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NU664C Study Guide for Midterm
Exam 2025/
Know the route of administration for newer agent asenapine (Saphris) and what instructions should be given to the patient regarding administration. - ANSWER Route- Sublingual Not to eat or drink for 10 minutes after medication administration Not to swallow or chew the capsule. Asenapine is an atypical antipsychotic (serotonin-dopamine antagonist, as a mood stabilizer). Asenapine is not absorbed after swallowing (less than 2% bioavailable orally) and thus must be administered sublingually (35% bioavailable), as swallowing would render asenapine inactive. Patients should be instructed to place the tablet under the tongue and allow it to dissolve completely, which will occur in seconds; tablet should not be divided, crushed, chewed, or swallowed. Patients may not eat or drink for 10 minutes following sublingual administration so that the drug in the oral cavity can be absorbed locally and not washed into the stomach (where it would not be absorbed). Due to rapid onset of action, can be used as a rapid acting "prn" or "as needed" dose for agitation or transient worsening of psychosis or mania instead of an injection. Treatment should be suspended if absolute neutrophil count falls below 1,000/mm3. Know and describe the top atypical antipsychotic with greatest incidence of prolonged QTc interval. - ANSWER Ziprasidone (Geodon). Normal QTc =450.
470, Call Cardiologist 500, stop all meds. Ziprasidone (Geodon) has been associated with a dose-related prolongation of the QTc QTc interval prolongation is greatest with ziprasidone and least with olanzapine.
Ziprasidone (Geodon) an atypical antipsychotic (serotonin-dopamine antagonist; second-generation antipsychotic; also a mood stabilizer. Ziprasidone is prescribed for Schizophrenia, delaying relapse in schizophrenia, acute agitation in schizophrenia (intramuscular), acute mania/mixed mania, bipolar maintenance, other psychotic d/o, bipolar depression, behavioral disturbances in dementias, behavioral disturbances in children and adolescents, and disorders associated with problems with impulse control. Ziprasidone blocks dopamine 2 receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms. Blocks serotonin 2A receptors, causing enhancement of dopamine release in certain brain regions and thus reducing motor side effects and possible improving cognitive and affective symptoms. EKGs may be useful for selected patients (e.g., those with personal or family history of QTc prolongation; cardiac arrhythmia; recent myocardial infarction; uncompensated heart failure; or those taking agents that prolong QTc interval (such as pimozide, thioridazine, selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.) Ziprasidone prolongs QTc interval more than some other antipsychotics. Ziprasidone is associated with rare but serious skin condition known as Drug Reaction with Eosinophilia (DRESS). DRESS may begin as a rash but can progress to other parts of the body and can include symptoms such as fever, swollen lymph nodes, swollen face, inflammation of organs, and an increase in white blood cells known as eosinophilia. In some cases, DRESS can lead to death. Clinic Know which antipsychotics have specific instructions for minimum food intake or diet restrictions. - ANSWER Geodon because food affects the absorption of the drug. Lurasidone - Latuda Know an alternative atypical antipsychotic for a patient who has developed diabetes and has a significant weight gain from treatment with olanzapine. - ANSWER Abilify or Geodon, or Lurasidone (Latuda) Because they are weight neutral or causes minimal weight gain.
Know what medication may be an option for patients noncompliant on antipsychotics resulting in multiple hospital stays - ANSWER Fluphenazine and haloperidol have been formulated as long-acting injectables (LAI)s. Long-acting forms of risperidone, paliperidone, aripiprazole, and olanzapine are also available. Know baseline labs and vital measurements tests for the patient who will be prescribed an antipsychotic such as quetiepine (Seroquel). - ANSWER A1C, Lipids, CBC, CMP, LFT Weight, HR, B/P = monitoring for metabolic syndrome Describe common side effects/disadvantages of antihistamines. - ANSWER ·Antihistamines are commonly associated with sedation, dizziness, and hypotension, all of which can experience the anticholinergic effects of those drugs. Other common adverse effects include epigastric distress, nausea, vomiting, diarrhea, and constipation. Because of mild anticholinergic activity, some people experience dry mouth, urinary retention, blurred vision, and constipation. For this reason, antihistamines should be used only as very low doses. Identify 3-4 disorders/situations when benzodiazepines may be indicated. - ANSWER · Acute Alcohol withdrawal · Acute Benzo withdrawal · Acute Agitation associated with substance use · Acute Panic Attack Describe 2-3 common side effects of atypical antipsychotics. - ANSWER · Weight gain · Sedation · Metabolic Syndrome · EPS (unlikely to cause? QTc Prolongation)
Know and describe the name of long-acting olanzapine and a key adverse side effect. - ANSWER Zyprexa Relprevv · Post-injection Delirium Sedation Syndrome (PDSS) Excessive Sedation Patients need to be monitored after getting the injection. Know and describe screening tools for depression, anxiety, schizophrenia, and mania symptoms. - ANSWER >Depression - Becks Depression Inventory: minimal range = 0-9, mild depression = 10-16, moderate depression = 17-29, and severe depression = 30-63. PHQ9: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
Anxiety - GAD7: 0-5 mild 6-10 moderate 11-15 moderately severe anxiety. 15- 21 severe anxiety. Hamilton Anxiety Rating Scale: <17 indicates mild severity, 18-24 mild to moderate severity and 25-30 moderate to severe. Schizophrenia - Positive & Negative Symptoms Scale (PANSS); Scale for the Assessment of Positive Symptoms (SAPS); Scale for the Assessment of Negative Symptoms (SANS); NSA-16; CGI-SCH). Mood Disorder/Mania - Young Mania Rating Scale (YMRS), Bech Rafaelsen Mania Rating Scale (MRS). Be able to describe baseline labs you would want to have prior to ordering antipsychotics. - ANSWER · CBC, CMP, LFTs, Lipid Panel, HgbA1c, U/A, Urine Drug Screen Compare and contrast Neuroleptic Malignant Syndrome (NMS) to Serotonin Syndrome. Know the key symptoms of each syndrome. What lab values may be elevated with NMS? What medications are associated with the development of each syndrome? How is each syndrome treated? - ANSWER >Neuroleptic Malignant Syndrome (NMS) · Stiffness, rigidity
What are some factors that may increase the risk for suicide? Protective factors? - ANSWER · Gender differences. - Men commit suicide more than four times as often as women. · Age. - Most suicides now are among those aged 35 to 64. Among men suicides peak after age 45; with women suicides occurs after age 55. · Race. - Suicide rates among white men and women are approximately two to three times as high as Black men and women across the life cycle. · Religion. - Protestants and Jews in the U. S. have had higher suicide rates than Catholics. · Marital Status. - Divorce increase suicide risk, with divorced men three times more likely to kill themselves as divorced women. Widows and widowers also have high rates. Homosexual men and women appear to have higher rates of suicides than heterosexuals. · Occupation. - The higher the person's social status, the greater the risk of suicide, but a drop in social status also increase the risk. Occupational rankings, professionals, particularly physicians, have traditionally been considered to be at greatest risk. WORK, IN GENERAL PROTECTS AGAINST SUICIDE. · Climate. - No significant seasonal correlation with suicide has been found. · Physical Health. - About one third of all persons who commit suicide have had medical attention within 6 months of death, and a physical illness is estimated to be an important contributing factor in about half of all suicides. Certain drugs can produce depression, which may lead to suicide in some cases. Among these drugs are reserpine (Serpasil), corticosteroids, antihypertensives, and some anticancer agents. Etoh-related illnesses, such as cirrhosis, are associated with higher suicide rates. · Mental Illness. - Almost 95% of all persons who commit, or attempt suicide have a diagnosed mental disorder. Depressive d/o accounts for 80%, schizophrenia accounts for 10%, and dementia or delirium for 5%. · Protective Factors. - Not all suicides ar What group/population has the shortest life span? - ANSWER Black males Know which organ systems need to be evaluated prior to and at scheduled intervals when prescribing lithium or Depakote (valproate acid). - ANSWER
Lithium
· Before initiating Lithium treatment, kidney function tests (including creatinine and urine specific gravity) and thyroid function tests; ecg for patients over 50 · Repeat kidney function tests 1-2 times per year. · Frequent test to monitor trough lithium plasma levels (about 12 hours after last dose; should generally be between 1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment). · Initial monitoring: every 1-2 weeks until desired serum concentration is achieved, then every 2-3 months for the first 6 months. · Stable monitoring: every 6-12 months. · One-off monitoring after dose change, other medication change, illness change (not before 1 week). · Since lithium is frequently associated with weight gain, before starting treatment, weigh all pts and determine if the pt. is already overweight (BMI 25.0-29.9) or obese (BMI >30). · Before giving drug determine if pt. is pre-diabetes (fasting plasma glucose 100- 125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or dyslipidemia (increase total cholesterol, LDL cholesterol, and triglycerides; decreased HDL cholesterol), and treat or refer such pt. for treatment. · Monitor weight and BMI during treatment. · While giving a drug to a pt. who has gained >5% of initial weight, consider evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider switching to a different agent.
Depakote (valproic acid) · Before starting treatment, complete blood counts, coagulation tests, and liver function tests. · Consider coagulation tests prior to planned surgery or if there is a history of bleeding. · During the first few months of treatment, regular liver function tests and platelet counts; this can be shifted to once or twice a year for the remainder of treatment. · Plasma drug levels can assist monitoring since valproate Know the general medication classes used to treat mental health disorders, such as depression, anxiety, bipolar disorder, psychotic disorders, etc. - ANSWER Depression/Bipolar disorder Lithium Anticonvulsants -Depakote, Divalproex, Valproic Acid
Non-Benzo/GABA Agonist
- Buspar, Buspirone Alternative to Benzos -Lyrica, pregabalin -Neurontin, gabapentin
Social Anxiety Disorder (SAD) CBT-1st line therapy Antidepressants (SSRI and SNRI(Cymbalta)) are 1st line
Lyrica/Neurontin-1st or s Know general considerations for safe prescribing measures you need to be mindful of when prescribing antidepressants and other medications (e.g., lab monitoring, potential interactions, risks of combining medications, potentially harmful side effects). - ANSWER What medications are used to treat an overdose of a benzodiazepine? An opiate? - ANSWER >Benzodiazepine · The availability of Flumazenil (Romazicon), a specific benzodiazepine antagonist, has reduced the lethality of the benzodiazepines. · Flumazenil can be used in emergency rooms to reverse the effects of the benzodiazepines.
Opiate · The first task in overdose treatment is to ensure an adequate airway. · The patient should be ventilated mechanically until naloxone, a specific opioid antagonist, can be given. · Naloxone is administered intravenously at a slow rate - initially about 0.8 mg per 70 kg of body weight. · In opioid-dependent pts, too much naloxone may produce signs of withdrawal as well as reversal of administration may be repeated after intervals of a few minutes. · It was thought that if no response was observed after 4 to 5 mg, the CNS depression was probably not caused solely by opioids.
Know the most common medications used to treat Alzheimer's Disease and the method of administration. - ANSWER · Donepezil is well tolerated and widely used. · Memantine (Namenda) protects neurons from excessive amounts of glutamate, which mat be neurotoxic. The drug is sometimes combined with Donepezil. It has been known to improve dementia. · In general, drugs with high anticholinergic activity should be avoided. · Donepezil (Aricept), rivastigmine (Exelon), galantamine (Remiryl), and tacrine (Cognex) are cholinesterase inhibitors used to treat mild to moderate cognitive impairment in Alzheimer's disease. Know and describe cognitive therapy strategies and how these are used to treat anxiety. - ANSWER · Three major schools of psychological theory - psychoanalytic, behavioral, and existential - have contributed theories about the causes of anxiety. · Psychoanalytic - To understand fully a particular patient's anxiety from a psychodynamic view, it is often useful to relate the anxiety to developmental issues. Some anxiety is obviously related to multiple conflicts at various developmental levels. · Behavioral - The behavioral or learning theories of anxiety postulate that anxiety is a conditioned response to a specific environmental stimulus. In the social learning model, a child may develop an anxiety response by imitating the anxiety in the environment, such as in anxious parents. · Existential - Existential theories of anxiety provide models for generalized anxiety, in which no specifically identifiable stimulus exists for a chronically anxious feeling. Anxiety is their response to the perceived void in existence and meaning. Describe 2-3 common side effects of typical (first-generation) Antipsychotics. - ANSWER · Antipsychotics can be categorized into two main groups: the older conventional antipsychotics, which have also been call first-generation antipsychotics or dopamine receptor antagonists, and the newer drugs, which have been called second-generation antipsychotics or serotonin dopamine antagonists (SDAs). · Clinicians have a number of alternatives for treating extra-pyramidal side effects. These include reducing the dose of the antipsychotic (which is most commonly a
