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  • Question 1 - Which of the following adverse effects caused by antipsychotic medications is not influenced...

    Incorrect

    • Which of the following adverse effects caused by antipsychotic medications is not influenced by dopaminergic receptors?

      Your Answer: Akathisia

      Correct Answer: Ejaculatory failure

      Explanation:

      Antipsychotics: Common Side Effects and Relative Adverse Effects

      Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.

      Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.

      Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.

      Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.

      Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.

      The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.

      Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
      Amisulpride – + + + – – +++
      Aripiprazole – +/- – +/- – – –
      Asenapine + + +/- +/- – – +/-
      Clozapine +++ +++ +++ – +++ +++ –
      Flupentixol + ++ + ++ ++ + +++
      Fluphenazine + + + +++ ++ + +++
      Haloperidol + + +/- +++ + + +++
      Olanzapine ++ +++ +++ +/- + + +
      Paliperidone + ++ + + + ++ +++
      Pimozide + + – + + + +++
      Quetiapine ++ ++ ++ – + ++ –
      Risperidone + ++ + + + ++ +++
      Zuclopenthixol ++ ++ + ++ ++ + +++

      Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 2 - Who is the originator of the term 'cheese effect' in reference to the...

    Incorrect

    • Who is the originator of the term 'cheese effect' in reference to the negative effects associated with MAOI antidepressants?

      Your Answer: Kuhn

      Correct Answer: Blackwell

      Explanation:

      A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

      In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

      Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 3 - What is an example of a second generation H1 antihistamine? ...

    Correct

    • What is an example of a second generation H1 antihistamine?

      Your Answer: Cetirizine

      Explanation:

      The second generation of H1 antihistamines exhibit limited ability to cross the blood-brain barrier, leading to their non-sedating properties. Furthermore, they possess greater receptor specificity and do not produce significant anticholinergic effects. These characteristics make them a more desirable option for managing allergic conditions, as they minimize the risk of adverse effects.

      Antihistamines: Types and Uses

      Antihistamines are drugs that block the effects of histamine, a neurotransmitter that regulates physiological function in the gut and potentiates the inflammatory and immune responses of the body. There are two types of antihistamines: H1 receptor blockers and H2 receptor blockers. H1 blockers are mainly used for allergic conditions and sedation, while H2 blockers are used for excess stomach acid.

      There are also first and second generation antihistamines. First generation antihistamines, such as diphenhydramine and promethazine, have uses in psychiatry due to their ability to cross the blood brain barrier and their anticholinergic properties. They tend to be sedating and are useful for managing extrapyramidal side effects. Second generation antihistamines, such as loratadine and cetirizine, show limited penetration of the blood brain barrier and are less sedating.

      It is important to note that there are contraindications to first-generation antihistamines, including benign prostatic hyperplasia, angle-closure glaucoma, and pyloric stenosis in infants. These do not apply to second-generation antihistamines.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 4 - Can you provide an example of a drug interaction that affects the way...

    Incorrect

    • Can you provide an example of a drug interaction that affects the way a drug works in the body?

      Your Answer: Enzyme inhibition

      Correct Answer: Competition at a receptor

      Explanation:

      Drug Interactions: Understanding the Different Types

      Drug interactions can occur in different ways, and it is important to understand the different types to avoid potential harm. Pharmacokinetic drug interactions happen when one drug affects the metabolism, absorption, of excretion of another drug. This can be due to enzyme induction of inhibition, changes in gastrointestinal tract motility and pH, chelation, competition for renal tubular transport, of changes in protein binding. On the other hand, pharmacodynamic drug interactions occur when one drug directly alters the effect of another drug. This can happen through synergism, antagonism, of interaction at receptors, such as allosteric modulation. It is important to note that pharmacodynamic drug interactions do not involve any absorption, distribution, metabolism, of excretion processes directly. By understanding the different types of drug interactions, healthcare professionals can better manage patients’ medications and prevent potential adverse effects.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 5 - Which of the following sites is not recognized for drug metabolism? ...

    Incorrect

    • Which of the following sites is not recognized for drug metabolism?

      Your Answer: Lungs

      Correct Answer: Bone marrow

      Explanation:

      Understanding Biotransformation: A Metabolic Process for Excretion

      Biotransformation is a metabolic process that occurs primarily in the liver, but also in other organs such as the kidneys, intestine, adipose, skin, and lungs. Its main function is to facilitate the excretion of both exogenous and endogenous substances by altering their chemical structures through a series of reactions. Enzymes found in the cytoplasm, endoplasmic reticulum, and mitochondria of cells catalyze these reactions, which can cause the substrate to become inactive, active, of even toxic.

      Biotransformation is divided into three phases. Phase I reactions involve oxidation, reduction, of hydrolysis of the drug, yielding a polar, water-soluble metabolite that is often still active. Phase II reactions consist of adding hydrophilic groups to the original molecule, a toxic intermediate, of a nontoxic metabolite formed in phase I, to increase its polarity. The most common method is conjugation with glucuronic acid, but other groups such as sulphate, amino acids, acetate, and methyl can also be added. Phase III reactions occur post-phase II, where a chemical substance can undergo further metabolism and excretion through active transport into the urinary of hepatobiliary system.

      Understanding biotransformation is crucial in pharmacology and toxicology, as it affects the efficacy and toxicity of drugs and other substances. By facilitating the excretion of these substances, biotransformation helps maintain homeostasis in the body and prevent accumulation of potentially harmful compounds.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 6 - Which antidepressant is commonly linked to priapism? ...

    Incorrect

    • Which antidepressant is commonly linked to priapism?

      Your Answer: Citalopram

      Correct Answer: Trazodone

      Explanation:

      Priapism: A Painful and Persistent Erection

      Priapism is a condition characterized by a prolonged and painful erection, which can occur in males and even in the clitoris. Although rare, certain medications such as antipsychotics and antidepressants have been known to cause priapism. The primary mechanism behind this condition is alpha blockade, although other mechanisms such as serotonin-mediated pathways have also been suggested. Some of the drugs most commonly associated with priapism include Trazodone, Chlorpromazine, and Thioridazine. Treatment involves the use of alpha-adrenergic agonists, which can be administered orally of injected directly into the penis. Priapism is a serious condition that can lead to complications such as penile amputation, although such cases are extremely rare.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 7 - A 35-year-old woman has just started taking antipsychotic medication for the first time...

    Correct

    • A 35-year-old woman has just started taking antipsychotic medication for the first time after being diagnosed with schizophrenia. Her spouse asks you when they can expect to see the most significant improvement in her symptoms.

      Your advice would be:

      Your Answer: Within week 1

      Explanation:

      The onset of antipsychotic effect is noticeable within the first week of treatment, as reported by a large meta-analysis of almost 7,500 patients. This study found that there was a significant improvement of nearly 22% in the first two weeks of treatment, which contradicts the previous belief that it may take two to four weeks for antipsychotic action to take effect. The reduction in BPRS scores was as follows: 13.8% within the first week, 8.1% in the second week, 4.2% in the third week, and 4.7% in the fourth week.

    • This question is part of the following fields:

      • Psychopharmacology
      753
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  • Question 8 - A 45-year-old woman arrives at the Emergency department during a weekend getaway with...

    Incorrect

    • A 45-year-old woman arrives at the Emergency department during a weekend getaway with friends. She reports feeling restless and experiencing unusual electric sensations in her head. She acknowledges not drinking excessively but admits to missing her usual antidepressant medication since Friday morning. What type of antidepressant is she likely prescribed?

      Your Answer: Bupropion

      Correct Answer: Venlafaxine

      Explanation:

      Discontinuation symptoms are less likely with bupropion, clomipramine, and fluvoxamine as their half life is around 21 hours, whereas venlafaxine has a relatively short half life of approximately five hours, leading to a higher rate of discontinuation symptoms. Mirtazapine has a half life of approximately 20-40 hours.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 9 - What is a common side effect of olanzapine? ...

    Incorrect

    • What is a common side effect of olanzapine?

      Your Answer: Hypoglycaemia

      Correct Answer: Akathisia

      Explanation:

      Olanzapine use is commonly linked to the development of akathisia, which is a type of side effect.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 10 - A recommended approach for managing hyponatremia induced by antidepressants is: ...

    Correct

    • A recommended approach for managing hyponatremia induced by antidepressants is:

      Your Answer: Demeclocycline

      Explanation:

      Hyponatremia in Psychiatric Patients

      Hyponatremia, of low serum sodium, can occur in psychiatric patients due to the disorder itself, its treatment, of other medical conditions. Symptoms include nausea, confusion, seizures, and muscular cramps. Drug-induced hyponatremia is known as the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), which results from excessive secretion of ADH and fluid overload. Diagnosis is based on clinically euvolaemic state with low serum sodium and osmolality, raised urine sodium and osmolality. SSRIs, SNRIs, and tricyclics are the most common drugs that can cause SIADH. Risk factors for SIADH include starting a new drug, and treatment usually involves fluid restriction and sometimes demeclocycline.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 11 - Which statement accurately describes Neuroleptic Malignant Syndrome (NMS)? ...

    Correct

    • Which statement accurately describes Neuroleptic Malignant Syndrome (NMS)?

      Your Answer: NMS can be caused by antidepressants

      Explanation:

      If a patient develops NMS, they may still require antipsychotic medication. However, it is recommended to stop antipsychotics for at least 5 days, and ideally longer. When restarting antipsychotics, it should be done slowly and at low doses, with close monitoring of blood pressure and temperature.

      Anticholinergic drugs are believed to worsen NMS, possibly due to their effect on reducing sweating and exacerbating hyperthermia. However, there is no direct causal relationship between anticholinergics and NMS.

      In cases where an alternative antipsychotic is needed, those with low dopamine affinity should be considered. These include clozapine, quetiapine, and aripiprazole.

      Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 12 - What substance acts as a partial agonist on the mu receptor? ...

    Correct

    • What substance acts as a partial agonist on the mu receptor?

      Your Answer: Buprenorphine

      Explanation:

      The mu receptor, one of several opioid receptors, is partially activated by buprenorphine. In contrast, opioid antagonists such as naloxone and naltrexone block the receptor.

      Mechanisms of Action of Different Drugs

      Understanding the mechanisms of action of different drugs is crucial for medical professionals. It is a common topic in exams and can earn easy marks if studied well. This article provides a list of drugs and their mechanisms of action in different categories such as antidepressants, anti dementia drugs, mood stabilizers, anxiolytic/hypnotic drugs, antipsychotics, drugs of abuse, and other drugs. For example, mirtazapine is a noradrenaline and serotonin specific antidepressant that works as a 5HT2 antagonist, 5HT3 antagonist, H1 antagonist, alpha 1 and alpha 2 antagonist, and moderate muscarinic antagonist. Similarly, donepezil is a reversible acetylcholinesterase inhibitor used as an anti dementia drug, while valproate is a GABA agonist and NMDA antagonist used as a mood stabilizer. The article also explains the mechanisms of action of drugs such as ketamine, phencyclidine, buprenorphine, naloxone, atomoxetine, varenicline, disulfiram, acamprosate, and sildenafil.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 13 - You are provided with a set of blood test outcomes that show serum...

    Correct

    • You are provided with a set of blood test outcomes that show serum levels for different medications. Which of the following falls outside the typical range for an elderly patient?

      Your Answer: Lithium 1.9 mmol/L

      Explanation:

      Lithium – Pharmacology

      Pharmacokinetics:
      Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

      Ebstein’s:
      Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

      Contraindications:
      Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

      Side-effects:
      Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

      Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

      Lithium-induced diabetes insipidus:
      Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

      Toxicity:
      Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

      Pre-prescribing:
      Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

      Monitoring:
      Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 14 - What is the most common cause of hyponatremia in an elderly patient? ...

    Incorrect

    • What is the most common cause of hyponatremia in an elderly patient?

      Your Answer: Moclobemide

      Correct Answer: Citalopram

      Explanation:

      Hyponatremia in Psychiatric Patients

      Hyponatremia, of low serum sodium, can occur in psychiatric patients due to the disorder itself, its treatment, of other medical conditions. Symptoms include nausea, confusion, seizures, and muscular cramps. Drug-induced hyponatremia is known as the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), which results from excessive secretion of ADH and fluid overload. Diagnosis is based on clinically euvolaemic state with low serum sodium and osmolality, raised urine sodium and osmolality. SSRIs, SNRIs, and tricyclics are the most common drugs that can cause SIADH. Risk factors for SIADH include starting a new drug, and treatment usually involves fluid restriction and sometimes demeclocycline.

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 15 - What is the estimated volume in which a drug is distributed throughout the...

    Incorrect

    • What is the estimated volume in which a drug is distributed throughout the body based on the plasma concentration of 0.1 mg/L after administering a 50 mg dose?

      Your Answer: 5 L

      Correct Answer: 500 L

      Explanation:

      The voltage drop (Vd) is equal to the ratio of the applied voltage (A) to the circuit resistance (C). Therefore, in this case, Vd is equal to 500 volts, as calculated by dividing 50 volts by 0.1 ohms.

      Understanding the Volume of Distribution in Pharmacology

      The volume of distribution (Vd) is a crucial concept in pharmacology that helps determine how a drug distributes in the body. It is also known as the apparent volume of distribution, as it is an abstract volume. The Vd indicates whether a drug concentrates in the plasma of spreads out in the body. Drugs that are highly polar tend to stay in central compartments such as the plasma, resulting in a low Vd. Conversely, drugs that are more lipid-soluble are distributed widely, such as in fat, resulting in a high Vd.

      The Vd is calculated by dividing the amount of drug in the body by the concentration in the plasma. Clinically, the Vd is used to determine the loading dose of a drug required for a desired blood concentration and to estimate blood concentration in the treatment of overdose. The units of Vd are in volume.

      The apparent volume of distribution is dependent on the drug’s lipid of water solubility, plasma protein binding, and tissue binding. Plasma protein binding affects the Vd, as drugs that bind to plasma proteins like albumin have a smaller apparent volume of distribution. This is because they are extracted from plasma and included in drug concentration measurements, which can give a misleading impression of their volume of distribution. Understanding the Vd is essential in pharmacology to ensure the safe and effective use of drugs.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 16 - What is a correct statement about antipsychotic depots? ...

    Incorrect

    • What is a correct statement about antipsychotic depots?

      Your Answer:

      Correct Answer: There is RCT evidence to suggest that Zuclopenthixol may be more effective in preventing relapses than other first-generation antipsychotic depots

      Explanation:

      , coma, respiratory depression (rare)

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 17 - Which options are typically not utilized for managing extrapyramidal side-effects? ...

    Incorrect

    • Which options are typically not utilized for managing extrapyramidal side-effects?

      Your Answer:

      Correct Answer: Dopamine agonists

      Explanation:

      EPSE’s result from the blocking of dopaminergic D2 receptors, so theoretically, dopamine agonists could alleviate them. However, they are not typically prescribed because they could worsen the underlying psychotic condition. Amantadine is an exception, as it is believed to work by stimulating dopamine receptors. It should be noted, however, that amantadine has complex effects and may exacerbate psychotic symptoms in certain patients.

      Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 18 - What is the term used to describe the mutual agreement between a doctor...

    Incorrect

    • What is the term used to describe the mutual agreement between a doctor and their patient regarding treatment?

      Your Answer:

      Correct Answer: Concordance

      Explanation:

      While adherence, compliance, and capacitance all refer to how well a patient follows a doctor’s instructions, they do not have the same meaning as concordance, which specifically refers to the agreement between patient and doctor on a treatment plan.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 19 - A 32-year-old woman receiving treatment for epilepsy is hospitalized due to severe abdominal...

    Incorrect

    • A 32-year-old woman receiving treatment for epilepsy is hospitalized due to severe abdominal pain in the center of her abdomen. Upon examination, it is discovered that her serum amylase levels are significantly elevated. What medication is the probable cause of this condition?

      Your Answer:

      Correct Answer: Sodium valproate

      Explanation:

      – Valproate is an anticonvulsant drug.
      – Side effects of valproate include weight gain, nausea, vomiting, hair loss, easy bruising, tremor, hepatic failure, and pancreatitis.
      – Acute drug-induced pancreatitis is a potential complication of valproate use.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 20 - What is the most common cause of QTc prolongation? ...

    Incorrect

    • What is the most common cause of QTc prolongation?

      Your Answer:

      Correct Answer: Citalopram

      Explanation:

      Citalopram can moderately prolong QTc (>10 msec), while aripiprazole and paliperidone have no effect. Haloperidol and pimozide have a high effect, and quetiapine and amisulpride have a moderate effect. Clozapine, risperidone, and olanzapine have a low effect (<10 msec prolongation). Lamotrigine, mirtazapine, and SSRIs (excluding citalopram) do not have an effect on QTc interval.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 21 - Under which category of antipsychotics does Quetiapine fall? ...

    Incorrect

    • Under which category of antipsychotics does Quetiapine fall?

      Your Answer:

      Correct Answer: Dibenzothiazepine

      Explanation:

      Antipsychotics can be classified in different ways, with the most common being typical (first generation) and atypical (second generation) types. Typical antipsychotics block dopamine (D2) receptors and have varying degrees of M1, Alpha-1, and H1 receptor blockade. Atypical antipsychotics have a lower propensity for extrapyramidal side-effects and are attributed to the combination of relatively lower D2 antagonism with 5HT2A antagonism. They are also classified by structure, with examples including phenothiazines, butyrophenones, thioxanthenes, diphenylbutylpiperidine, dibenzodiazepines, benzoxazoles, thienobenzodiazepine, substituted benzamides, and arylpiperidylindole (quinolone). Studies have found little evidence to support the superiority of atypicals over typicals in terms of efficacy, discontinuation rates, of adherence, with the main difference being the side-effect profile. The Royal College also favors classification by structure.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 22 - A 42 year old man with depression and reduced sexual desire has been...

    Incorrect

    • A 42 year old man with depression and reduced sexual desire has been referred to our clinic. Following a thorough discussion of his symptoms, he has agreed to a trial of antidepressants. However, he is concerned about potential side effects and specifically requests a medication that is less likely to exacerbate his sexual dysfunction. What antidepressant would you recommend in this case?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      To ensure adherence, it is crucial to prescribe medication based on the individual’s needs to prevent sexual issues. Among the options provided, mirtazapine has the least occurrence of sexual dysfunction.

      Antidepressants can cause sexual dysfunction as a side-effect, although the rates vary. The impact on sexual desire, arousal, and orgasm can differ depending on the type of antidepressant. It is important to rule out other causes and consider non-pharmacological strategies such as reducing the dosage of taking drug holidays. If necessary, switching to a lower risk antidepressant of using pharmacological options such as phosphodiesterase inhibitors of mirtazapine augmentation can be considered. The Maudsley Guidelines 14th Edition provides a helpful table outlining the risk of sexual dysfunction for different antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 23 - What are the potential side effects of lithium that you would inform a...

    Incorrect

    • What are the potential side effects of lithium that you would inform a patient about before starting the medication?

      Your Answer:

      Correct Answer: Fine tremor

      Explanation:

      Lithium – Pharmacology

      Pharmacokinetics:
      Lithium salts are rapidly absorbed following oral administration and are almost exclusively excreted by the kidneys unchanged. Blood samples for lithium should be taken 12 hours post-dose.

      Ebstein’s:
      Ebstein’s anomaly is a congenital malformation consisting of a prolapse of the tricuspid valve into the right ventricle. It occurs in 1:20,000 of the general population. Initial data suggested it was more common in those using lithium but this had not held to be true.

      Contraindications:
      Addison’s disease, Brugada syndrome, cardiac disease associated with rhythm disorders, clinically significant renal impairment, untreated of untreatable hypothyroidism, low sodium levels.

      Side-effects:
      Common side effects include nausea, tremor, polyuria/polydipsia, rash/dermatitis, blurred vision, dizziness, decreased appetite, drowsiness, metallic taste, and diarrhea. Side-effects are often dose-related.

      Long-term use is associated with hypothyroidism, hyperthyroidism, hypercalcemia/hyperparathyroidism, irreversible nephrogenic diabetes insipidus, and reduced GFR.

      Lithium-induced diabetes insipidus:
      Treatment options include stopping lithium (if feasible), keeping levels within 0.4-0.8 mmol/L, once-daily dose of the drug taken at bedtime, amiloride, thiazide diuretics, indomethacin, and desmopressin.

      Toxicity:
      Lithium salts have a narrow therapeutic/toxic ratio. Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI symptoms and neuro symptoms.

      Pre-prescribing:
      Before prescribing lithium, renal function, cardiac function, thyroid function, FBC, and BMI should be checked. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

      Monitoring:
      Lithium blood levels should be checked weekly until stable, and then every 3-6 months once stable. Thyroid and renal function should be checked every 6 months. Patients should be issued with an information booklet, alert card, and record book.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 24 - What is a true statement about flumazenil? ...

    Incorrect

    • What is a true statement about flumazenil?

      Your Answer:

      Correct Answer: Flumazenil is not currently licensed for the treatment of benzodiazepine overdose in the UK

      Explanation:

      Flumazenil is not authorized for treating benzodiazepine overdose in the UK, despite its widespread use. It works by competitively inhibiting the benzodiazepine binding site on the GABAA receptor, reversing the effects of benzodiazepines. Due to its short half-life of 60 minutes, it is important to note that multiple doses may be necessary in cases of benzodiazepine overdose.

      Flumazenil: A Selective GABAA Receptor Antagonist

      Flumazenil is a medication that selectively blocks the effects of benzodiazepines on the GABAA receptor. It is used to reverse the sedative effects caused by benzodiazepines, either partially or completely. Flumazenil works by competitively interacting with benzodiazepine receptors, which can reverse the binding of benzodiazepines to these receptors. It is administered intravenously and has a short half-life of about 60 minutes. The effects of flumazenil are usually shorter than those of benzodiazepines, and sedation may recur. Flumazenil also blocks non-benzodiazepine-agonists like zopiclone. However, it has no effect on other drugs such as barbiturates, ethanol, of other GABA-mimetic agents unless they act on the benzodiazepine receptor site. The hypnosedative effects of benzodiazepines are rapidly blocked within 1-2 minutes after intravenous administration, and the duration of action ranges from 20 to 50 minutes.

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      • Psychopharmacology
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  • Question 25 - A 35-year-old woman with mild anxiety was prescribed an antidepressant but experienced sexual...

    Incorrect

    • A 35-year-old woman with mild anxiety was prescribed an antidepressant but experienced sexual side effects. Her doctor suggested switching to a medication that is a serotonin norepinephrine reuptake inhibitor (SNRI). What is an example of an SNRI?

      Your Answer:

      Correct Answer: Milnacipran

      Explanation:

      SNRIs are a type of antidepressant medication that work by blocking the reuptake of both serotonin and norepinephrine, providing two mechanisms to help with the antidepressant effect. They are particularly effective at inhibiting the norepinephrine transporter compared to the serotonin transporter. Examples of SNRIs include Venlafaxine, Desvenlafaxine, Duloxetine, and Milnacipran. Bupropion is a different type of antidepressant that works by inhibiting the reuptake of norepinephrine and dopamine (NDRI). Escitalopram is a selective serotonin reuptake inhibitor (SSRI), while Mirtazapine is a noradrenergic and specific serotonin antidepressant (NaSSA). Nefazodone is a serotonin antagonist/reuptake inhibitor (SARI).

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      • Psychopharmacology
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  • Question 26 - A 72-year-old male is experiencing depression after being admitted for a flare-up of...

    Incorrect

    • A 72-year-old male is experiencing depression after being admitted for a flare-up of chronic obstructive pulmonary disease. Which antidepressant would be the most suitable to initiate?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      Unless there is a specific reason stated in the vignette, the first-line treatment for depression with medication is typically a selective serotonin reuptake inhibitor (SSRI). However, an alternative option may be duloxetine, which is a serotonin-norepinephrine reuptake inhibitor (SNRI).

      SSRIs, of selective serotonin reuptake inhibitors, are the first-line treatment for depression in most patients. However, some SSRIs have different side effects and interactions than others. For example, fluoxetine, fluvoxamine, and paroxetine have a higher propensity for drug interactions, while citalopram is useful for elderly patients as it is associated with lower risks of drug interactions. SSRIs should be used with caution in children and adolescents, and fluoxetine is the drug of choice in this population.

      Common side effects of SSRIs include gastrointestinal symptoms, sedation, and sexual dysfunction. Paroxetine is considered the most sedating and anticholinergic, while vortioxetine is associated with the least sexual dysfunction. Patients taking SSRIs are at an increased risk of gastrointestinal bleeding, and a proton pump inhibitor should be prescribed if they are also taking an NSAID.

      When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, which can include mood changes, restlessness, difficulty sleeping, and gastrointestinal symptoms.

      SSRIs can also have interactions with other medications, such as NSAIDs, warfarin/heparin, aspirin, and triptans. Patients should be reviewed by a doctor after starting antidepressant therapy, and if they make a good response, they should continue treatment for at least 6 months after remission to reduce the risk of relapse.

      In patients who have had a myocardial infarction, approximately 20% develop depression. SSRIs are the preferred antidepressant group post-MI, but they can increase the bleeding risk, especially in those using anticoagulation. Mirtazapine is an alternative option, but it too is associated with bleeding. The SADHART study found sertraline to be a safe treatment for depression post-myocardial infarction.

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      • Psychopharmacology
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  • Question 27 - What is a true statement about valproate? ...

    Incorrect

    • What is a true statement about valproate?

      Your Answer:

      Correct Answer: The risk of congenital malformations is dose dependent

      Explanation:

      Valproate can pass through the placenta, increasing the likelihood of birth defects. The extent of risk during pregnancy is not fully understood, but it is believed to be influenced by the dosage. Children who were exposed to valproate in the womb may have a lower IQ, with those aged 6 showing an average decrease of 7-10 points compared to those exposed to other antiepileptic medications.

      Valproate: Forms, Doses, and Adverse Effects

      Valproate comes in three forms: semi-sodium valproate, valproic acid, and sodium valproate. Semi-sodium valproate is a mix of sodium valproate and valproic acid and is licensed for acute mania associated with bipolar disorder. Valproic acid is also licensed for acute mania, but this is not consistent with the Maudsley Guidelines. Sodium valproate is licensed for epilepsy. It is important to note that doses of sodium valproate and semi-sodium valproate are not the same, with a slightly higher dose required for sodium valproate.

      Valproate is associated with many adverse effects, including nausea, tremor, liver injury, vomiting/diarrhea, gingival hyperplasia, memory impairment/confusional state, somnolence, weight gain, anaemia/thrombocytopenia, alopecia (with curly regrowth), severe liver damage, and pancreatitis. Increased liver enzymes are common, particularly at the beginning of therapy, and tend to be transient. Vomiting and diarrhea tend to occur at the start of treatment and remit after a few days. Severe liver damage is most likely to occur in the first six months of therapy, with the maximum risk being between two and twelve weeks. The risk also declines with advancing age.

      Valproate is a teratogen and should not be initiated in women of childbearing potential. Approximately 10% of children exposed to valproate monotherapy during pregnancy suffer from congenital malformations, with the risk being dose-dependent. The most common malformations are neural tube defects, facial dysmorphism, cleft lip and palate, craniostenosis, cardiac, renal and urogenital defects, and limb defects. There is also a dose-dependent relationship between valproate and developmental delay, with approximately 30-40% of children exposed in utero experiencing delay in their early development, such as talking and walking later, lower intellectual abilities, poor language skills, and memory problems. There is also a thought to be a 3-fold increase of autism in children exposed in utero.

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      • Psychopharmacology
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  • Question 28 - A 65-year-old patient presents to the emergency department with complaints of feeling unwell....

    Incorrect

    • A 65-year-old patient presents to the emergency department with complaints of feeling unwell. They have developed mouth ulcers and a rash since starting a new medication two weeks ago, which was prescribed by their psychiatrist. The patient cannot remember the name of the drug they were started on. What medication do you suspect they have been prescribed?

      Your Answer:

      Correct Answer: Lamotrigine

      Explanation:

      Stevens-Johnson syndrome, a condition that can be triggered by various anticonvulsants including lamotrigine, appears to align with the patient’s medical history.

      Stevens-Johnson syndrome is a severe skin condition that can be caused by medication use of infection. Anticonvulsants, particularly lamotrigine, are often the cause. Symptoms include fever, sore throat, fatigue, and the appearance of ulcers and lesions in the mucous membranes. A rash of round lesions also appears on the face, trunk, arms, legs, and soles of the feet. It is a life-threatening condition that requires immediate medical attention.

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      • Psychopharmacology
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  • Question 29 - A teenager you are caring for is prescribed imipramine for depression. What combination...

    Incorrect

    • A teenager you are caring for is prescribed imipramine for depression. What combination of side-effects is most commonly observed in patients taking this type of antidepressant medication?

      Your Answer:

      Correct Answer: Blurred vision + dry mouth

      Explanation:

      Tricyclic Antidepressants: Uses, Types, and Side-Effects

      Tricyclic antidepressants (TCAs) are a type of medication used for depression and neuropathic pain. However, due to their side-effects and toxicity in overdose, they are not commonly used for depression anymore. TCAs can be divided into two types: first generation (tertiary amines) and second generation (secondary amines). The secondary amines have a lower side effect profile and act primarily on noradrenaline, while the tertiary amines boost serotonin and noradrenaline.

      Some examples of secondary amines include desipramine, nortriptyline, protriptyline, and amoxapine. Examples of tertiary amines include amitriptyline, lofepramine, imipramine, clomipramine, dosulepin (dothiepin), doxepin, trimipramine, and butriptyline. Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, and urinary retention.

      Low-dose amitriptyline is commonly used for neuropathic pain and prophylaxis of headache. Lofepramine has a lower incidence of toxicity in overdose. However, amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose. It is important to consult with a healthcare provider before taking any medication and to follow their instructions carefully.

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      • Psychopharmacology
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  • Question 30 - A woman in her 40s with schizophrenia who takes haloperidol develops neuroleptic malignant...

    Incorrect

    • A woman in her 40s with schizophrenia who takes haloperidol develops neuroleptic malignant syndrome following a sudden change in her dose. The haloperidol is stopped for a 2 week period but this results in a deterioration of her mental state. The team agree that she requires an antipsychotic. Which of the following would you recommend?:

      Your Answer:

      Correct Answer: Quetiapine

      Explanation:

      Serotonin Syndrome and Neuroleptic Malignant Syndrome are two conditions that can be difficult to differentiate. Serotonin Syndrome is caused by excess serotonergic activity in the CNS and is characterized by neuromuscular abnormalities, altered mental state, and autonomic dysfunction. On the other hand, Neuroleptic Malignant Syndrome is a rare acute disorder of thermoregulation and neuromotor control that is almost exclusively caused by antipsychotics. The symptoms of both syndromes can overlap, but there are some distinguishing clinical features. Hyper-reflexia, ocular clonus, and tremors are more prominent in Serotonin Syndrome, while Neuroleptic Malignant Syndrome is characterized by uniform ‘lead-pipe’ rigidity and hyporeflexia. Symptoms of Serotonin Syndrome usually resolve within a few days of stopping the medication, while Neuroleptic Malignant Syndrome can take up to 14 days to remit with appropriate treatment. The following table provides a useful guide to the main differentials of Serotonin Syndrome and Neuroleptic Malignant Syndrome.

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      • Psychopharmacology
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