Avoiding other QT agents
- Key prescribing considerations include checking A1c, baseline lipids, and a baseline ECG
- Patient education should include Sedation, Weight gain, and awareness of Cholesterol risks.
- There are benefits and risks to depot preparations:
- Benefits include Improved adherence, Reduced hospitalization, Predictability, Less risk of overdose, and Bypassing hepatic elimination.
- Risks include Delayed clinical improvement, Adverse effects persist, Perceived lack of autonomy, High acquisition costs, and Special storage requirements.
- Three major objectives in treatment of Schizophrenia: -Reduce symptoms -Prevent relapses -Improve Quality of Life
General Approach to Drug Treatment
- Drug selection/Route/Dose:
- Aripiprazole has a lower risk of weight gain.
- If rapid improvement needed use Olanzapine/Haldol.
- Use the Lowest effective dose.
- Consider degree of symptoms for route
- Maintenance therapy:
- Usually can titrate down once stable
- Adherence is roughly 50-60%. Side effects and Poor discharge planning affect this rate
- Non-drug therapy:
- CBT
- Dialogue
- Social skill training
- Assertive Community Treatment
- Vocational rehab
- CBT
Bipolar Disorder
- Review the characteristics of bipolar disorder, including types, patterns, and etiology.
- Describe the 3 major types of drugs used to treat bipolar disorder.
- Differentiate between the drugs of choice for acute therapy for manic episodes, depressive episodes, and long-term prevention.
- Summarize the key prescribing considerations, lab monitoring, and patient education for Lithium.
- Know the black box warnings for lithium, carbamazepine, lamotrigine, and antipsychotics (in older populations).
- Bipolar I (Mania)
- Bipolar II (Hypomania)
- Cyclothymic (Mild depression)
- Patterns:
- Certain times of day or year
- Rapid Cycling (4+x/year)
- Etiology:
- Multi-factorial with genetic components and may include Trauma.
- There are 3 major drug types:
- Anticonvulsants:
- Valproic Acid
- Lamotrigine
- Mood stabilizers:
- Lithium
- Antipsychotics:
- Quetiapine
- Medication selection:
- Acute Mania:
- Quetiapine
- Olanzapine
- Depressive episodes:
- Valproic Acid
- Lamotrigine
- Lithium
- Long term:
- Monotherapy or combination of other agents
- Lithium management includes:
- Prescribing Considerations:
- Kidney disease
- Ability to monitor
- Intake
- Lab Monitoring:
- TSH
- Creatinine
- Lithium Levels
- Patient Education:
- Small therapeutic window
- Hydration
- Routine monitoring
- Risk of thyroid disease
Chlorpromazine: Antipsychotic
- Alternate name is Thorazine.
- MOA: Dopaminergic and serotonergic antagonist
- It is indicated for Schizophrenia, Bipolar I, and agitation.
- Adverse effects include Xerostomia, Dizziness, Urinary retention, and Sedation.
- Contraindications include hypotension, poorly controlled seizure disorder.
- Major interactions: CNS depressants, Levodopa/Carbidopa, and SSRIs
- Patient Education/Clinical Pearls:
- Don't take with alcohol.
- Carries a risk of TD/akathisia (lower than others).
- Black box warning: Increased mortality in Elderly patients with dementia related psychosis
Haloperidol: Antipsychotic
- Alternate name is Haldol.
- MOA: Dopaminergic antagonist
- It is indicated for Schizophrenia, Tourette syndrome, severe behavioral disorders, and agitation or mania (OFF LABEL).
- Adverse effects include Dystonia, Akathisia, Neuroleptic Malignant Syndrome, Parkinsonism, Tardive Dyskinesia, weight gain, and xerostomia.
- Contraindications include Parkinsons and dementia.
- Major interactions: CNS depressant
- Patient Education/Clinical Pearls: Often utilized for patients with dementia in settings of delirium/agitation.
- Black box warning: Increased mortality in Elderly patients with dementia related psychosis
Clozapine: Antipsychotic
- Alternate name is Clozaril.
- MOA: Dopamine and serotonin antagonist, impacts alpha-adrenergic, histamine, and cholinergic receptors as well
- It is indicated for Psychosis, Resistant Bipolar, and Resistant Schizophrenia.
- Adverse effects include severe neutropenia, seizures, bradycardia, myocarditis, and small bowel obstruction (High risk drug)
- Contraindications: Myeloproliferative disorders, severe renal or cardiac disease
- Major interactions: QT Prolonging medications
- Patient Education/Clinical Pearls: Requires close monitoring during titration with frequent blood draws. Assistance with managing the drug from a PharmD is needed.
- Black box warnings:
- Increased mortality in Elderly patients with dementia related psychosis
- Neutropenia
- Orthostatic hypotension
- Seizures
- Myocarditis and mitral valve incompetence
- Patients, Pharmacies, and Prescribers must all be certified in the Clozapine REMS program
Aripiprazole: Antipsychotic
- Alternate name is Abilify.
- MOA: Quinolinone antipsychotic, dopamine/serotonin antagonist/agonist
- It is indicated for Bipolar/Acute mania, aggression, and schizophrenia.
- Adverse effects include sedating, akathisia, and dystonia.
- Contraindications include bariatric surgery, CV disease, Parkinsons, and Seizures.
- Major interactions: QT prolonging medications
- Patient Education/Clinical Pearls: Fairly safe, well tolerated
- Black box warning: Increased mortality in Elderly patients with dementia related psychosis and increased suicidality in children/young adults"
Olanzapine: Antipsychotic
- Alternate name is Zyprexa.
- MOA: Serotonergic and dopaminergic antagonist
- It is indicated for Agitation, Bipolar I, and Schizophrenia.
- Adverse effects are Hyperprolactinemia.
- Contraindications QT include prolonging medications.
- Major interactions: Anticholinergic medications
- Patient Education/Clinical Pearls: Sedating and fast acting
- Black box warning: Increased mortality in Elderly patients with dementia related psychosis
Lithium: Antimanic
- Alternate name is Lithobid.
- MOA: Unknown, possibly due to cation transport
- It is indicated for Bipolar I and MDD.
- Adverse effects Pseudotumor include cerebri, serotonin syndrome.
- Contraindications include dehydration and Renal disease.
- Major interactions: MAOI
- Patient Education/Clinical Pearls: Need to be well hydrated and know the narrow therapeutic window.
- Black box warning: Lithium toxicity can occur at doses close to therapeutic levels and plan for close monitoring must be in place prior to initiating.
Carbamazepine: Antimanic
- Alternate name is Tegratol.
- MOA: Depresses activity in thalamus and limits sodium ion influx.
- It is indicated for bipolar disorder and seizures.
- Adverse effects include aplastic anemia, heart failure, hyponatremia, ataxia, dizziness, and drowsiness.
- Contraindications include known blood disorder and caution is advised with patients with heart failure.
- Major interactions include Apixaban (decrease effect), MAOIs, Rivaroxaban (decrease effect), and HIV meds.
- Patient Education/Clinical Pearls: Patients w/Asian ancestry should be screened for HLA-B*1502 allele variant because it carries a high risk of SJS/TEN.
- Black box warning: Serious dermatologic effects (HLA-B*1502) and Aplastic anemia
Lamotrigine: Antiseizure
- Alternate name is Lamictal.
- MOA: Inhibits glutamate and sodium channels
- It is indicated for bipolar disorder and seizures.
- Adverse effects include blood disorders and increased SI.
- Contraindications include known blood disorders.
- Major interactions: No major interactions
- Patient Education/Clinical Pearls: Weight gain is expected
- Black box warning: Serious dermatologic reactions
Valproic Acid: Antimanic
- Alternate name is Depakote.
- MOA: Increased GABA and sodium channel inhibition
- It is indicated for bipolar, seizure, and Migraines.
- Adverse effects include dizziness, blood disorders, hepatotoxicity, and hyperammonemia.
- Contraindications include liver failure.
- Major interactions: No major interactions
- Patient Education/Clinical Pearls: Generally well tolerated. Be aware of the hyperammonemia on initiation if patient gets acutely confused.
- Black box warning: Hepatotoxicity, increased risk with mitochondrial disease, major congenital malformations, and life-threatening pancreatitis
Risperidone: Antipsychotic
- Alternate name is Risperdal.
- MOA: Serotonergic and dopaminergic antagonist
- It is indicated for Bipolar, Delusional disorder, MDD, and Schizophrenia.
- Adverse effects: Akathisia, drowsiness, hyperlipidemia, dystonia, hyperglycemia, QT prolongation, weight gain
- Contraindications: No absolute contraindications
- Major interactions: No major interactions
- Patient Education/Clinical Pearls: Metabolic impacts.
- Black box warning: Increased mortality in Elderly patients with dementia related psychosis
Quetiapine: Antipsychotic
- Alternate name is Seroquel.
- MOA: Dopaminergic and serotonergic antagonist
- It is indicated for Bipolar disorder, Delusional disorder, MDD, PTSD, and Schizophrenia (Therapeutic Use).
- Adverse effects include Constipation, urinary retention, hyperlipidemia, hyperglycemia, weight gain, and QT prolongation.
- Contraindications: No absolute contraindications
- Major interactions: QT prolonging medications.
- Patient Education/Clinical Pearls: Metabolic effects.
- Black box warning: Increased mortality in Elderly patients with dementia related psychosis and increased suicidality in children/young adults .
Case Studies
- Case #1: 23 year old presents concern for lack of motivation and paranoid thinking. Not affecting day to day life, however, the patients is worried about schizophrenia based off their mother.
- Case #2: 30 year old spitting on a restaurant window and yelling at customers inside. Brought to the emergency is yelling that they're being held hostage and the FBI is after them.
- Case #3: 27 year old on their 4th admission this year. Decompensated schizophrenia results from with medication non-adherence. States pills stolen/lost shelter.
- Case #4: 25 year old with schizophrenia who attempted suicide. via ingestion of 45 tablets of olanzapine. ECG obtained and QTc 650, Patient noted to have twisting/jerking movements
- Case #1: 22-year-old woman, feeling depressed for the last few weeks, struggling to get out of bed in the mornings and feeling like nothing will ever get better. Trouble concentrating feels hopeless future. She has experienced moments of extreme excitement, staying up ideas flooding mind. Calling friends non-stop, starting projects, and feeling creative, then crashing again into depressive episodes shortly after.
- Case #2: 29-year-old woman, brought emergency increasingly agitated and reckless over the past few days. History of bipolar disorder over a year. She's Stopped medication because she felt "better than ever" didn't need them. For the past week, behavior has been increasingly erratic. She hasn't been sleeping, staying up days Engaging impulsive activities luxury items grandiose plans. Speech is rapid, difficulty staying focused single topic. Family worried safety.
- Case #3: 40-year-old man, has long history of cycling moods. In the past, weeks of feeling overly happy, productive, and energetic, followed episodes extreme sadness, loss of interest, and fatigue. Hypomanic, he feels he feels unusually flirtatious with his coworkers. He has trouble managing.
- Case #4: 25 has feelings of irritability and being energetic. Planning to travel internationally and starting multiple projects without completing them, with her going from being cheerful to snappy the next. thoughts feel jumbled. is disrupted, stay still long periods. Now feeling hopeless. with difficulty getting out of bed for days.
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Description
These questions address treatment strategies for bipolar disorder, focusing on acute manic episodes, persistent depressive symptoms, and family planning. They emphasize the importance of vigilant monitoring for potential iatrogenic complications, adverse cognitive effects, and teratogenic potential associated with different treatment approaches. Careful consideration of endocrine, metabolic, and cognitive impacts is crucial.
