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Questions and Answers
What are common symptoms of toxicity that a patient may experience?
Which drug should have its dosage reduced by 50% when used in combination with Depakote?
What is the maximum dose for administering a medication for acute mania when using the initial rapid dosing method?
What is the typical starting dose range for a certain medication expressed in mg/day?
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What is a significant mechanism of action of Carbamazepine?
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What is the half-life (T ½) of Carbamazepine during long-term administration?
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Which of the following is NOT a common side effect of Carbamazepine?
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What should be monitored to check the safety of Carbamazepine therapy?
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What is the mechanism of action of Lamotrigine?
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What is a potential pregnancy effect of Carbamazepine?
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Which side effect is linked to the quick titration of Lamotrigine?
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What is the initial dosing recommendation for Carbamazepine?
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What is the primary symptom of toxicity for both Carbamazepine and Lamotrigine?
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What is the maximum daily dose of Lurasidone for adults with schizophrenia?
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What is a common side effect of Lurasidone?
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Which medication requires the patient to take it with food?
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Which of the following medications is indicated for bipolar depression in patients aged 10 and older?
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What is the therapeutic monitoring parameter for Ziprasidone?
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What does the acronym 'MDD' stand for in mental health medications?
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What is a symptom of toxicity associated with Lurasidone?
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Which medication is noted for having the lowest risk of weight gain?
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What category is Ziprasidone in regarding pregnancy safety?
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When titrating medications like Lurasidone, what is the recommended approach?
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What are the signs and symptoms associated with Alcohol Use Disorder (AUD)?
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Which withdrawal symptom is associated with the earliest stage (4-8 hours) after reducing alcohol intake?
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What is the primary purpose of using benzodiazepines such as Ativan and Librium in the management of alcohol withdrawal?
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What is a significant risk associated with untreated Delirium Tremens (DTs) during alcohol withdrawal?
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What is the role of Vitamin B1 (Thiamine) in treating Alcohol Use Disorder?
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Which of the following is NOT a reason why benzodiazepines must be used cautiously in AUD?
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What is one of the main withdrawal symptoms experienced in the 12-24 hour stage of alcohol withdrawal?
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How should benzodiazepines be handled after the acute withdrawal phase in individuals with AUD?
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What is the primary mechanism of action of Topiramate?
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Which medication is indicated for treatment-resistant schizophrenia?
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What is a common side effect of Risperidone?
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In which category are the pregnancy effects of Atypical antipsychotics classified?
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What kind of monitoring is recommended for patients taking Oxcarbazepine?
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Which of the following is a symptom of toxicity associated with Topiramate?
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What is a key consideration when titrating doses of antipsychotics?
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Which neurotransmitter receptors does Aripiprazole act upon?
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Which medication's common interactions include diuretics and ACE inhibitors?
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What symptoms can be observed as a result of Clozapine toxicity?
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What is the common side effect associated with Quetiapine?
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Which of the following is NOT a targeted symptom of Topiramate?
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What is the initial dosing range for Risperidone in adults for bipolar mania?
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What category does Oxcarbazepine fall under concerning pregnancy effects?
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Study Notes
Valproic Acid (Depakote)
- Indications: Bipolar disorder, epilepsy
- Mechanism of action: Unknown, increases GABA levels
- Targeted neurotransmitters: GABA
- Targeted symptoms: Mania, seizures, migraine headaches
- Metabolism and excretion: Hepatic
- Common side effects: Nausea, vomiting, diarrhea, abdominal pain, weakness, lethargy
- Pregnancy effects: Spina bifida, neural tube defects
- Monitoring parameters: Liver function tests (LFTs), CBC
- Therapeutic levels: 50 - 125 mcg/mL
- Symptoms of toxicity: Nausea, vomiting, diarrhea, abdominal pain, weakness, lethargy
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Titrate slowly to response or side effects, can increase dose by 8-20% when converting from IR to ER
- Commonly known interactions: Carbamazepine, phenytoin, rifampin
Carbamazepine (Tegretol)
- Indications: Acute mania / mixed mania
- Mechanism of action: Blocks sodium channels, potent inducer of many CYP enzymes
- CYP 450 autoinduction (3A4): Drug encourages its own metabolism so it becomes less effective after a few weeks
- Targeted neurotransmitters: Unknown
- Targeted symptoms: Mania, seizures, pain
- Metabolism and excretion: Hepatic
- Common side effects: Dizziness, diplopia, ataxia, somnolence, nausea, headache, dry mouth, hyponatremia
- Rare SE: Aplastic anemia, agranulocytosis, purpura, Stevens–Johnson syndrome (SJS)
- Pregnancy effects: Spina Bifida, Must use adequate birth control methods (non-hormonal, higher doses of estrogen)
- Monitoring parameters: Carbamazepine level, CBC, LFTs, pregnancy, agranulocytosis, screen for HLA-B 1502 allele in Asian populations (increased risk of SJS)
- Therapeutic levels: 4-12 mg/L. Response NOT correlated with blood levels
- Symptoms of toxicity: Drowsiness, confusion, seizures
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Titrate slowly to response or side effects
- Commonly known interactions: Oxcarbazepine, phenytoin, valproic acid
Lamotrigine (Lamictal)
- Indications: Prevent recurrence of mania and depression in bipolar disorder
- Mechanism of action: Blocks glutamate and sodium channels
- Targeted neurotransmitters: Glutamate, GABA
- Targeted symptoms: Mania, seizures
- Metabolism and excretion: Hepatic
- Common side effects: Rash, dizziness, nausea, fatigue
- Pregnancy effects: May interact with birth control - possible need to increase the dose of both medications
- Monitoring parameters: Liver function tests
- Therapeutic levels: Not established
- Symptoms of toxicity: Rash, fever, swollen lymph nodes, Stevens - Johnson – risk with quick titration, high doses and with use of valproic acid
Oxcarbazepine (Trileptal)
- Indications: Bipolar disorder, epilepsy.
- Mechanism of action: Blocks sodium channels
- Targeted neurotransmitters: Unknown
- Targeted symptoms: Mania, seizures
- Metabolism and excretion: Hepatic
- Common side effects: Dizziness, nausea, drowsiness, headache
- Pregnancy effects: Category C
- Monitoring parameters: Liver function tests
- Therapeutic levels: Not established
- Symptoms of toxicity: Drowsiness, confusion, seizures
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Carbamazepine, phenytoin, valproic acid
Topiramate
- Indications: Bipolar disorder, epilepsy, migraine
- Mechanism of action: Blocks glutamate and GABA receptors
- Targeted neurotransmitters: Glutamate, GABA
- Targeted symptoms: Mania, seizures, weight loss
- Metabolism and excretion: Renal
- Common side effects: Drowsiness, paresthesia, cognitive impairment
- Pregnancy effects: Category C
- Monitoring parameters: Kidney function tests
- Therapeutic levels: Not established
- Symptoms of toxicity: Drowsiness, confusion, seizures
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Diuretics, NSAIDs, ACE inhibitors
Atypical Antipsychotics
Aripiprazole (Abilify)
- Indications: Bipolar Mania / maintenance, schizophrenia, depression Adjuvant, Tourette’s
- Mechanism of action: Partial dopamine agonist, serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Akathisia, insomnia, nausea, weight gain
- Pregnancy effects: Category C
- Monitoring parameters: Lipid profile, glucose levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
Risperidone
- Indications: Bipolar mania/ mixed/ maintenance, schizophrenia, depression
- Mechanism of action: Dopamine and serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Drowsiness, sedation, weight gain, prolactin elevation, gynecomastia, Akathisia
- Pregnancy effects: Category C
- Monitoring parameters: Lipid profile, glucose levels, prolactin levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
- Dosing: Adults: initial – 2mg; target 4mg -16mg Daily (bipolar mania 1mg-6mg Daily). Peds: initial – 0.5mg; target 1mg – 6mg Daily. 60% D2 blockade at 4mg
Clozapine
- Indications: Treatment-resistant schizophrenia
- Mechanism of action: Dopamine and serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis
- Metabolism and excretion: Hepatic
- Common side effects: Drowsiness, sedation, weight gain, agranulocytosis
- Pregnancy effects: Category C
- Monitoring parameters: Complete blood count (CBC), white blood cell count (WBC)
- Therapeutic levels: Not established
- Symptoms of toxicity: Agranulocytosis, seizures, myocarditis
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
Olanzapine (Zyprexa)
- Indications: Bipolar disorder mania/mixed, schizophrenia, depression (with fluoxetine)
- Mechanism of action: Dopamine and serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Drowsiness, severe sedation, weight gain, increased cholesterol and triglycerides, Extrapyramidal Symptoms, Tardive Dyskinesia
- Pregnancy effects: Category C
- Monitoring parameters: Lipid profile, glucose levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
- Dosing: Adults: 5mg – 20mg Daily. Peds: 2.5mg – 20mg Daily. Used IM for acute psychosis/aggression (NEVER with benzo)
Quetiapine (Seroquel)
- Indications: Bipolar Mania/mixed, maintenance, schizophrenia, depression adjunctive
- Mechanism of action: NET Inhibition
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Drowsiness, Severe sedation, severe weight gain, increased cholesterol and triglycerides
- Pregnancy effects: Category C
- Monitoring parameters: Lipid profile, glucose levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine, St John’s Wort makes ineffective
- Dosing: IR: Daily, receptor occupancy remains after blood levels decrease. XR: once Daily, 3-4 hours before bedtime WITHOUT FOOD. Schizophrenia: 300mg/day (400mg-800mg daily), peds 13-17 50mg/day. Bipolar: 300mg/day (400mg – 800mg), peds 50mg/day. MDD & Bipolar depression: 50mg/day (up to 300mg/day)
Lurasidone (Latuda)
- Indications: Bipolar depression, schizophrenia
- Mechanism of action: Dopamine and serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin, glutamate
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Drowsiness, sedation, weight gain, increased cholesterol and triglycerides
- Pregnancy effects: Category B, May consider
- Monitoring parameters: Lipid profile, glucose levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
- Dosing: MUST TAKE WITH FOOD. Schizophrenia: Adult – 40mg – 160mg daily. Peds – 40mg – 80mg daily. Bipolar Depression: Adult – 20-120mg Daily. Peds – 20-80mg Daily.
Ziprasidone (Geodon)
- Indications: Bipolar disorder, schizophrenia
- Mechanism of action: Dopamine and serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Dizziness, Drowsiness, QT Prolongation, sedation, LOWEST risk of weight gain
- Pregnancy effects: Category C
- Monitoring parameters: EKG, Lipid profile, glucose levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
Asenapine
- Indications: Bipolar disorder, schizophrenia
- Mechanism of action: Dopamine and serotonin antagonist
- Targeted neurotransmitters: Dopamine, serotonin
- Targeted symptoms: Positive and negative symptoms of psychosis, mood stabilization
- Metabolism and excretion: Hepatic
- Common side effects: Drowsiness, sedation, weight gain, increased cholesterol and triglycerides
- Pregnancy effects: Category C
- Monitoring parameters: Lipid profile, glucose levels
- Therapeutic levels: Not established
- Symptoms of toxicity: Tardive dyskinesia, hyperprolactinemia
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
- Commonly known interactions: Fluoxetine, paroxetine
Varenicline (Chantix)
- Indications: Smoking cessation
- Mechanism of action: Partial agonist at nicotinic acetylcholine receptors
- Targeted neurotransmitters: Acetylcholine
- Targeted symptoms: Reduce cravings
- Metabolism and excretion: Hepatic
- Common side effects: Nausea, vomiting, headache, insomnia, vivid dreams
- Pregnancy effects: Category C
- Monitoring parameters: Neuropsychiatric side effects
- Therapeutic levels: Not established
- Symptoms of toxicity: Serious neuropsychiatric side effects
- Treatment of toxicity: Discontinue medication, supportive care
- Titrating up and tapering down: Start low, go slow, monitor for side effects
Alcohol Use Disorder (AUD) and Withdrawal
- Signs and symptoms of AUD: Craving, loss of control, physical dependence, tolerance, withdrawal symptoms.
- Withdrawal symptoms: Anxiety, tremors, sweating, nausea, vomiting, seizures, delirium tremens (DTs).
-
Stages of withdrawal:
- 4 - 8 hours - tremors
- 8 – 10 hours – psychosis
- 12 – 24 hours – seizures
- 24 – 36 hours – Delirium Tremens (DTs) – 20% risk of death if not treated.
AUD Treatments
Benzodiazepines
-
Rationale: Alcohol withdrawal can be dangerous, even life-threatening. Benzodiazepines like lorazepam (Ativan) and chlordiazepoxide (Librium) are central nervous system depressants that act on GABA receptors. This helps to:
- Reduce anxiety: A major symptom of alcohol withdrawal
- Prevent seizures: Alcohol withdrawal can cause seizures
- Ease withdrawal symptoms: Lessen the severity of tremors, agitation, and insomnia
- Manage delirium tremens (DTs): DTs is a severe form of alcohol withdrawal
- Important Note: Should be used cautiously in AUD due to their own potential for dependence and abuse. They are typically tapered off gradually once the acute withdrawal phase has passed.
Vitamin B1 (Thiamine)
- Rationale: People with AUD are often deficient in thiamine (vitamin B1) due to poor nutrition and alcohol's interference with thiamine absorption. Thiamine is essential for brain function.
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Description
This quiz covers key information about Valproic Acid (Depakote) and Carbamazepine (Tegretol), including their indications, mechanisms of action, common side effects, and monitoring parameters. Test your understanding of these medications used for bipolar disorder and epilepsy.
