for the Psychiatry Clerkship

is proudis proudto presentto present

And Now Here

Is The Host . . .

Insert Name Here

The categories for today’s Jeopardy on Mood Stabilizers will be:

Lithium

Divalproex Sodium

Carbamazepine

Lamotrigine

Antipsychotics

100 100

200

300

800

700

500

800

Lithium Carbamazepine Anitpsychotics

100

700

500

700

400

800

600

100

900 900 900 900

300

500

800

Lamotrigine

100

900

500

400

300

200

300

400

600

800

200

300

600

200

500

400

700

600

200

400

700

600

Divalproex Sodium

Row 1, Col 1

Blood levels should be drawn about this many hours after the last dose

What is 12 hours? (Trough)

1,2

For maintenance treatment of Bipolar disorder, lithium levels should

generally be above this

What is 0.6-0.8 mEq/L?

1,3

Before starting a young male patient on lithium, labs that should

routinely be done are these

What is TSH & BUN/creatinine?

1,4

In lithium maintenance treatment, ideally these labs are done

1-2 times per year

What is lithium level, TSH, BUN/creatinine?

1,5

This lithium side effect can be worsened by caffeine or improved with propranolol

treatment

What is tremor? (resting or postural?)

1,6

Unlike any antidepressant or mood stabilizer, Lithium treatment decreases patient’s mortality

risk from this

What is suicide?

1,7

Lithium toxicity with a lithium level greater than 4.0 mEq/L is

treated with this

What is dialysis?

1,8

After starting lithium or increasing the dose, a lithium level

should be done after this number of days

What is 5 days? (Lithium half life = ?)

1,9

For patients taking lithium, renal impairment, sodium depletion,

or dehydration all increase the risk of this

What is lithium toxicity?

2,1

Divalproex Sodium (Depakote) exposure during the first

trimester of pregnancy increases the risk this serious congenital

anomaly

What is neural tube defect (spina bifida)?

2,2

Before starting a male patient on Divalproex Sodium (Depakote), these two

lab tests should be done

What are LFT’s & platelets?

2,3

If a patient is taking Lamotrigine (Lamictal) this needs to be done if Divalproex Sodium (Depakote)

is to be added to the medication regimen.

What is decrease Lamotrigine dose by half?

2,4

Propranolol 2-3x’s per day may be used to treat this common side effect of divalproex (depakote)

What is tremor? (resting or postural?)

2,5

The age range of patients most at risk for divalproex’s (depakote)

side effect of serious, possibly fatal, hepatoxicity is this

What is under 2 years old ?

2,6

Because divalproex (depakote) is enteric coated this side effect is

less likely, or at least less severe, than in the generic form of valproic acid (depakene)

What are GI side effects? (N/V/D, GI discomfort)

2,7

Ironically, divalproex (depakote) is indicated as prophylaxis for

this condition, which is also one of divalproex (depakote)’s

common side effects

What is Headache? (indicated for migraine prophylaxis)

2,8

For divalproex (depakote), while the trough level of the Immediate Release

(IR) should be drawn 12 hrs after the last dose, the trough level of Extended Release (ER) should

be drawn at this time

What is 18 hour after the last dose?IR-last dose 10pm, blood draw 10amER-last dose 10pm, blood draw 4 pm

2,9

For a patient taking Divalproex Sodium (Depakote), taking aspirin

increases the risk of this

What is decreased platelets? Thrombocytopenia

3,1

Over the first few weeks of taking carbamazepine (tegretol) its t1/2

will decease to less than 50%of its initial t1/2 due to this

What is auto-induction?

3,2

Exposure of the fetus during the 1st trimester of pregnancy leads to

an unacceptable risk of this

What is neural tube defect?

3,3

Carbamazepine (tegretol) has a black box warning for these two

rare (~1/100,000 = 0.001%) but serious side effects on the hematopoietic system

What is agranulocytosis & aplastic anemia?

3,4

This electrolyte that may be abnormally low in patient’s who

are taking carbamazepine (tegretol)

What is sodium?

3,5

CYP: 3A4 2D6 2C9

This cytochrome p450 enzyme systemmakes up ~55% of the cytochrome p450

enzymes & Carbamazepine (Tegretol) is both a substrate & an inducer

of this system

What is CYP 3A4?

3,6

Sexually active women taking carbamazepine (tegretol) & hormonal birth control are

at risk of this

What is becoming pregnant?

3,7

Closely related structurally to carbamazepine (tegretol), this medication has far fewer side

effects but is not FDA approved for treatment of

bipolar disorder

What is oxcarbamazepine (trileptal)?

3,8

Patients who are getting long term treatment with divalproex (depakote) or carbamazepine (tegretol) need to have

regular labs done to check their medication blood levels, platelets/blood count, and this

What is liver function test?

3,9

To the risk of birth defects, a woman on carbemazepine (tegretol)

who desires to become pregnant should also take this medication

What is folate?

4,1

Patients who start taking lamotrigine (lamictal) have a this % risk of

developing a benign rash

What is 10%?

4,2

While the side effect of a benign rash is relatively common, the risk of a severe rash is about 0.3%, and the

risk of this is about 0.02-0.1%

What is Steven’s Johnson Syndrome?

4,3

The 4 picture set shows this side effect of lamictal(lamotrigine)

What is Steven’s Johnson Syndrome?

4,4

The drug-drug interaction between lamotrigine (lamictal) & divalproex

sodium (depakote) results in lamictal’s blood level

doing this

What is increasing? (doubles)

4,5

Lamotrigine (lamictal), quetiapine (seroquel), lithium, olanzapine/fluoxetine (symbyax), & latuda (lurasidone) all have this in

common regarding their usage in the treatment of pts with bipolar disorder

What is treats bipolar depression

4,6

Lamotrigine (lamictal), lithium, quetiapine (seroquel), olanzapine (zyprexa) & aripiprazole (abilify)

all have this in common regarding their usage in treatment of pts

with bipolar disorder

What is use in maintenance treatment of bipolar disorder?

4,7

Lithium, divalproex (depakote), carbamazepine ER (tegretol ER)

quetiapine (seroquel), ziprasidone (geodon), & asenapine (saphris) can treat this

phase of bipolar disorder but lamotrigine (lamictal) cannot

What is an acute manic episode?

4,8

Two common side effects of lithium, divalproex (depakote), quetiapine (seroquel), & olanzapine (zyprexa)

are this & this which are NOT side effects

of lamotrigine (lamictal)

What is weight gain and sedation?

4,9

Similar to mood stabilizers such as carbamazepine (tegretol), and

divalproex (depakote), lamotrigine’s (lamictal)

mechanism of action includes blocking these

What is Sodium channels?

5,1

This SGA is used to treat acute mania or for maintenance treatment of bipolar disorder, but of all the SGA’s it has

the highest risk for weight gain, elevated lipids, and diabetes

What is olanzapine (zyprexa)?

5,2

This SGA is used to treat acute mania or for maintenance treatment of bipolar

disorder, but must be taken with food or > 50% will not be absorbed in the

digestive tract

What is ziprasidone (geodon)?

5,3

While this SGA is used to treat acute mania or for maintenance

treatment of bipolar disorder, it has a particularly long half life of ~75 hours and takes nearly 2 weeks to

reach steady state

What is aripiprazole (abilify)?

5,4

This SGA is used to treat acute mania or for maintenance treatment of bipolar

disorder, but at doses > 6 mg it acts more like a FGA and has a much higher rate

of EPS side effects

What is risperidone (risperdal)?

5,5

This SGA is used to treat acute mania & must be taken sublingually

because if it is swallowed only ~5% will be bioavailable due to 1st pass

liver metabolism

What is asenapine (saphris)?

5,6

These 2 SGA’s, in addition to being used to treat acute mania or for

maintenance treatment of bipolar disorder, are the least likely of the

SGA’s to cause weight gain or metabolic syndrome

What is ziprasidone (geodon) & aripiprazole (abilify)?

5,7

This SGA is used to treat acute mania or for maintenance treatment of bipolar disorder, but should not be used in

patient’s with ECG’s that show an QTc > 500 milliseconds

What is ziprasidone (geodon)?

5,8

These three SGA’s are useful is treating bipolar depression;

two by themselves, the other in combination with fluoxetine (prozac)

What are quetiapine (seroquel), latuda (lurasidone) & olanzapine (zyprexa)?

5,9

Risperidone (risperdal consta), paliperidone (invenga sustenna),

and these 2 SGA’s are available in a long acting injectable form

What is aripiprazole (abilify maintena) & olanzapine (zyprexa relprevv)