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  • Question 1 - Which of the following conditions is not licensed for the use of duloxetine?...

    Correct

    • Which of the following conditions is not licensed for the use of duloxetine?

      Your Answer: Acne vulgaris

      Explanation:

      Duloxetine is also licensed for the treatment of generalised anxiety disorder.

      Antidepressants (Licensed Indications)

      The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

      – Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
      – Phobic and obsessional states: Clomipramine
      – Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
      – Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
      – Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
      – Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
      – OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
      – Bulimia nervosa: Fluoxetine
      – PTSD: Paroxetine, Sertraline

    • This question is part of the following fields:

      • Psychopharmacology
      16.1
      Seconds
  • Question 2 - What is a known risk factor for QT prolongation when analyzing an ECG?...

    Incorrect

    • What is a known risk factor for QT prolongation when analyzing an ECG?

      Your Answer: Hypercalcemia

      Correct Answer: Hypokalemia

      Explanation:

      Amantadine and QTc Prolongation

      Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

    • This question is part of the following fields:

      • Psychopharmacology
      30.3
      Seconds
  • Question 3 - What is a true statement about depot antipsychotics? ...

    Incorrect

    • What is a true statement about depot antipsychotics?

      Your Answer: Neuroleptic malignant syndrome is a contraindication for subsequent depot use

      Correct Answer: The risk of tardive dyskinesia is equal for depot and oral formulation of same drug

      Explanation:

      Contrary to popular belief, the risk of neuroleptic malignant syndrome is not higher with depot antipsychotics compared to oral drugs. Additionally, there is no evidence to suggest that a prior history of NMS should prevent the use of depot antipsychotics. While caution may be warranted, a history of NMS is not a complete contraindication for depot antipsychotic use. These findings were reported by Patel in a 2005 article titled Why aren’t depot antipsychotics prescribed more often and what can be done about it? published in Advances in Psychiatric Treatment.

      , coma, respiratory depression (rare)

    • This question is part of the following fields:

      • Psychopharmacology
      96.7
      Seconds
  • Question 4 - A 65-year-old patient with a history of treatment-resistant schizophrenia has been stabilized on...

    Incorrect

    • A 65-year-old patient with a history of treatment-resistant schizophrenia has been stabilized on clozapine, but is experiencing clinical deterioration with a serum clozapine level below 1000 µg/L. What medication should be added if the patient's clozapine serum levels remain above this value?

      Your Answer: Hyoscine hydrobromide

      Correct Answer: Sodium valproate

      Explanation:

      If serum clozapine levels remain elevated, it is recommended to add anticonvulsant cover due to the increased risk of seizures and EEG changes. While some clinicians may advocate for higher clozapine levels, there is limited evidence to support this practice. Amisulpride can be used to augment clozapine, but it is not necessary in this situation. Beta-blockers are used to treat persistent tachycardia caused by clozapine, while hyoscine hydrobromide is used to manage clozapine-associated hypersalivation. Loperamide is unlikely to be needed as clozapine is known to cause constipation.

    • This question is part of the following fields:

      • Psychopharmacology
      23.9
      Seconds
  • Question 5 - A 24-year-old male patient with a history of hallucinations and delusions was started...

    Incorrect

    • A 24-year-old male patient with a history of hallucinations and delusions was started on multiple medications by a psychiatrist. However, on the second day of treatment, he developed excessive sweating, fever, agitation, and aggressive behavior. The psychiatrist continued with the medications, which were eventually stopped after 4 days. Over the next few days, the patient's condition worsened, and he developed diarrhea and sustained high-grade fever. He was transferred to a hospital, where he was found to have hypertonia in all four limbs, mainly in the lower extremities, and hyper-reflexia, including bilateral sustained ankle clonus.

      These signs and symptoms are most helpful in distinguishing between serotonin syndrome and neuroleptic malignant syndrome.

      Your Answer:

      Correct Answer: Hyper-reflexia

      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.

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 6 - What is a true statement about antihistamines? ...

    Incorrect

    • What is a true statement about antihistamines?

      Your Answer:

      Correct Answer: First generation antihistamines should be avoided in people at risk of angle closure glaucoma

      Explanation:

      First generation antihistamines should be avoided in individuals who are at risk of angle closure glaucoma due to their tendency to cause anticholinergic side effects. Pupil dilation (mydriasis) caused by these medications can increase the risk of angle closure glaucoma in individuals with narrow anterior chamber angles, but this is not a concern for those with open angle glaucoma.

      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
      0
      Seconds
  • Question 7 - What factors contribute to an increased likelihood of developing pseudo-parkinsonism when taking typical...

    Incorrect

    • What factors contribute to an increased likelihood of developing pseudo-parkinsonism when taking typical antipsychotics?

      Your Answer:

      Correct Answer: Previous stroke

      Explanation:

      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
      0
      Seconds
  • Question 8 - The Maudsley guidelines suggest a particular approach for managing restlessness resulting from the...

    Incorrect

    • The Maudsley guidelines suggest a particular approach for managing restlessness resulting from the use of antipsychotics.

      Your Answer:

      Correct Answer: Clonazepam

      Explanation:

      The Maudsley Guidelines recommend the use of diazepam and clonazepam in their treatment plan for antipsychotic induced akathisia, likely because of their extended duration of action.

      Benzodiazepines are a class of drugs commonly used to treat anxiety and sleep disorders. It is important to have a working knowledge of the more common benzodiazepines and their half-life. Half-life refers to the amount of time it takes for half of the drug to be eliminated from the body.

      Some of the more common benzodiazepines and their half-life include diazepam with a half-life of 20-100 hours, clonazepam with a half-life of 18-50 hours, chlordiazepoxide with a half-life of 5-30 hours, nitrazepam with a half-life of 15-38 hours, temazepam with a half-life of 8-22 hours, lorazepam with a half-life of 10-20 hours, alprazolam with a half-life of 10-15 hours, oxazepam with a half-life of 6-10 hours, zopiclone with a half-life of 5-6 hours, zolpidem with a half-life of 2 hours, and zaleplon with a half-life of 2 hours. Understanding the half-life of these drugs is important for determining dosages and timing of administration.

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 9 - What is the accurate statement about the post-injection syndrome linked with olanzapine embonate?...

    Incorrect

    • What is the accurate statement about the post-injection syndrome linked with olanzapine embonate?

      Your Answer:

      Correct Answer:

      Explanation:

      Although the occurrence of the post-injection syndrome is rare, patients must still be observed for three hours after receiving the depot injection.

      , coma, respiratory depression (rare)

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 10 - What is a side effect of sildenafil that occurs frequently, affecting more than...

    Incorrect

    • What is a side effect of sildenafil that occurs frequently, affecting more than 10% of users?

      Your Answer:

      Correct Answer: Headache

      Explanation:

      Side effects of sildenafil (viagra) that occur frequently (affecting more than 1 in 10 people) include:

      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
      0
      Seconds
  • Question 11 - What statement accurately describes the Volume of Distribution (Vd)? ...

    Incorrect

    • What statement accurately describes the Volume of Distribution (Vd)?

      Your Answer:

      Correct Answer: It can be greater than the total body water content of the body

      Explanation:

      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
      0
      Seconds
  • Question 12 - What is the primary mechanism of action for buspirone, an agent used to...

    Incorrect

    • What is the primary mechanism of action for buspirone, an agent used to treat anxiety?

      Your Answer:

      Correct Answer: 5HT1a partial agonism

      Explanation:

      Buspirone is a medication that acts as a partial agonist for the 5HT1a receptor, and its chemical structure is distinct from that of benzodiazepines.

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 13 - Which antihistamine should be avoided when a patient is taking an MAOI medication?...

    Incorrect

    • Which antihistamine should be avoided when a patient is taking an MAOI medication?

      Your Answer:

      Correct Answer: Chlorpheniramine

      Explanation:

      According to Gillman (1998), it is recommended to avoid using the antihistamines brompheniramine and chlorpheniramine as they act as serotonin reuptake inhibitors (SRIs). However, all other antihistamines are considered safe for use. Gillman’s study focused on the history and risk of serotonin syndrome.

      MAOIs: A Guide to Mechanism of Action, Adverse Effects, and Dietary Restrictions

      First introduced in the 1950s, MAOIs were the first antidepressants introduced. However, they are not the first choice in treating mental health disorders due to several dietary restrictions and safety concerns. They are only a treatment option when all other medications are unsuccessful. MAOIs may be particularly useful in atypical depression (over eating / over sleeping, mood reactivity).

      MAOIs block the monoamine oxidase enzyme, which breaks down different types of neurotransmitters from the brain: norepinephrine, serotonin, dopamine, as well as tyramine. There are two types of monoamine oxidase, A and B. The MOA A are mostly distributed in the placenta, gut, and liver, but MOA B is present in the brain, liver, and platelets. Selegiline and rasagiline are irreversible and selective inhibitors of MAO type B, but safinamide is a reversible and selective MAO B inhibitor.

      The most common adverse effects of MAOIs occurring early in treatment are orthostatic hypotension, daytime sleepiness, insomnia, and nausea; later common effects include weight gain, muscle pain, myoclonus, paraesthesia, and sexual dysfunction.

      Pharmacodynamic interactions with MAOIs can cause two types of problem: serotonin syndrome (mainly due to SSRIs) and elevated blood pressure (caused by indirectly acting sympathomimetic amines releasers, like pseudoephedrine and phenylephrine). The combination of MAOIs and some TCAs appears safe. Only those TCAs with significant serotonin reuptake inhibition (clomipramine and imipramine) are likely to increase the risk of serotonin syndrome.

      Tyramine is a monoamine found in various foods, and is an indirect sympathomimetic that can cause a hypertensive reaction in patients receiving MAOI therapy. For this reason, dietary restrictions are required for patients receiving MAOIs. These restrictions include avoiding matured/aged cheese, fermented sausage, improperly stored meat, fava of broad bean pods, and certain drinks such as on-tap beer. Allowed foods include fresh cottage cheese, processed cheese slices, fresh packaged of processed meat, and other alcohol (no more than two bottled or canned beers of two standard glasses of wine, per day).

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 14 - What is a typical adverse effect associated with the use of carbamazepine? ...

    Incorrect

    • What is a typical adverse effect associated with the use of carbamazepine?

      Your Answer:

      Correct Answer: Diplopia

      Explanation:

      Diplopia is a frequently occurring side-effect, while the other options are infrequent of extremely infrequent side-effects of carbamazepine.

      Carbamazepine: Uses, Mechanism of Action, Contraindications, Warnings, and Side-Effects

      Carbamazepine, also known as Tegretol, is a medication commonly used in the treatment of epilepsy, particularly partial seizures. It is also used for neuropathic pain, bipolar disorder, and other conditions. The drug works by binding to sodium channels and increasing their refractory period.

      However, carbamazepine has notable contraindications, including a history of bone marrow depression and combination with monoamine oxidase inhibitors (MAOIs). It also carries warnings for serious dermatological reactions such as toxic epidermal necrolysis (TEN) and Stevens Johnson syndrome.

      Common side-effects of carbamazepine include leucopenia, ataxia, dizziness, somnolence, vomiting, nausea, urticaria, and fatigue. Other side-effects include thrombocytopenia, eosinophilia, oedema, fluid retention, weight increase, hyponatraemia, and blood osmolarity decreased due to an antidiuretic hormone (ADH)-like effect, leading in rare cases to water intoxication accompanied by lethargy, vomiting, headache, confusional state, neurological disorders, diplopia, accommodation disorders (e.g. blurred vision), and dry mouth.

      In summary, carbamazepine is a medication with multiple uses, but it also carries significant contraindications, warnings, and side-effects that should be carefully considered before use.

    • This question is part of the following fields:

      • Psychopharmacology
      0
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  • Question 15 - Which receptor antagonism is most likely to result in Priapism? ...

    Incorrect

    • Which receptor antagonism is most likely to result in Priapism?

      Your Answer:

      Correct Answer: Alpha 1

      Explanation:

      Priapism is a rare condition where the penis remains erect for more than four hours without any stimulation, and it can occur as a side effect of antipsychotic and antidepressant medications.

      Receptors and Side-Effects

      Histamine H1 Blockade:
      – Weight gain
      – Sedation

      Alpha 1 Blockade:
      – Orthostatic hypotension
      – Sedation
      – Sexual dysfunction
      – Priapism

      Muscarinic Central M1 Blockade:
      – Agitation
      – Delirium
      – Memory impairment
      – Confusion
      – Seizures

      Muscarinic Peripheral M1 Blockade:
      – Dry mouth
      – Ataxia
      – Blurred vision
      – Narrow angle glaucoma
      – Constipation
      – Urinary retention
      – Tachycardia

      Each receptor has specific effects on the body, but they can also have side-effects. Histamine H1 blockade can cause weight gain and sedation. Alpha 1 blockade can lead to orthostatic hypotension, sedation, sexual dysfunction, and priapism. Muscarinic central M1 blockade can cause agitation, delirium, memory impairment, confusion, and seizures. Muscarinic peripheral M1 blockade can result in dry mouth, ataxia, blurred vision, narrow angle glaucoma, constipation, urinary retention, and tachycardia. It is important to be aware of these potential side-effects when using medications that affect these receptors.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 16 - A 25-year-old female who has a past of opioid addiction has successfully maintained...

    Incorrect

    • A 25-year-old female who has a past of opioid addiction has successfully maintained sobriety and is seeking support in controlling her urges.
      What would be the most suitable medication intervention for managing her cravings?

      Your Answer:

      Correct Answer: Acamprosate calcium

      Explanation:

      Pharmacological Treatments for Alcohol Dependence

      Acamprosate, when used in conjunction with counselling, has been found to be effective in helping alcohol-dependent patients with strong cravings maintain abstinence. Bupropion hydrochloride, which is primarily used as an antidepressant, has also been shown to be effective in maintaining smoking cessation. Disulfiram, on the other hand, causes an unpleasant systemic reaction when alcohol is consumed due to the buildup of acetaldehyde. Nalmefene has recently been licensed for the reduction of alcohol consumption in alcohol-dependent patients with a high drinking risk level who do not have physical withdrawal symptoms and do not require immediate detoxification. Finally, naltrexone, an opioid-receptor antagonist, may be used in the treatment of alcohol dependence after successful withdrawal.

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 17 - What medications have the potential to cause elevated levels of lithium in the...

    Incorrect

    • What medications have the potential to cause elevated levels of lithium in the body?

      Your Answer:

      Correct Answer: Bendroflumethiazide

      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
      0
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  • Question 18 - What medication, often prescribed, is known to elevate the risk of hyponatremia when...

    Incorrect

    • What medication, often prescribed, is known to elevate the risk of hyponatremia when taken in conjunction with SSRIs?

      Your Answer:

      Correct Answer: Lisinopril

      Explanation:

      Lisinopril is a medication that belongs to the class of ACE inhibitors and is commonly prescribed to treat hypertension and heart failure.

      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
      0
      Seconds
  • Question 19 - Which option is not a treatment for neuroleptic malignant syndrome? ...

    Incorrect

    • Which option is not a treatment for neuroleptic malignant syndrome?

      Your Answer:

      Correct Answer: Antipsychotics

      Explanation:

      NMS is a potential side effect of antipsychotics.

      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. Hyperreflexia, 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
      0
      Seconds
  • Question 20 - Which antidepressant is known for having a lower occurrence of sexual dysfunction as...

    Incorrect

    • Which antidepressant is known for having a lower occurrence of sexual dysfunction as a side effect?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      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
      0
      Seconds
  • Question 21 - A 45-year-old man with a mild depressive disorder currently taking an SSRI reports...

    Incorrect

    • A 45-year-old man with a mild depressive disorder currently taking an SSRI reports worsening tiredness. His blood test shows a sodium level of 122 mmol/L.
      Which antidepressant would be more suitable in this situation?

      Your Answer:

      Correct Answer: Agomelatine

      Explanation:

      Unlike other antidepressants, agomelatine (Valdoxan) does not affect serotonin transmission and is a melatonin agonist. It has a good safety profile and there have been no reported cases of hyponatraemia associated with its use. On the other hand, the other listed antidepressants have been linked to hyponatraemia.

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 22 - Which of the following is most likely to cause dysgeusia? ...

    Incorrect

    • Which of the following is most likely to cause dysgeusia?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      Taste disturbance is known as Dysgeusia in medical terminology and can be caused by various medications. Lithium is a frequently encountered culprit, but other drugs such as certain antidepressants, benzodiazepines, z-drugs, and opiates can also lead to this condition. Additionally, any medication that causes dry mouth may result in taste disturbance. This information is sourced from D Kaufman’s book, Clinical neurology for psychiatrists, published in 2007 on page 38.

      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
      0
      Seconds
  • Question 23 - What is a type of hypnotic medication that is not classified as a...

    Incorrect

    • What is a type of hypnotic medication that is not classified as a benzodiazepine?

      Your Answer:

      Correct Answer: Zaleplon

      Explanation:

      Hypnotic Drugs and Their Side Effects

      Hypnotic drugs are medications that act on GABA receptors, specifically the BZ1, BZ2, and BZ3 receptors. The BZ1 receptor is responsible for sedative effects, while the BZ2 receptor is responsible for myorelaxant and anticonvulsant effects. The BZ3 receptor is responsible for anxiolytic effects.

      Older benzodiazepines bind to all three types of receptors, while newer drugs like Z-drugs primarily bind to the BZ1 receptor. Zopiclone is a cyclopyrrolone drug that was marketed as a non-benzodiazepine sleep aid, but it can produce hangover effects and dependence. It is contraindicated in patients with marked neuromuscular respiratory weakness, respiratory failure, and severe sleep apnea syndrome. Zopiclone can cause alterations in EEG readings and sleep architecture similar to benzodiazepines. It should not be used by breastfeeding women as it passes through to the milk in high quantities. Side effects of zopiclone include metallic taste, heartburn, and lightening of sleep on withdrawal.

      Zolpidem is another hypnotic drug that acts on the BZ1 receptor. Side effects of zolpidem include drowsiness, fatigue, depression, falls, and amnesia. It is important to be aware of the potential side effects of hypnotic drugs and to use them only as directed by a healthcare provider.

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      • Psychopharmacology
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  • Question 24 - What substance acts as a partial agonist on nicotinic receptors? ...

    Incorrect

    • What substance acts as a partial agonist on nicotinic receptors?

      Your Answer:

      Correct Answer: Varenicline

      Explanation:

      Varenicline is a medication that helps people quit smoking by partially activating specific nicotine receptors in the body.

      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 25 - Which of the following is not a licensed treatment for obsessive compulsive disorder?...

    Incorrect

    • Which of the following is not a licensed treatment for obsessive compulsive disorder?

      Your Answer:

      Correct Answer: Citalopram

      Explanation:

      Antidepressants (Licensed Indications)

      The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

      – Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
      – Phobic and obsessional states: Clomipramine
      – Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
      – Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
      – Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
      – Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
      – OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
      – Bulimia nervosa: Fluoxetine
      – PTSD: Paroxetine, Sertraline

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      • Psychopharmacology
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  • Question 26 - What is the most frequently reported side-effect of methylphenidate? ...

    Incorrect

    • What is the most frequently reported side-effect of methylphenidate?

      Your Answer:

      Correct Answer: Nausea

      Explanation:

      ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

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      • Psychopharmacology
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  • Question 27 - What precautions should be taken for a patient with pseudocholinesterase deficiency to avoid...

    Incorrect

    • What precautions should be taken for a patient with pseudocholinesterase deficiency to avoid potential complications?

      Your Answer:

      Correct Answer: Donepezil

      Explanation:

      Pseudocholinesterase Deficiency

      Pseudocholinesterase deficiency, also known as butyrylcholinesterase deficiency, is a medical condition that can lead to increased sensitivity to certain drugs. This condition affects approximately 1 in 3200 to 1 in 5000 people, with higher prevalence in certain populations such as the Persian Jewish community and Alaska Natives. Interestingly, this condition does not cause any noticeable symptoms until an abnormal drug reaction occurs.

      It is important for individuals with pseudocholinesterase deficiency to avoid certain drugs, including donepezil, galantamine, procaine, succinylcholine, and pilocarpine. By avoiding these drugs, individuals with this condition can reduce their risk of experiencing adverse reactions.

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      • Psychopharmacology
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  • Question 28 - 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:

      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.

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  • Question 29 - A young female African American patient of yours is found to have an...

    Incorrect

    • A young female African American patient of yours is found to have an elevated serum clozapine assay. She is a non-smoker and is also taking valproic acid in addition to her antipsychotic medication. What is the most likely variable that explains her elevated assay result?

      Your Answer:

      Correct Answer: Asian ethnicity

      Explanation:

      Elevated plasma levels of clozapine have been observed in individuals of Asian ethnicity. Conversely, younger patients, males, and smokers tend to have lower plasma levels. The use of carbamazepine can accelerate the metabolism of clozapine, resulting in decreased serum assay levels. However, it is not recommended to use carbamazepine and clozapine together due to the increased risk of bone marrow suppression.

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      • Psychopharmacology
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  • Question 30 - 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:

      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.

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      • Psychopharmacology
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  • Question 31 - What is the accurate statement about the impact of antidepressants on the heart?...

    Incorrect

    • What is the accurate statement about the impact of antidepressants on the heart?

      Your Answer:

      Correct Answer: The arrhythmogenic potential of antidepressants is dose-related

      Explanation:

      Antidepressants and Their Cardiac Effects

      SSRIs are generally recommended for patients with cardiac disease as they may protect against myocardial infarction (MI). Untreated depression worsens prognosis in cardiovascular disease. Post MI, SSRIs and mirtazapine have either a neutral of beneficial effect on mortality. Sertraline is recommended post MI, but other SSRIs and mirtazapine are also likely to be safe. However, citalopram is associated with Torsades de pointes (mainly in overdose). Bupropion, citalopram, escitalopram, moclobemide, lofepramine, and venlafaxine should be used with caution of avoided in those at risk of serious arrhythmia (those with heart failure, left ventricular hypertrophy, previous arrhythmia, of MI).

      Tricyclic antidepressants (TCAs) have established arrhythmogenic activity which arises as a result of potent blockade of cardiac sodium channels and variable activity at potassium channels. ECG changes produced include PR, QRS, and QT prolongation and the Brugada syndrome. Lofepramine is less cardiotoxic than other TCAs and seems to lack the overdose arrhythmogenicity of other TCAs. QT changes are not usually seen at normal clinical doses of antidepressants (but can occur, particularly with citalopram/escitalopram). The arrhythmogenic potential of TCAs and other antidepressants is dose-related.

      Overall, SSRIs are recommended for patients with cardiac disease, while caution should be exercised when prescribing TCAs and other antidepressants, especially in those at risk of serious arrhythmia. It is important to monitor patients closely for any cardiac effects when prescribing antidepressants.

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  • Question 32 - What is the suggested way in which St John's Wort works? ...

    Incorrect

    • What is the suggested way in which St John's Wort works?

      Your Answer:

      Correct Answer: SNRI and MAOI

      Explanation:

      Antidepressants: Mechanism of Action

      Antidepressants are a class of drugs used to treat depression and other mood disorders. The mechanism of action of antidepressants varies depending on the specific drug. Here are some examples:

      Mirtazapine is a noradrenaline and serotonin specific antidepressant (NaSSa). It works by blocking certain receptors in the brain, including 5HT-1, 5HT-2, 5HT-3, and H1 receptors. It also acts as a presynaptic alpha 2 antagonist, which stimulates the release of noradrenaline and serotonin.

      Venlafaxine and duloxetine are both serotonin and noradrenaline reuptake inhibitors (SNRIs). They work by blocking the reuptake of these neurotransmitters, which increases their availability in the brain.

      Reboxetine is a noradrenaline reuptake inhibitor (NRI). It works by blocking the reuptake of noradrenaline, which increases its availability in the brain.

      Bupropion is a noradrenaline and dopamine reuptake inhibitor (NDRI). It works by blocking the reuptake of these neurotransmitters, which increases their availability in the brain.

      Trazodone is a weak serotonin reuptake inhibitor (SRI) and 5HT agonist. It works by increasing the availability of serotonin in the brain.

      St John’s Wort is a natural supplement that has been used to treat depression. It has a weak monoamine oxidase inhibitor (MAOI) effect and a weak SNRI effect.

      In summary, antidepressants work by increasing the availability of certain neurotransmitters in the brain, such as serotonin, noradrenaline, and dopamine. The specific mechanism of action varies depending on the drug.

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      • Psychopharmacology
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  • Question 33 - What is the most sleep-inducing SSRI for older adults? ...

    Incorrect

    • What is the most sleep-inducing SSRI for older adults?

      Your Answer:

      Correct Answer: Paroxetine

      Explanation:

      Compared to other SSRIs, paroxetine has a higher affinity for muscarinic acetylcholine receptors, resulting in greater sedation. Conversely, citalopram and escitalopram have a low likelihood of causing sedation. Fluoxetine and sertraline do not typically induce sedation.

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  • Question 34 - Which drug has the largest margin of safety between its therapeutic and toxic...

    Incorrect

    • Which drug has the largest margin of safety between its therapeutic and toxic doses?

      Your Answer:

      Correct Answer: Gabapentin

      Explanation:

      Narrow Therapeutic Index Drugs

      Narrow therapeutic index (NTI) drugs are medications that have a small difference between the amount that causes a therapeutic effect and the amount that causes toxicity. In other words, the therapeutic index (TI) of these drugs is narrow. The TI is a ratio that compares the blood concentration at which a drug causes a therapeutic effect to the amount that causes death of toxicity.

      In clinical practice, the TI is the range of doses at which a medication appeared to be effective in clinical trials for a median of participants without unacceptable adverse effects. For most drugs, this range is wide enough, and the maximum plasma concentration of the drug achieved when the recommended doses of a drug are prescribed lie sufficiently above the minimum therapeutic concentration and sufficiently below the toxic concentration.

      However, some drugs have a narrow therapeutic index, which means that even small changes in dose of blood concentration can lead to serious adverse effects. The US Food and Drug Administration (FDA) defines a drug product as having an NTI when there is less than a twofold difference in the minimum toxic concentrations and minimum effective concentrations in the blood and safe and effective use of the drug requires careful titration and patient monitoring.

      Examples of drugs with a narrow therapeutic index include carbamazepine, lithium, phenytoin, warfarin, digoxin, and gentamicin. These drugs require close monitoring to ensure that the blood concentration remains within the therapeutic range and does not reach toxic levels.

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  • Question 35 - 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:

      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.

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      • Psychopharmacology
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  • Question 36 - What is the number of half-lives needed for a drug to be eliminated...

    Incorrect

    • What is the number of half-lives needed for a drug to be eliminated by 97% from the body?

      Your Answer:

      Correct Answer: 5

      Explanation:

      The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

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      • Psychopharmacology
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  • Question 37 - Which antipsychotic medication belongs to the substituted benzamide class? ...

    Incorrect

    • Which antipsychotic medication belongs to the substituted benzamide class?

      Your Answer:

      Correct Answer: Sulpiride

      Explanation:

      Sulpiride belongs to the substituted benzamide class of drugs.
      Chlorpromazine falls under the phenothiazine category.
      Flupentixol is classified as a thioxanthene medication.
      Haloperidol is a butyrophenone compound.
      Pimozide is a diphenylbutylpiperidine drug.

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      • Psychopharmacology
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  • Question 38 - Which of the following examples best illustrates a drug interaction that affects the...

    Incorrect

    • Which of the following examples best illustrates a drug interaction that affects the way a drug is absorbed, distributed, metabolized, of eliminated in the body?

      Your Answer:

      Correct Answer: Change in gastrointestinal tract motility

      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.

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      • Psychopharmacology
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  • Question 39 - What is the cause of diabetes insipidus induced by lithium? ...

    Incorrect

    • What is the cause of diabetes insipidus induced by lithium?

      Your Answer:

      Correct Answer: Impaired action of ADH on principal cells

      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.

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      • Psychopharmacology
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  • Question 40 - A clinical trial involving participants with depression administered an intravenous infusion of a...

    Incorrect

    • A clinical trial involving participants with depression administered an intravenous infusion of a trial drug, while the control arm received midazolam (benzodiazepine). Within 24 hours of the infusion, those in the active arm of the trial exhibited a higher average response on the clinical rating scale and a greater number of responders overall. However, notable side effects were observed in the active trial arm, including dizziness, blurred vision, headache, nausea of vomiting, dry mouth, poor coordination, poor concentration, feelings of dissociation, and restlessness. What is the most likely drug used in the active arm of the trial?

      Your Answer:

      Correct Answer: Ketamine

      Explanation:

      Ketamine, typically used in emergency medicine and paediatric anaesthesia, has been found to possess antidepressant properties and is currently being studied for its rapid onset efficacy. However, its acute side effect of inducing dissociation has raised concerns about its suitability for individuals with psychotic symptoms of emotionally unstable personality disorder.

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      • Psychopharmacology
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  • Question 41 - Which medication, prescribed for individuals with Alzheimer's disease, functions as an NMDA antagonist?...

    Incorrect

    • Which medication, prescribed for individuals with Alzheimer's disease, functions as an NMDA antagonist?

      Your Answer:

      Correct Answer: Memantine

      Explanation:

      Memantine is an NMDA antagonist that reduces glutamate mediated excitotoxicity and is recommended by NICE guidelines for managing Alzheimer’s disease in patients with moderate of severe disease who are intolerant of of have a contraindication to acetylcholinesterase inhibitors. Donepezil and galantamine are reversible acetylcholinesterase inhibitors, while rivastigmine is both a reversible acetylcholinesterase inhibitor and butyrylcholinesterase inhibitor. Tacrine, which is not licensed in the UK, has been associated with hepatotoxicity and limited cognitive benefits. Treatment should only be initiated and continued by specialists in dementia care, with regular reviews and assessments of patient benefits. Specialists include psychiatrists, neurologists, and care of the elderly physicians.

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  • Question 42 - A 55-year-old man complains of frequent nighttime urination. He has been taking lithium...

    Incorrect

    • A 55-year-old man complains of frequent nighttime urination. He has been taking lithium for his bipolar disorder for more than two decades without any notable adverse effects.
      His eGFR is 34 mL/min, and his serum creatinine level is slightly above the normal range.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Nephrogenic diabetes insipidus

      Explanation:

      Water intoxication can cause polyuria and dilutional hyponatremia, but it does not typically lead to renal impairment. It is important to differentiate this condition from nephrogenic diabetes insipidus, which can develop in a significant percentage of patients on long-term lithium therapy and may present with nocturia as an early sign. While elevated calcium levels may occur in some patients on lithium, hyperparathyroidism is not a common clinical symptom. Tubulointerstitial nephritis is a rare complication of lithium therapy. The syndrome of inappropriate ADH secretion is not typically associated with polyuria of renal impairment and is not commonly linked to lithium therapy.

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  • Question 43 - What condition of situation would make the use of lithium inappropriate of unsafe?...

    Incorrect

    • What condition of situation would make the use of lithium inappropriate of unsafe?

      Your Answer:

      Correct Answer: Brugada syndrome

      Explanation:

      Brugada syndrome typically appears in males during adulthood, usually around age 40, and sudden death may be the initial symptom. This genetic disorder is inherited in an autosomal dominant pattern. This information is sourced from the National Organization for Rare Disorders (NORD).

      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.

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      • Psychopharmacology
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  • Question 44 - What substance is classified as a butyrylcholinesterase inhibitor? ...

    Incorrect

    • What substance is classified as a butyrylcholinesterase inhibitor?

      Your Answer:

      Correct Answer: Rivastigmine

      Explanation:

      Semorinemab is a potential treatment for dementia that works by targeting the N-terminal region of the tau protein. By binding to tau, it aims to reduce its spread within neurons and slow down the progression of the disease.

      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.

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      • Psychopharmacology
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  • Question 45 - In addition to functioning as a melatonin receptor agonist, what other roles does...

    Incorrect

    • In addition to functioning as a melatonin receptor agonist, what other roles does agomelatine play?

      Your Answer:

      Correct Answer: Selective serotonin-receptor antagonist

      Explanation:

      Agomelatine acts as a melatonin receptor agonist and a selective antagonist of serotonin receptors, without affecting the uptake of serotonin, noradrenaline, of dopamine. Second-generation antipsychotics exhibit some level of dopamine D2 antagonism. Mirtazapine functions as a presynaptic antagonist of alpha-2 adrenoceptors. Reboxetine selectively inhibits the reuptake of noradrenaline. Venlafaxine and duloxetine are recognized as inhibitors of serotonin and noradrenaline reuptake.

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  • Question 46 - What cardiac condition can be a potential side effect of tricyclic antidepressants? ...

    Incorrect

    • What cardiac condition can be a potential side effect of tricyclic antidepressants?

      Your Answer:

      Correct Answer: Tachycardia

      Explanation:

      Tricyclic antidepressants (TCAs) have side effects that are linked to their anticholinergic, antihistaminergic, and antiadrenergic properties. Even when taken at recommended doses, TCAs can lead to prolonged QT, flattened T wave, depressed ST segment, and tachycardia. Overdosing on TCAs can be fatal and may result in cardiac arrhythmias, which can occur approximately 72-96 hours after the overdose.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 47 - What is a regulator of glutamate receptors? ...

    Incorrect

    • What is a regulator of glutamate receptors?

      Your Answer:

      Correct Answer: Acamprosate

      Explanation:

      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 48 - A woman with schizophrenia, successfully treated with olanzapine, is seen in the outpatient...

    Incorrect

    • A woman with schizophrenia, successfully treated with olanzapine, is seen in the outpatient clinic. She has put on a significant amount of weight since starting medication and now has a BMI of 40. She has consistently failed to lose weight through diet and exercise. Augmentation with which of the following would be an appropriate intervention to help reduce her weight?

      Your Answer:

      Correct Answer: Aripiprazole

      Explanation:

      Antipsychotic drugs are known to cause weight gain, but some more than others. The reason for this is not due to a direct metabolic effect, but rather an increase in appetite and a decrease in activity levels. The risk of weight gain appears to be linked to clinical response. There are several suggested mechanisms for this, including antagonism of certain receptors and hormones that stimulate appetite. The risk of weight gain varies among different antipsychotics, with clozapine and olanzapine having the highest risk. Management strategies for antipsychotic-induced weight gain include calorie restriction, low glycemic index diet, exercise, and switching to an alternative antipsychotic. Aripiprazole, ziprasidone, and lurasidone are recommended as alternative options. Other options include aripiprazole augmentation, metformin, orlistat, liraglutide, and topiramate.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 49 - What is the lowest daily amount of citalopram that is effective for treating...

    Incorrect

    • What is the lowest daily amount of citalopram that is effective for treating depression in adults?

      Your Answer:

      Correct Answer: 20 mg

      Explanation:

      Antidepressants: Minimum Effective Doses

      According to the Maudsley 13th, the following are the minimum effective doses for various antidepressants:

      – Citalopram: 20 mg/day
      – Fluoxetine: 20 mg/day
      – Fluvoxamine: 50 mg/day
      – Paroxetine: 20 mg/day
      – Sertraline: 50 mg/day
      – Mirtazapine: 30 mg/day
      – Venlafaxine: 75 mg/day
      – Duloxetine: 60 mg/day
      – Agomelatine: 25 mg/day
      – Moclobemide: 300 mg/day
      – Trazodone: 150 mg/day

      Note that these are minimum effective doses and may vary depending on individual factors and response to treatment. It is important to consult with a healthcare professional before starting of changing any medication regimen.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 50 - What is the defining feature of arched posturing of the head, trunk, and...

    Incorrect

    • What is the defining feature of arched posturing of the head, trunk, and extremities?

      Your Answer:

      Correct Answer: Opisthotonus

      Explanation:

      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 51 - A 35-year-old man with treatment-resistant depression has been prescribed tranylcypromine, the only class...

    Incorrect

    • A 35-year-old man with treatment-resistant depression has been prescribed tranylcypromine, the only class of antidepressants he has not yet tried. What dietary restriction should he follow to prevent a hypertensive crisis?

      Your Answer:

      Correct Answer: Broad bean pods

      Explanation:

      When monoamine oxidase inhibitors (MAOIs) are present, the enzyme that breaks down norepinephrine is inhibited. This can lead to a hypertensive crisis if a high tyramine meal is consumed. Broad bean pods contain tyramine, which increases the release of norepinephrine. Therefore, it is important to avoid certain foods when taking MAOIs, including dried, aged, smoked, fermented, spoiled of improperly stored meat, poultry and fish, aged cheese, tap and unpasteurized beers, Marmite, and soy products.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 52 - Which receptor genes' promoter polymorphisms are strongly linked to weight gain caused by...

    Incorrect

    • Which receptor genes' promoter polymorphisms are strongly linked to weight gain caused by antipsychotic medications?

      Your Answer:

      Correct Answer: 5-HT2C

      Explanation:

      Genome-wide association studies (GWAS) have demonstrated that individuals carrying specific variant alleles in the promoter region of the 5-HT2C receptor gene are less susceptible to significant weight gain when undergoing antipsychotic treatment.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 53 - What drug acts as a partial agonist for the D2 receptor? ...

    Incorrect

    • What drug acts as a partial agonist for the D2 receptor?

      Your Answer:

      Correct Answer: Aripiprazole

      Explanation:

      Aripiprazole exhibits partial agonism at D2 receptors and acts as an agonist at 5HT1A receptors while antagonizing 5HT2A receptors.

      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 54 - 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 55 - What was the main reason for categorizing antipsychotics into typical and atypical groups?...

    Incorrect

    • What was the main reason for categorizing antipsychotics into typical and atypical groups?

      Your Answer:

      Correct Answer: Propensity for EPS

      Explanation:

      Antipsychotics were initially classified as typical of atypical based on their propensity for EPS, with only clozapine and quetiapine being considered fully atypical due to their low risk of EPS. However, a more recent classification system categorizes antipsychotics as first- of second-generation (FGAs/SGAs) based on their introduction date.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 56 - Which agent is a significant inhibitor of CYP3A4? ...

    Incorrect

    • Which agent is a significant inhibitor of CYP3A4?

      Your Answer:

      Correct Answer: Grapefruit juice

      Explanation:

      Grapefruit juice has been found to inhibit the activity of CYP3A4, an enzyme that plays a crucial role in the metabolism of various important drugs including aripiprazole, quetiapine, and tertiary amines like amitriptyline and imipramine. As a result, consumption of grapefruit juice can lead to increased levels of these drugs in the body. On the other hand, other drugs that induce the activity of CYP3A4 can decrease the levels of these drugs.

      The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 57 - Which substance follows zero order kinetics during metabolism? ...

    Incorrect

    • Which substance follows zero order kinetics during metabolism?

      Your Answer:

      Correct Answer: Alcohol

      Explanation:

      The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 58 - A 35-year-old individual who wants to quit smoking is considering bupropion. What class...

    Incorrect

    • A 35-year-old individual who wants to quit smoking is considering bupropion. What class of antidepressant does bupropion fall under?

      Your Answer:

      Correct Answer: Norepinephrine dopamine reuptake inhibitor (NDRI)

      Explanation:

      Bupropion is classified as a norepinephrine dopamine reuptake inhibitor (NDRI) and is used in smoking cessation by increasing dopamine levels in the limbic area, which reduces cravings. Other types of reuptake inhibitors include norepinephrine reuptake inhibitors (NRIs) such as atomoxetine and reboxetine, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, citalopram, escitalopram, sertraline, and fluvoxamine, serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine, desvenlafaxine, duloxetine, and milnacipran, and tricyclic antidepressants such as amitriptyline, nortriptyline, trazodone, and nefazodone.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 59 - What is typically considered a hazardous combination with an MAOI? ...

    Incorrect

    • What is typically considered a hazardous combination with an MAOI?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      It is not recommended to combine MAOIs with SSRIs, clomipramine, of ephedrine.

      MAOIs: A Guide to Mechanism of Action, Adverse Effects, and Dietary Restrictions

      First introduced in the 1950s, MAOIs were the first antidepressants introduced. However, they are not the first choice in treating mental health disorders due to several dietary restrictions and safety concerns. They are only a treatment option when all other medications are unsuccessful. MAOIs may be particularly useful in atypical depression (over eating / over sleeping, mood reactivity).

      MAOIs block the monoamine oxidase enzyme, which breaks down different types of neurotransmitters from the brain: norepinephrine, serotonin, dopamine, as well as tyramine. There are two types of monoamine oxidase, A and B. The MOA A are mostly distributed in the placenta, gut, and liver, but MOA B is present in the brain, liver, and platelets. Selegiline and rasagiline are irreversible and selective inhibitors of MAO type B, but safinamide is a reversible and selective MAO B inhibitor.

      The most common adverse effects of MAOIs occurring early in treatment are orthostatic hypotension, daytime sleepiness, insomnia, and nausea; later common effects include weight gain, muscle pain, myoclonus, paraesthesia, and sexual dysfunction.

      Pharmacodynamic interactions with MAOIs can cause two types of problem: serotonin syndrome (mainly due to SSRIs) and elevated blood pressure (caused by indirectly acting sympathomimetic amines releasers, like pseudoephedrine and phenylephrine). The combination of MAOIs and some TCAs appears safe. Only those TCAs with significant serotonin reuptake inhibition (clomipramine and imipramine) are likely to increase the risk of serotonin syndrome.

      Tyramine is a monoamine found in various foods, and is an indirect sympathomimetic that can cause a hypertensive reaction in patients receiving MAOI therapy. For this reason, dietary restrictions are required for patients receiving MAOIs. These restrictions include avoiding matured/aged cheese, fermented sausage, improperly stored meat, fava of broad bean pods, and certain drinks such as on-tap beer. Allowed foods include fresh cottage cheese, processed cheese slices, fresh packaged of processed meat, and other alcohol (no more than two bottled or canned beers of two standard glasses of wine, per day).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 60 - Which medication does not create a significant active metabolite? ...

    Incorrect

    • Which medication does not create a significant active metabolite?

      Your Answer:

      Correct Answer: Oxazepam

      Explanation:

      Oxazepam is a significant metabolite found in various benzodiazepines, but it does not produce any significant metabolites of its own. It is occasionally prescribed to individuals with liver impairment because it does not necessitate hepatic oxidation and is instead metabolized through glucuronidation (which is often preserved even in severe liver disease).

      The Significance of Active Metabolites in Drug Discovery and Development

      Certain drugs are classified as prodrugs, which means that they are inactive when administered and require metabolism to become active. These drugs are converted into an active form, which is referred to as an active metabolite. Some drugs have important active metabolites, such as diazepam, dothiepin, fluoxetine, imipramine, risperidone, amitriptyline, and codeine, which are desmethyldiazepam, dothiepin sulfoxide, norfluoxetine, desipramine, 9-hydroxyrisperidone, nortriptyline, and morphine, respectively.

      The role of pharmacologically active metabolites in drug discovery and development is significant. Understanding the active metabolites of a drug can help in the development of more effective and safer drugs. Active metabolites can also provide insights into the pharmacokinetics and pharmacodynamics of a drug, which can aid in the optimization of dosing regimens. Additionally, active metabolites can have different pharmacological properties than the parent drug, which can lead to the discovery of new therapeutic uses for a drug. Therefore, the study of active metabolites is an important aspect of drug discovery and development.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 61 - A friend contacts you about her elderly mother who has come to her...

    Incorrect

    • A friend contacts you about her elderly mother who has come to her complaining of withdrawal symptoms. She suspects that her mother may be seeking drugs for non-medical reasons. The mother explains that she recently moved into a retirement home and does not have access to her usual pain medication. What non-addictive options are available to alleviate her withdrawal symptoms?

      Your Answer:

      Correct Answer: Lofexidine

      Explanation:

      Lofexidine is administered to relieve the symptoms of withdrawal from heroin and opiates. Alprazolam and lormetazepam belong to the benzodiazepine class of drugs and are likely to cause physical dependence with prolonged use. Codeine is an analgesic opiate and frequent use can result in significant physical dependence. Phenobarbitone is a potent barbiturate with anaesthetic properties and its regular use can lead to the development of physical dependence.

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      • Psychopharmacology
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  • Question 62 - A client is gradually tapering off venlafaxine and experiencing unbearable discontinuation symptoms. What...

    Incorrect

    • A client is gradually tapering off venlafaxine and experiencing unbearable discontinuation symptoms. What options are available to alleviate these symptoms?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      Fluoxetine may be effective in treating discontinuation symptoms that occur when stopping venlafaxine and clomipramine, possibly due to its extended half-life.

      Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

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      • Psychopharmacology
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  • Question 63 - Which antidepressant specifically targets the inhibition of noradrenaline reuptake and does not have...

    Incorrect

    • Which antidepressant specifically targets the inhibition of noradrenaline reuptake and does not have significant affinity for 5-HT?

      Your Answer:

      Correct Answer: Reboxetine

      Explanation:

      Reboxetine, Atomoxetine, and Maprotiline are all important Norepinephrine Reuptake Inhibitors (NRIs) that specifically target noradrenaline.

      Antidepressants: Mechanism of Action

      Antidepressants are a class of drugs used to treat depression and other mood disorders. The mechanism of action of antidepressants varies depending on the specific drug. Here are some examples:

      Mirtazapine is a noradrenaline and serotonin specific antidepressant (NaSSa). It works by blocking certain receptors in the brain, including 5HT-1, 5HT-2, 5HT-3, and H1 receptors. It also acts as a presynaptic alpha 2 antagonist, which stimulates the release of noradrenaline and serotonin.

      Venlafaxine and duloxetine are both serotonin and noradrenaline reuptake inhibitors (SNRIs). They work by blocking the reuptake of these neurotransmitters, which increases their availability in the brain.

      Reboxetine is a noradrenaline reuptake inhibitor (NRI). It works by blocking the reuptake of noradrenaline, which increases its availability in the brain.

      Bupropion is a noradrenaline and dopamine reuptake inhibitor (NDRI). It works by blocking the reuptake of these neurotransmitters, which increases their availability in the brain.

      Trazodone is a weak serotonin reuptake inhibitor (SRI) and 5HT agonist. It works by increasing the availability of serotonin in the brain.

      St John’s Wort is a natural supplement that has been used to treat depression. It has a weak monoamine oxidase inhibitor (MAOI) effect and a weak SNRI effect.

      In summary, antidepressants work by increasing the availability of certain neurotransmitters in the brain, such as serotonin, noradrenaline, and dopamine. The specific mechanism of action varies depending on the drug.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 64 - What is a true statement about lithium? ...

    Incorrect

    • What is a true statement about lithium?

      Your Answer:

      Correct Answer: It exists in an unbound form in the blood

      Explanation:

      Lithium has a tendency to remain unattached to proteins and instead remains unbound within the body, resulting in its efficient elimination from the bloodstream through haemodialysis.

      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.

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      • Psychopharmacology
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  • Question 65 - A middle-aged man with a long standing history of recurrent depression, who is...

    Incorrect

    • A middle-aged man with a long standing history of recurrent depression, who is currently taking nortriptyline and lithium, presents to the clinic with complaints of fatigue, a deepening voice, and a decreased sex drive. During the physical examination, you observe that the outer edges of his eyebrows are notably sparse. Which of the following tests is most likely to reveal an abnormality?

      Your Answer:

      Correct Answer: Thyroid function test

      Explanation:

      A thyroid function test would confirm a diagnosis of hypothyroidism based on the patient’s medical history and symptoms.

      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 66 - What is the accurate definition of drug clearance? ...

    Incorrect

    • What is the accurate definition of drug clearance?

      Your Answer:

      Correct Answer: The volume of plasma cleared of a drug over a specified time period

      Explanation:

      Drug Clearance: Understanding the Rate of Drug Removal from the Body

      Drug clearance refers to the efficiency of drug removal from the plasma, and is measured as the volume of plasma cleared of a drug over a specific time period. The unit of measurement for drug clearance is volume per time. Clearance of a drug involves both metabolism and excretion. When drug intake equals clearance, it is referred to as a steady state, which is usually achieved by 4.5 half-lives. The time taken to reach steady state depends on the half-life of the drug.

      There are two main types of clearance: hepatic and renal. Hepatic clearance involves the conversion of the parent drug into a different chemical entity by the liver enzymes, while renal clearance involves the removal of the drug from the plasma into the urine. The clearance of a drug can take one of two forms: zero and first-order kinetics. In zero-order reactions, the clearance of a drug is constant and not related to the concentration of the drug in the plasma. This type of reaction is typically found when the material needed for the reaction to proceed (e.g. enzyme) is saturated. Ethanol and Phenytoin are good examples of this.

      Most drugs tend to follow first-order reactions, where the clearance is related to the concentration of the drug in the plasma. The half-life of a drug is the time taken for its concentration to fall by half. In first-order reactions, this is constant. In zero-order reactions, it gets progressively shorter.

      It is important to note that elimination and clearance are not the same. Elimination is the irreversible removal of the drug from the body, while clearance is a theoretical volume of blood that is cleared of the drug per unit of time, which is independent of the drug dose of concentration. Understanding drug clearance is crucial in determining the appropriate dosing regimen for a drug.

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      • Psychopharmacology
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  • Question 67 - What factor is most likely to increase the levels of clozapine in the...

    Incorrect

    • What factor is most likely to increase the levels of clozapine in the bloodstream?

      Your Answer:

      Correct Answer: Caffeine

      Explanation:

      CYP1A2 is responsible for metabolizing caffeine, and it competes with other drugs that are also metabolized by this enzyme. When caffeine is consumed excessively, it can deplete the CYP1A2, leaving none available to metabolize clozapine, resulting in increased levels of clozapine. However, this is not a common issue in clinical settings.

      The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 68 - Which of the following is not a recognized symptom associated with hyponatremia? ...

    Incorrect

    • Which of the following is not a recognized symptom associated with hyponatremia?

      Your Answer:

      Correct Answer: Chest pain

      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 69 - What is a significant byproduct of clozapine metabolism? ...

    Incorrect

    • What is a significant byproduct of clozapine metabolism?

      Your Answer:

      Correct Answer: N-desmethylclozapine

      Explanation:

      Clozapine is an atypical antipsychotic drug that acts as an antagonist at various receptors, including dopamine, histamine, serotonin, adrenergic, and cholinergic receptors. It is mainly metabolized by CYP1A2, and its plasma levels can be affected by inducers and inhibitors of this enzyme. Clozapine is associated with several side effects, including drowsiness, constipation, weight gain, and hypersalivation. Hypersalivation is a paradoxical side effect, and its mechanism is not fully understood, but it may involve clozapine agonist activity at the muscarinic M4 receptor and antagonist activity at the alpha-2 adrenoceptor. Clozapine is also associated with several potentially dangerous adverse events, including agranulocytosis, myocarditis, seizures, severe orthostatic hypotension, increased mortality in elderly patients with dementia-related psychosis, colitis, pancreatitis, thrombocytopenia, thromboembolism, and insulin resistance and diabetes mellitus. The BNF advises caution in using clozapine in patients with prostatic hypertrophy, susceptibility to angle-closure glaucoma, and adults over 60 years. Valproate should be considered when using high doses of clozapine, plasma levels > 0.5 mg/l, of when the patient experiences seizures. Myocarditis is a rare but potentially fatal adverse event associated with clozapine use, and its diagnosis is based on biomarkers and clinical features. The mortality rate of clozapine-induced myocarditis is high, and subsequent use of clozapine in such cases leads to recurrence of myocarditis in most cases.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 70 - What is the name of the opioid antagonist that is used for the...

    Incorrect

    • What is the name of the opioid antagonist that is used for the treatment of opioid and alcohol dependence and has a long-lasting effect?

      Your Answer:

      Correct Answer: Naltrexone

      Explanation:

      There exist two primary opioid antagonists.

      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 71 - What is the correct statement regarding adverse drug reactions (ADRs)? ...

    Incorrect

    • What is the correct statement regarding adverse drug reactions (ADRs)?

      Your Answer:

      Correct Answer: An ADR is a harmful outcome of a medication when used at a high dose

      Explanation:

      ADRs only occur when medications are used at ABNORMAL doses. (FALSE)

      Adverse Drug Reactions (ADRs) refer to the harmful effects associated with the use of a medication at a normal dose. These reactions are classified into two types: Type A and Type B. Type A reactions can be predicted from the pharmacology of the drug and are dose-dependent, meaning they can be reversed by withdrawing the drug. On the other hand, Type B reactions cannot be predicted from the known pharmacology of the drug and include allergic reactions.

      Type A reactions account for up to 80% of all ADRs, while Type B reactions are less common. Allergic reactions are a type of Type B reaction and are further subdivided by Gell and Coombs into four types: Type I (IgE-mediated) reactions, Type II (cytotoxic) reactions, Type III (immune complex) reactions, and Type IV (cell-mediated) reactions. Proper identification and management of ADRs are crucial in ensuring patient safety and optimizing treatment outcomes.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 72 - What is a known factor that can cause a cleft lip when used...

    Incorrect

    • What is a known factor that can cause a cleft lip when used during pregnancy?

      Your Answer:

      Correct Answer: Diazepam

      Explanation:

      By week 12 of embryonic development, the lip and palate region is usually completely developed. Cleft lip and palate are primarily caused by the use of anticonvulsants, benzodiazepines, and steroids as medications.

      Teratogens and Their Associated Defects

      Valproic acid is a teratogen that has been linked to various birth defects, including neural tube defects, hypospadias, cleft lip/palate, cardiovascular abnormalities, developmental delay, endocrinological disorders, limb defects, and autism (Alsdorf, 2005). Lithium has been associated with cardiac anomalies, specifically Ebstein’s anomaly. Alcohol consumption during pregnancy can lead to cleft lip/palate and fetal alcohol syndrome. Phenytoin has been linked to fingernail hypoplasia, craniofacial defects, limb defects, cerebrovascular defects, and mental retardation. Similarly, carbamazepine has been associated with fingernail hypoplasia and craniofacial defects. Diazepam has been linked to craniofacial defects, specifically cleft lip/palate (Palmieri, 2008). The evidence for steroids causing craniofacial defects is not convincing, according to the British National Formulary (BNF). Selective serotonin reuptake inhibitors (SSRIs) have been associated with congenital heart defects and persistent pulmonary hypertension (BNF). It is important for pregnant women to avoid exposure to these teratogens to reduce the risk of birth defects in their babies.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 73 - An HIV+ patient in their 60s attends clinic in view of ongoing depression....

    Incorrect

    • An HIV+ patient in their 60s attends clinic in view of ongoing depression. You note a number of cutaneous lesions in the form of purple-red macules on their face and neck. These are also apparent on the mucous membranes. Which of the following would you most suspect?:

      Your Answer:

      Correct Answer: Kaposi's sarcoma

      Explanation:

      Kaposi’s sarcoma is a type of tumor that is caused by human herpesvirus 8. When it is associated with AIDS, it typically appears as red to purple-red macules on the skin that quickly progress to papules, nodules, and plaques. These lesions tend to occur on the head, back, neck, trunk, and mucous membranes, and can also be found in the lymph nodes, stomach, intestines, and lungs in more advanced cases. Individuals with severe mental illness are at a higher risk of contracting and transmitting HIV, and are more likely to have HIV infection compared to the general population. Therefore, it is important to have a basic understanding of the symptoms of this condition.

      HIV and Mental Health: Understanding the Relationship and Treatment Options

      Human immunodeficiency virus (HIV) is a blood-borne virus that causes cellular immune deficiency, resulting in a decrease in the number of CD4+ T-cells. People with severe mental illness are at increased risk of contracting and transmitting HIV, and the prevalence of HIV infection among them is higher than in the general population. Antiretroviral drugs are used to manage HIV, but they are not curative.

      Depression is the most common mental disorder in the HIV population, and it can result from HIV of the psycho-social consequences of having the condition. HIV-associated neurocognitive disorder (HAND) is the umbrella term for the spectrum of neurocognitive impairment induced by HIV, ranging from mild impairment through to dementia. Poor episodic memory is the most frequently reported cognitive difficulty in HIV-positive individuals.

      Treatment options for mental health issues in people with HIV include atypical antipsychotics for psychosis, SSRIs for depression and anxiety, valproate for bipolar disorder, and antiretroviral therapy for HAND. It is important to avoid benzodiazepines for delirium and MAOIs for depression. Understanding the relationship between HIV and mental health and providing appropriate treatment options can improve the quality of life for people living with HIV.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 74 - Which antidepressant is known for having a lower occurrence of sexual dysfunction as...

    Incorrect

    • Which antidepressant is known for having a lower occurrence of sexual dysfunction as a side effect?

      Your Answer:

      Correct Answer: Reboxetine

      Explanation:

      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 75 - What molecule binds to the nicotinic acetylcholine receptor through allosteric regulation? ...

    Incorrect

    • What molecule binds to the nicotinic acetylcholine receptor through allosteric regulation?

      Your Answer:

      Correct Answer: Galantamine

      Explanation:

      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 76 - A woman with schizophrenia in her 30s has recently changed some of her...

    Incorrect

    • A woman with schizophrenia in her 30s has recently changed some of her medication. She attends clinic and appears restless and states she is feeling agitated. What do you suspect could be the reason for her restlessness and agitation?

      Your Answer:

      Correct Answer: Akathisia

      Explanation:

      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 77 - Which receptors are believed to be hypersensitive and responsible for causing tardive dyskinesia?...

    Incorrect

    • Which receptors are believed to be hypersensitive and responsible for causing tardive dyskinesia?

      Your Answer:

      Correct Answer: D2

      Explanation:

      The development of tardive dyskinesia is thought to be caused by an increased sensitivity of postsynaptic D2 receptors in the nigrostriatal pathway. Therefore, clozapine is recommended as a treatment option since it has minimal binding affinity for D2 receptors.

      Tardive Dyskinesia: Symptoms, Causes, Risk Factors, and Management

      Tardive dyskinesia (TD) is a condition that affects the face, limbs, and trunk of individuals who have been on neuroleptics for months to years. The movements fluctuate over time, increase with emotional arousal, decrease with relaxation, and disappear with sleep. The cause of TD remains theoretical, but the postsynaptic dopamine (D2) receptor supersensitivity hypothesis is the most persistent. Other hypotheses include the presynaptic dopaminergic/noradrenergic hyperactivity hypothesis, the cholinergic interneuron burnout hypothesis, the excitatory/oxidative stress hypothesis, and the synaptic plasticity hypothesis. Risk factors for TD include advancing age, female sex, ethnicity, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, diabetes, smoking, alcohol and substance misuse, FGA vs SGA treatment, higher antipsychotic dose, anticholinergic co-treatment, and akathisia.

      Management options for TD include stopping any anticholinergic, reducing antipsychotic dose, changing to an antipsychotic with lower propensity for TD, and using tetrabenazine, vitamin E, of amantadine as add-on options. Clozapine is the antipsychotic most likely to be associated with resolution of symptoms. Vesicular monoamine transporter type 2 (VMAT2) inhibitors are agents that cause a depletion of neuroactive peptides such as dopamine in nerve terminals and are used to treat chorea due to neurodegenerative diseases of dyskinesias due to neuroleptic medications (tardive dyskinesia).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 78 - Which of the following is not a way in which galantamine works? ...

    Incorrect

    • Which of the following is not a way in which galantamine works?

      Your Answer:

      Correct Answer: Inhibits butyrylcholinesterase

      Explanation:

      In the treatment of Alzheimer’s disease, acetylcholinesterase inhibitors such as galantamine are utilized to enhance central acetylcholine levels. Although they share this common mechanism of action, there are variations in how they function. Unlike galantamine, rivastigmine has the ability to inhibit butyrylcholinesterase.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 79 - What is the term used to describe an agonist that elicits the maximum...

    Incorrect

    • What is the term used to describe an agonist that elicits the maximum effect at a receptor?

      Your Answer:

      Correct Answer: A full agonist

      Explanation:

      Agonists and Antagonists in Pharmacology

      In pharmacology, an agonist is a substance that binds to a receptor and triggers a biological response. On the other hand, an antagonist is a substance that blocks the effects of an agonist. A partial agonist produces a response but cannot produce the maximum response even at high doses.

      Competitive antagonists bind to the receptor in a reversible way without affecting the biological response. They make the agonist appear less potent. Inverse agonists, on the other hand, have opposite effects from those of full agonists. They are not the same as antagonists, which block the effect of both agonists and inverse agonists.

      Full agonists display full efficacy at a receptor. Some substances can act as an agonist at certain receptors and as an antagonist at others. Such a substance is called an agonist-antagonist. Understanding the differences between agonists and antagonists is crucial in drug development and treatment.

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      • Psychopharmacology
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  • Question 80 - The most probable diagnosis for a diabetic patient who has started taking antidepressants...

    Incorrect

    • The most probable diagnosis for a diabetic patient who has started taking antidepressants and presents with symptoms of nausea, headaches, and low plasma sodium levels is:

      Your Answer:

      Correct Answer: SIADH

      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 81 - What is the maximum duration of a normal QTc interval in an adult...

    Incorrect

    • What is the maximum duration of a normal QTc interval in an adult male?

      Your Answer:

      Correct Answer: 440

      Explanation:

      While the upper limit technically reaches 439, it is evident that 440 is the optimal choice among the options provided.

      Amantadine and QTc Prolongation

      Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

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      • Psychopharmacology
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  • Question 82 - Which option is considered to have the lowest risk of causing damage to...

    Incorrect

    • Which option is considered to have the lowest risk of causing damage to the heart?

      Your Answer:

      Correct Answer: Lofepramine

      Explanation:

      Among the tricyclic antidepressants, Lofepramine has the lowest potential for causing cardiotoxicity.

      Antidepressants and Their Cardiac Effects

      SSRIs are generally recommended for patients with cardiac disease as they may protect against myocardial infarction (MI). Untreated depression worsens prognosis in cardiovascular disease. Post MI, SSRIs and mirtazapine have either a neutral of beneficial effect on mortality. Sertraline is recommended post MI, but other SSRIs and mirtazapine are also likely to be safe. However, citalopram is associated with Torsades de pointes (mainly in overdose). Bupropion, citalopram, escitalopram, moclobemide, lofepramine, and venlafaxine should be used with caution of avoided in those at risk of serious arrhythmia (those with heart failure, left ventricular hypertrophy, previous arrhythmia, of MI).

      Tricyclic antidepressants (TCAs) have established arrhythmogenic activity which arises as a result of potent blockade of cardiac sodium channels and variable activity at potassium channels. ECG changes produced include PR, QRS, and QT prolongation and the Brugada syndrome. Lofepramine is less cardiotoxic than other TCAs and seems to lack the overdose arrhythmogenicity of other TCAs. QT changes are not usually seen at normal clinical doses of antidepressants (but can occur, particularly with citalopram/escitalopram). The arrhythmogenic potential of TCAs and other antidepressants is dose-related.

      Overall, SSRIs are recommended for patients with cardiac disease, while caution should be exercised when prescribing TCAs and other antidepressants, especially in those at risk of serious arrhythmia. It is important to monitor patients closely for any cardiac effects when prescribing antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 83 - You are provided with a set of blood test outcomes that show serum...

    Incorrect

    • 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:

      Correct 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 84 - What is the mechanism of action of sildenafil? ...

    Incorrect

    • What is the mechanism of action of sildenafil?

      Your Answer:

      Correct Answer: Inhibition of phosphodiesterase

      Explanation:

      Nitrous oxide functions as a vasodilator during penile erection by diffusing through the muscle cell membrane and binding to guanylyl cyclase. This enzyme catalyzes the conversion of GTP to cyclic GMP, which activates a cGMP-dependent protein kinase. This kinase stimulates the uptake of calcium by the endoplasmic reticulum of the muscle cell, leading to muscle relaxation and vasodilation, resulting in an erection.

      To end the erection, cGMP is converted into GMP by a specific phosphodiesterase (PDE). There are ten families of PDEs, with PDE5 being the primary PDE found in vascular smooth muscle. Sildenafil (Viagra) is a specific inhibitor of PDE5, blocking the breakdown of cGMP and prolonging the effects of cGMP, thereby prolonging the erection.

      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 85 - A 28-year-old female with a history of bipolar disorder is being treated with...

    Incorrect

    • A 28-year-old female with a history of bipolar disorder is being treated with lithium but shows incomplete response; persistent manic symptoms remain. Lithium blood levels are within the therapeutic range and you decide to start an adjunctive medication. An anticonvulsant is prescribed but the patient develops a rapidly spreading rash all over her chest, face and legs. She becomes systemically ill and requires hospitalization. What is the most probable causative agent?

      Your Answer:

      Correct Answer: Lamotrigine

      Explanation:

      Lamotrigine is prescribed to enhance the effectiveness of clozapine in treating schizophrenia that is resistant to clozapine. However, it is important to note that lamotrigine can cause Stevens-Johnson syndrome, a serious skin condition that requires immediate medical attention. Therefore, if a rash appears, treatment with lamotrigine should be discontinued promptly.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 86 - What is true about hyponatremia caused by antidepressants? ...

    Incorrect

    • What is true about hyponatremia caused by antidepressants?

      Your Answer:

      Correct Answer: Onset is usually within 30 days of starting treatment

      Explanation:

      Hyponatremia is commonly linked to the use of SSRIs (antidepressants) and typical antipsychotics.

      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 euvolemic 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 87 - 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:

      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 88 - When used in higher doses, which medication should be prescribed twice daily? ...

    Incorrect

    • When used in higher doses, which medication should be prescribed twice daily?

      Your Answer:

      Correct Answer: Amisulpride

      Explanation:

      Antipsychotics are commonly used to treat various mental health conditions. Most atypical antipsychotics require twice daily administration due to their short half-lives, except for olanzapine, aripiprazole, and risperidone. These medications have longer half-lives and can be administered once daily. A recent randomized controlled trial compared once versus twice daily dosing of risperidone and olanzapine and found no significant difference in effectiveness and efficacy outcomes. However, the study suggests that once-daily dosing may be preferable due to lower mean dose and better side effect profile, especially for olanzapine.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 89 - A 50-year-old woman is experiencing symptoms of alcohol withdrawal. What class of medication...

    Incorrect

    • A 50-year-old woman is experiencing symptoms of alcohol withdrawal. What class of medication would be the most suitable for her treatment?

      Your Answer:

      Correct Answer: Benzodiazepine

      Explanation:

      The preferred initial treatment for alcohol withdrawal syndrome is benzodiazepines.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 90 - A 28-year-old woman presents with confusion after experiencing a seizure. She has a...

    Incorrect

    • A 28-year-old woman presents with confusion after experiencing a seizure. She has a past medical history of epilepsy and is currently under the care of the community psychiatry team. Upon examination, her temperature is 37°C, blood pressure is 138/84 mmHg, and she has a coarse tremor with a pulse of 90 bpm. Brisk reflexes and 7 beats of nystagmus on lateral gaze are also noted. What is the most probable underlying diagnosis?

      Your Answer:

      Correct Answer: Lithium toxicity

      Explanation:

      – Lithium toxicity occurs at levels above 1.4 mmol/L
      – Symptoms include anorexia, diarrhea, vomiting, ataxia, nystagmus, dysarthria, confusion, and seizures
      – Fine tremor can occur in therapeutic range, but becomes coarser in toxicity
      – If allowed to progress, toxicity can result in coma with hyperreflexia and increased tone, and irreversible neurological damage
      – Treatment is supportive, with attention to electrolytes, fluid balance, renal function, and seizure control
      – Bowel irrigation can be used in significant recent overdose, diuretics should be avoided, and haemodialysis may be required
      – Benzodiazepines can control agitation.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 91 - What is the most appropriate antipsychotic medication for a patient with liver failure...

    Incorrect

    • What is the most appropriate antipsychotic medication for a patient with liver failure who has developed a psychotic illness and has a normal GFR of 120?

      Your Answer:

      Correct Answer: Amisulpride

      Explanation:

      Out of the given options, amisulpride is the most suitable medication as it is not extensively metabolized by the liver. However, it should be avoided in individuals with established renal failure as a normal glomerular filtration rate is considered to be >90 ml/min/1.73m2.

      Hepatic Impairment: Recommended Drugs

      Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

      Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

      Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

      Mood stabilizers: Lithium

      Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

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      • Psychopharmacology
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  • Question 92 - Which antibiotic may have anti-inflammatory and neuroprotective effects and could be used in...

    Incorrect

    • Which antibiotic may have anti-inflammatory and neuroprotective effects and could be used in combination with clozapine to treat schizophrenia that is resistant to other treatments?

      Your Answer:

      Correct Answer: Minocycline

      Explanation:

      There is evidence to suggest that minocycline has anti-inflammatory and neuroprotective properties. Additionally, both an open study and a randomized controlled trial indicate that it may have positive effects on cognitive and negative symptoms.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 93 - What is a medication that acts as a partial agonist for 5HT1A receptors?...

    Incorrect

    • What is a medication that acts as a partial agonist for 5HT1A receptors?

      Your Answer:

      Correct Answer: Buspirone

      Explanation:

      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 94 - Which of the following is not a factor that increases the risk of...

    Incorrect

    • Which of the following is not a factor that increases the risk of developing neuroleptic malignant syndrome when administering antipsychotics?

      Your Answer:

      Correct Answer: Being female

      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.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 95 - What potential adverse effects of diazepam use could explain a patient's complaints of...

    Incorrect

    • What potential adverse effects of diazepam use could explain a patient's complaints of abdominal pain, constipation, and muscle weakness upon returning to the clinic for follow-up?

      Your Answer:

      Correct Answer: Porphyria

      Explanation:

      Porphyria: The Little Imitator

      Porphyria is a medical condition that is often referred to as the little imitator because it can mimic various common psychiatric presentations. This condition can be triggered by the use of certain psychotropic drugs, including barbiturates, benzodiazepines, sulpiride, and some mood stabilizers.

      Porphyria can manifest in different ways, and it is important to be aware of the symptoms. These may include abdominal pain, mental state changes, constipation, vomiting, and muscle weakness.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 96 - What substance is eliminated from the body through urine without undergoing any chemical...

    Incorrect

    • What substance is eliminated from the body through urine without undergoing any chemical changes?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      The First Pass Effect in Psychiatric Drugs

      The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

      Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 97 - 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 98 - What is a true statement about priapism? ...

    Incorrect

    • What is a true statement about priapism?

      Your Answer:

      Correct Answer: It is associated with chlorpromazine use

      Explanation:

      Females can experience priapism of the clitoris.

      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 99 - A cohort study aimed to determine the likelihood of postoperative bleeding in elderly...

    Incorrect

    • A cohort study aimed to determine the likelihood of postoperative bleeding in elderly patients undergoing surgery while taking anticoagulant medication.
      Anticoagulants were categorized into direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs).
      What were the results of the study?

      Your Answer:

      Correct Answer: Increased risk of bleeding with all antidepressants

      Explanation:

      The use of selective serotonin reuptake inhibitors (SSRIs) can lead to a decrease in platelet aggregation, potentially increasing the risk of bleeding. However, the discovery that other types of antidepressants may also increase the risk of bleeding was unexpected and requires further investigation.

      A recent cohort study followed women who were currently using antidepressants, had used them within the past month, had used them within the past 1-5 months, of had never used them. The study found that women who had any current of recent exposure to antidepressants were at a slightly increased risk of experiencing postpartum hemorrhage (with a relative risk of 1.4-1.9).

      The study was conducted in the United States and focused on women who received Medicaid, which represents approximately 40% of the US population and includes a higher proportion of economically disadvantaged and minority populations.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 100 - Which antidepressant would be the best option for a patient who has been...

    Incorrect

    • Which antidepressant would be the best option for a patient who has been diagnosed with depression and has also experienced a heart attack in the recent past?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      Antidepressant Medications and Ischaemic Heart Disease

      The SADHART investigation has shown that sertraline is a safe and effective antidepressant for patients with ischaemic heart disease. However, other medications have not yet been proven safe for this population.

      Amitriptyline, a tricyclic antidepressant, is not recommended for patients with comorbid coronary heart disease due to its high relative risk of myocardial infarction and direct cardiac effects. It may also induce weight gain and increase the risk of diabetes, both of which are known risk factors for cardiovascular disease.

      Mirtazapine has been studied as a safe second line/alternative treatment to SSRIs in post MI depression, but it can also cause weight gain. Further research is needed to determine the safety and efficacy of other antidepressant medications in patients with ischaemic heart disease.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 101 - A 45-year-old male on an acute psychiatric unit was diagnosed with severe depression...

    Incorrect

    • A 45-year-old male on an acute psychiatric unit was diagnosed with severe depression with psychotic features. He is being treated with oral haloperidol, venlafaxine, mirtazapine, and procyclidine, but his adherence to the medication regimen is inconsistent. He experiences restlessness, sweating, tremors, shivering, myoclonus, and confusion.
      What is the probable reason for these symptoms?

      Your Answer:

      Correct Answer: Serotonin syndrome

      Explanation:

      The symptoms listed are indicative of serotonin syndrome, which is a potential risk when prescribing two antidepressants. If left untreated, serotonin syndrome can lead to seizures and even death. Treatment typically involves supportive measures such as benzodiazepines and IV access, as well as serotonin receptor antagonists like cyproheptadine. Anticholinergic syndrome, on the other hand, presents with symptoms such as fever, dry skin and mucous membranes, mydriasis, and hyperthermia. Antidepressant discontinuation syndrome can cause a range of neurological, gastrointestinal, and affective symptoms. Idiopathic parkinsonism is characterized by tremors, rigidity, and bradykinesia, while neuroleptic malignant syndrome presents with symptoms such as hyperthermia, rigidity, confusion, tachycardia, and elevated CK and WCC levels.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 102 - What is the method used by bodybuilders to alleviate the negative effects of...

    Incorrect

    • What is the method used by bodybuilders to alleviate the negative effects of misusing anabolic steroids?

      Your Answer:

      Correct Answer: Tamoxifen

      Explanation:

      Anabolic Steroids: Uses, Misuse, and Complications

      Anabolic steroids are synthetic derivatives of testosterone that have both anabolic and androgenic properties. They are commonly used by athletes to enhance performance and by individuals to improve physical appearance. However, their misuse is not uncommon, with nearly half of users of dedicated bodybuilding gyms admitting to taking anabolic agents. Misuse can lead to dependence, tolerance, and the development of psychiatric disorders such as aggression, psychosis, mania, and depression/anxiety.

      There are three common regimes practised by steroid misusers: ‘cycling’, ‘stacking’ and ‘pyramiding’. Anabolic steroids can be taken orally, injected intramuscularly, and applied topically in the form of creams and gels. Other drugs are also used by athletes, such as clenbuterol, ephedrine, thyroxine, insulin, tamoxifen, human chorionic Gonadotropin, diuretics, and growth hormone.

      Medical complications are common and can affect various systems, such as the musculoskeletal, cardiovascular, hepatic, reproductive (males and females), dermatological, and other systems. Complications include muscular hypertrophy, increased blood pressure, decreased high-density lipoprotein cholesterol and increased low-density lipoprotein cholesterol, cholestatic jaundice, benign and malignant liver tumours, testicular atrophy, sterility, gynaecomastia, breast tissue shrinkage, menstrual abnormalities, masculinisation, male-pattern baldness, acne, sleep apnoea, exacerbation of tic disorders, polycythaemia, altered immunity, and glucose intolerance.

      Anabolic steroids are a class C controlled drug and can only be obtained legally through a medical prescription. It is important to educate individuals about the risks and complications associated with their misuse and to promote safe and legal use.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 103 - How can a dosette box help the elderly gentleman remember to take his...

    Incorrect

    • How can a dosette box help the elderly gentleman remember to take his medication?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      Drug Stability

      The stability of drugs can vary greatly, with some medications being unable to be included in compliance aids due to their susceptibility to environmental factors. Certain drugs have a tendency to absorb moisture from the air, rendering them ineffective, with light known to accelerate this process. Examples of drugs that are unsuitable for compliance aids due to their susceptibility to environmental factors include Sodium valproate, Zopiclone, Venlafaxine, Topiramate, Methylphenidate, Mirtazapine, Olanzapine, Amisulpride, and Aripiprazole.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 104 - What is an example of an atypical antipsychotic medication? ...

    Incorrect

    • What is an example of an atypical antipsychotic medication?

      Your Answer:

      Correct Answer: Aripiprazole

      Explanation:

      Antipsychotics can be classified in different ways, including by typical (first generation) and atypical (second generation) categories of by chemical structure. Aripiprazole is an atypical antipsychotic that works as a dopamine D2 partial agonist, a weak 5HT1a partial agonist, and a 5HT2a receptor antagonist. It has a lower risk of causing movement disorders than typical antipsychotics and can also lower prolactin levels.

      Typical antipsychotics, developed in the 1950s, block dopamine D2 receptors in the brain and can cause various side effects, including extrapyramidal symptoms and elevated prolactin. They are not selective for any of the four dopamine pathways in the brain.

      In elderly patients with dementia, antipsychotics are associated with an increased risk of stroke and transient ischaemic attack, as well as a small increased risk of mortality. Prescribing guidelines for the elderly can be found in the British National Formulary (BNF).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 105 - A 42-year-old female with a history of bipolar disorder is undergoing second line...

    Incorrect

    • A 42-year-old female with a history of bipolar disorder is undergoing second line mood stabilisation therapy due to inadequate response to first line agents. She was discovered unconscious on the street. She has no history of seizures of fainting. All laboratory tests are normal except for a serum sodium level of 105 mmol/L (135-150). What is the most probable cause of this?

      Your Answer:

      Correct Answer: Carbamazepine

      Explanation:

      Monitoring for hyponatraemia is essential when administering carbamazepine due to its established side effect. However, it is important to note that NICE recommends lithium, olanzapine, and valproate as first line agents for treating bipolar disorder, with carbamazepine being a second line option.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 106 - Which SSRI medications have a higher likelihood of causing QTc interval prolongation? ...

    Incorrect

    • Which SSRI medications have a higher likelihood of causing QTc interval prolongation?

      Your Answer:

      Correct Answer: Citalopram

      Explanation:

      While the majority of SSRIs are believed to have minimal impact on the QTc interval, studies have demonstrated that citalopram and escitalopram can lead to QTc prolongation.

      Antidepressants and Their Cardiac Effects

      SSRIs are generally recommended for patients with cardiac disease as they may protect against myocardial infarction (MI). Untreated depression worsens prognosis in cardiovascular disease. Post MI, SSRIs and mirtazapine have either a neutral of beneficial effect on mortality. Sertraline is recommended post MI, but other SSRIs and mirtazapine are also likely to be safe. However, citalopram is associated with Torsades de pointes (mainly in overdose). Bupropion, citalopram, escitalopram, moclobemide, lofepramine, and venlafaxine should be used with caution of avoided in those at risk of serious arrhythmia (those with heart failure, left ventricular hypertrophy, previous arrhythmia, of MI).

      Tricyclic antidepressants (TCAs) have established arrhythmogenic activity which arises as a result of potent blockade of cardiac sodium channels and variable activity at potassium channels. ECG changes produced include PR, QRS, and QT prolongation and the Brugada syndrome. Lofepramine is less cardiotoxic than other TCAs and seems to lack the overdose arrhythmogenicity of other TCAs. QT changes are not usually seen at normal clinical doses of antidepressants (but can occur, particularly with citalopram/escitalopram). The arrhythmogenic potential of TCAs and other antidepressants is dose-related.

      Overall, SSRIs are recommended for patients with cardiac disease, while caution should be exercised when prescribing TCAs and other antidepressants, especially in those at risk of serious arrhythmia. It is important to monitor patients closely for any cardiac effects when prescribing antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 107 - What is the most frequent side effect of methylphenidate in children? ...

    Incorrect

    • What is the most frequent side effect of methylphenidate in children?

      Your Answer:

      Correct Answer: Decreased appetite

      Explanation:

      Methylphenidate commonly causes a decrease in appetite, while the other listed side-effects are considered rare of uncommon.

      ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 108 - Zopiclone is thought to exert its effects by targeting which type of receptor?...

    Incorrect

    • Zopiclone is thought to exert its effects by targeting which type of receptor?

      Your Answer:

      Correct Answer: GABA

      Explanation:

      Benzodiazepines and Z-drugs (such as zopiclone and zolpidem) have a common mechanism of action on the GABA receptor. It is noteworthy that alcohol also affects this receptor, which explains the similar effects observed in alcohol and benzodiazepine use. Additionally, benzodiazepines play a role in managing alcohol withdrawal symptoms.

      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 109 - Which SSRI can be administered intravenously to treat depression? ...

    Incorrect

    • Which SSRI can be administered intravenously to treat depression?

      Your Answer:

      Correct Answer: Citalopram

      Explanation:

      Alternative Routes of Administration for Antidepressants

      While most antidepressants are taken orally, there are a few alternative routes of administration available. However, it is important to note that these non-oral preparations should only be used when absolutely necessary, as they may not have a UK licence.

      One effective alternative route is sublingual administration of fluoxetine liquid. Buccal administration of selegiline is also available. Crushed amitriptyline has been shown to be effective when administered via this route.

      Intravenous administration is another option, with several antidepressants available in IV preparations, including citalopram, escitalopram, mirtazapine, amitriptyline, clomipramine, and allopregnanolone (which is licensed in the US for postpartum depression). Ketamine has also been shown to be effective when administered intravenously.

      Intramuscular administration of flupentixol has been shown to have a mood elevating effect, but amitriptyline was discontinued as an IM preparation due to the high volumes required.

      Transdermal administration of selegiline is available, and suppositories containing amitriptyline, clomipramine, imipramine, and trazodone have been manufactured by pharmacies, although there is no clear data on their effectiveness. Sertraline tablets and doxepin capsules have also been given rectally.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 110 - What substance is considered a monoamine oxidase-A (MAOI) inhibitor? ...

    Incorrect

    • What substance is considered a monoamine oxidase-A (MAOI) inhibitor?

      Your Answer:

      Correct Answer: Phenelzine

      Explanation:

      Phenelzine is the most commonly prescribed MAOI in the UK and is considered the safest among the MAOIs. Tranylcypromine and isocarboxazid are the other MAOIs that are licensed for use. Perphenazine and pericyazine are typical antipsychotics, while promazine is less effective when taken orally and is related to chlorpromazine. Promethazine, also known as Phenergan, is a sedating antihistamine.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 111 - What substance do bodybuilders misuse in order to increase their overall body mass?...

    Incorrect

    • What substance do bodybuilders misuse in order to increase their overall body mass?

      Your Answer:

      Correct Answer: Insulin

      Explanation:

      Anabolic Steroids: Uses, Misuse, and Complications

      Anabolic steroids are synthetic derivatives of testosterone that have both anabolic and androgenic properties. They are commonly used by athletes to enhance performance and by individuals to improve physical appearance. However, their misuse is not uncommon, with nearly half of users of dedicated bodybuilding gyms admitting to taking anabolic agents. Misuse can lead to dependence, tolerance, and the development of psychiatric disorders such as aggression, psychosis, mania, and depression/anxiety.

      There are three common regimes practised by steroid misusers: ‘cycling’, ‘stacking’ and ‘pyramiding’. Anabolic steroids can be taken orally, injected intramuscularly, and applied topically in the form of creams and gels. Other drugs are also used by athletes, such as clenbuterol, ephedrine, thyroxine, insulin, tamoxifen, human chorionic Gonadotropin, diuretics, and growth hormone.

      Medical complications are common and can affect various systems, such as the musculoskeletal, cardiovascular, hepatic, reproductive (males and females), dermatological, and other systems. Complications include muscular hypertrophy, increased blood pressure, decreased high-density lipoprotein cholesterol and increased low-density lipoprotein cholesterol, cholestatic jaundice, benign and malignant liver tumours, testicular atrophy, sterility, gynaecomastia, breast tissue shrinkage, menstrual abnormalities, masculinisation, male-pattern baldness, acne, sleep apnoea, exacerbation of tic disorders, polycythaemia, altered immunity, and glucose intolerance.

      Anabolic steroids are a class C controlled drug and can only be obtained legally through a medical prescription. It is important to educate individuals about the risks and complications associated with their misuse and to promote safe and legal use.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 112 - You are requested to consult with Ms. Johnson, a patient who is experiencing...

    Incorrect

    • You are requested to consult with Ms. Johnson, a patient who is experiencing depression symptoms. She has been taking her prescribed sertraline (SSRI) for the past two months, but she wishes to discontinue her antidepressant due to sexual dysfunction. What alternative antidepressant would you suggest to Ms. Johnson that is less likely to cause sexual side effects?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      Sexual dysfunction is a common side effect of antidepressants, with varying rates depending on the medication. For example, amitriptyline (TCA) has a prevalence of 30%, while citalopram, sertraline (SSRI), and venlafaxine have rates of 60-70% and 70%, respectively. The mechanisms behind this side effect include sedation, hormonal changes, disturbance of cholinergic/adrenergic balance, peripheral alpha-adrenergic antagonism, inhibition of nitric oxide, and increased serotonin neurotransmission.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 113 - Which of the following is not a known adverse effect of valproate? ...

    Incorrect

    • Which of the following is not a known adverse effect of valproate?

      Your Answer:

      Correct Answer: Weight loss

      Explanation:

      Valproate can cause weight gain, which is particularly concerning when it is combined with other medications like clozapine.

      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.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 114 - What is the most common side-effect of methylphenidate? ...

    Incorrect

    • What is the most common side-effect of methylphenidate?

      Your Answer:

      Correct Answer: Insomnia

      Explanation:

      ADHD medications can be classified into stimulant and non-stimulant drugs. The therapeutic effects of these drugs are believed to be mediated through the action of noradrenaline in the prefrontal cortex. Common side effects of these drugs include decreased appetite, insomnia, nervousness, headache, and nausea. Stimulant drugs like dexamphetamine, methylphenidate, and lisdexamfetamine inhibit the reuptake of dopamine and noradrenaline. Non-stimulant drugs like atomoxetine, guanfacine, and clonidine work by increasing noradrenaline levels in the synaptic cleft through different mechanisms. The most common side effects of these drugs are decreased appetite, somnolence, headache, and abdominal pain.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 115 - 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 116 - Which statement regarding the volume of distribution is not true? ...

    Incorrect

    • Which statement regarding the volume of distribution is not true?

      Your Answer:

      Correct Answer: It is calculated by dividing the drug concentration in the plasma by the amount in the body

      Explanation:

      Which of the following is NOT true regarding the equation Vd = amount in body / plasma concentration?

      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 117 - What is the sole authorized therapy for tardive dyskinesia in the United Kingdom?...

    Incorrect

    • What is the sole authorized therapy for tardive dyskinesia in the United Kingdom?

      Your Answer:

      Correct Answer: Tetrabenazine

      Explanation:

      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 118 - Which medication is metabolized into nortriptyline as its active form? ...

    Incorrect

    • Which medication is metabolized into nortriptyline as its active form?

      Your Answer:

      Correct Answer: Amitriptyline

      Explanation:

      Antidepressants with Active Metabolites

      Many antidepressants have active metabolites that can affect the body’s response to the medication. For example, amitriptyline has nortriptyline as an active metabolite, while clomipramine has desmethyl-clomipramine. Other antidepressants with active metabolites include dosulepin, doxepin, imipramine, lofepramine, fluoxetine, mirtazapine, trazodone, and venlafaxine.

      These active metabolites can have different effects on the body compared to the original medication. For example, nortriptyline is a more potent inhibitor of serotonin and norepinephrine reuptake than amitriptyline. Similarly, desipramine, the active metabolite of imipramine and lofepramine, has a longer half-life and is less sedating than the original medication.

      It is important for healthcare providers to be aware of the active metabolites of antidepressants when prescribing medication and monitoring patients for side effects and efficacy.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 119 - Which of the following is not preferentially metabolized by MAO-A? ...

    Incorrect

    • Which of the following is not preferentially metabolized by MAO-A?

      Your Answer:

      Correct Answer: Phenethylamine

      Explanation:

      Phenethylamine is NOT a metabolite of MAO-A, but rather of MAO-B.

      Monoamine Oxidase (MAO)

      Monoamine oxidase (MAO) is an enzyme that plays a crucial role in the metabolism of various neurotransmitters and hormones in the body. There are two forms of MAO, namely MAO-A and MAO-B. MAO-A is responsible for metabolising dopamine, serotonin, noradrenaline, adrenaline, and melatonin, while MAO-B metabolises dopamine and phenylethylamine. These neurotransmitters and hormones are essential for regulating mood, emotions, and behaviour. Any imbalance in their levels can lead to various mental health disorders such as depression, anxiety, and bipolar disorder. Therefore, MAO inhibitors are commonly used as antidepressants and anxiolytics to regulate the levels of these neurotransmitters and hormones in the body.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 120 - Which of the following antipsychotics is currently offered in the United Kingdom as...

    Incorrect

    • Which of the following antipsychotics is currently offered in the United Kingdom as a prolonged-release injection?

      Your Answer:

      Correct Answer: Olanzapine

      Explanation:

      Olanzapine pamoate is the only antipsychotic with a long acting injectable (LAI) form. A three hour observation period is necessary after administration due to the potential for post-injection syndrome. The remaining antipsychotics do not have an LAI form available.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 121 - Your consultant inquires about the time it takes for aripiprazole to reach a...

    Incorrect

    • Your consultant inquires about the time it takes for aripiprazole to reach a steady state when prescribing it to a new patient. With knowledge of the drug's half-life of 75 hours, what is the expected duration for achieving a steady state?

      Your Answer:

      Correct Answer: 14 days

      Explanation:

      The steady state for this scenario is 337.5 hours, which is equivalent to 14 days. This calculation was obtained by multiplying the half-life of 75 hours by a factor of 4.5, as per the given formula.

      The half-life of a drug is the time taken for its concentration to fall to one half of its value. Drugs with long half-lives may require a loading dose to achieve therapeutic plasma concentrations rapidly. It takes about 4.5 half-lives to reach steady state plasma levels. Most drugs follow first order kinetics, where a constant fraction of the drug in the body is eliminated per unit time. However, some drugs may follow zero order kinetics, where the plasma concentration of the drug decreases at a constant rate, despite the concentration of the drug. For drugs with nonlinear kinetics of dose-dependent kinetics, the relationship between the AUC of CSS and dose is not linear, and the kinetic parameters may vary depending on the administered dose.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 122 - Regarding clozapine, which class of receptors does not experience any impact? ...

    Incorrect

    • Regarding clozapine, which class of receptors does not experience any impact?

      Your Answer:

      Correct Answer: Glutamatergic

      Explanation:

      Clozapine is an atypical antipsychotic drug that acts as an antagonist at various receptors, including dopamine, histamine, serotonin, adrenergic, and cholinergic receptors. It is mainly metabolized by CYP1A2, and its plasma levels can be affected by inducers and inhibitors of this enzyme. Clozapine is associated with several side effects, including drowsiness, constipation, weight gain, and hypersalivation. Hypersalivation is a paradoxical side effect, and its mechanism is not fully understood, but it may involve clozapine agonist activity at the muscarinic M4 receptor and antagonist activity at the alpha-2 adrenoceptor. Clozapine is also associated with several potentially dangerous adverse events, including agranulocytosis, myocarditis, seizures, severe orthostatic hypotension, increased mortality in elderly patients with dementia-related psychosis, colitis, pancreatitis, thrombocytopenia, thromboembolism, and insulin resistance and diabetes mellitus. The BNF advises caution in using clozapine in patients with prostatic hypertrophy, susceptibility to angle-closure glaucoma, and adults over 60 years. Valproate should be considered when using high doses of clozapine, plasma levels > 0.5 mg/l, of when the patient experiences seizures. Myocarditis is a rare but potentially fatal adverse event associated with clozapine use, and its diagnosis is based on biomarkers and clinical features. The mortality rate of clozapine-induced myocarditis is high, and subsequent use of clozapine in such cases leads to recurrence of myocarditis in most cases.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 123 - What is the opioid system modulator that is prescribed to decrease alcohol consumption?...

    Incorrect

    • What is the opioid system modulator that is prescribed to decrease alcohol consumption?

      Your Answer:

      Correct Answer: Nalmefene

      Explanation:

      Nalmefene is a medication that affects the opioid system by partially activating the κ receptor and blocking the μ and σ receptors. It is believed to reduce the pleasurable effects of alcohol by targeting the mesolimbic system and opioid receptors, helping individuals decrease their alcohol consumption.

      Acamprosate works by targeting NMDA and GABA receptors, which can reduce the urge to drink alcohol.

      Disulfiram inhibits the enzyme acetaldehyde dehydrogenase, which is involved in breaking down alcohol. If someone drinks alcohol while taking disulfiram, they may experience a severe and potentially deadly reaction due to the buildup of acetaldehyde. Disulfiram is typically used by individuals who have stopped drinking and want to maintain their sobriety.

      Naltrexone is a medication that blocks opioid receptors and can be used to treat both opioid and alcohol addiction.

      Naloxone is a short-acting medication that blocks opioid receptors and is used in emergency situations to treat opioid overdose.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 124 - Which medication has been associated with the occurrence of extrapyramidal side effects? ...

    Incorrect

    • Which medication has been associated with the occurrence of extrapyramidal side effects?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      EPSEs have been linked to the use of fluoxetine, and all of the treatment options are utilized to address them.

      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 125 - Which statement about EPSEs is incorrect? ...

    Incorrect

    • Which statement about EPSEs is incorrect?

      Your Answer:

      Correct Answer: Anticholinergics are indicated in the treatment of tardive dyskinesia

      Explanation:

      Patients who develop TD who are prescribed an anticholinergic drug should not have this discontinued if possible.

      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 126 - Which of the options has the lowest degree of first pass effect association?...

    Incorrect

    • Which of the options has the lowest degree of first pass effect association?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      The First Pass Effect in Psychiatric Drugs

      The first-pass effect is a process in drug metabolism that significantly reduces the concentration of a drug before it reaches the systemic circulation. This phenomenon is related to the liver and gut wall, which absorb and metabolize the drug before it can enter the bloodstream. Psychiatric drugs are not exempt from this effect, and some undergo a significant reduction in concentration before reaching their target site. Examples of psychiatric drugs that undergo a significant first-pass effect include imipramine, fluphenazine, morphine, diazepam, and buprenorphine. On the other hand, some drugs undergo little to no first-pass effect, such as lithium and pregabalin.

      Orally administered drugs are the most affected by the first-pass effect. However, there are other routes of administration that can avoid of partly avoid this effect. These include sublingual, rectal (partly avoids first pass), intravenous, intramuscular, transdermal, and inhalation. Understanding the first-pass effect is crucial in drug development and administration, especially in psychiatric drugs, where the concentration of the drug can significantly affect its efficacy and safety.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 127 - What is a true statement about flumazenil? ...

    Incorrect

    • What is a true statement about flumazenil?

      Your Answer:

      Correct Answer: It blocks the effect of zopiclone

      Explanation:

      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.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 128 - You are asked to review a woman on a hospital ward with hemochromatosis...

    Incorrect

    • You are asked to review a woman on a hospital ward with hemochromatosis who has been observed to be low in mood. On review of her blood results you note significant hepatic impairment. Your history and examination confirms that she is depressed. Which of the following medications would be indicated to manage her depression?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      Individuals with hepatic impairment should avoid taking agomelatine and duloxetine due to contraindications. It is recommended to avoid sedative TCAs, such as trimipramine, imipramine, dothiepin, and amitriptyline.

      Hepatic Impairment: Recommended Drugs

      Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

      Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

      Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

      Mood stabilizers: Lithium

      Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 129 - What substance can be safely consumed along with monoamine oxidase inhibitors (MAOIs)? ...

    Incorrect

    • What substance can be safely consumed along with monoamine oxidase inhibitors (MAOIs)?

      Your Answer:

      Correct Answer: Paracetamol

      Explanation:

      Taking paracetamol with MAOIs is safe, but other medications and certain foods and drinks should be avoided to prevent the cheese reaction. The list of high-tyramine foods is provided in the drug’s leaflet. MAOIs are not commonly prescribed in primary care.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 130 - Which of the following is a side effect that is not associated with...

    Incorrect

    • Which of the following is a side effect that is not associated with tricyclic antidepressants?

      Your Answer:

      Correct Answer:

      Explanation:

      Tricyclic antidepressants are known to cause various side effects, which can be attributed to their mechanisms of action. These include antimuscarinic effects, which can lead to dry mouth and urinary retention, antihistaminergic effects, which can cause weight gain and drowsiness, antiadrenergic effects, which can result in postural hypotension, sexual dysfunction, and cognitive impairment, and antiserotonergic effects, which can lead to weight gain. Additionally, tricyclic antidepressants can cause cardiotoxicity and reduce the seizure threshold due to their membrane stabilizing effects. Other important side effects of these drugs include arrhythmias and ECG changes, black tongue, tremor, altered liver function tests, paralytic ileus, and neuroleptic malignant syndrome. Black hairy tongue, a harmless condition where the tongue appears black and hairy due to elongated filiform papillae, is also a possible side effect of tricyclic antidepressants.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 131 - Which tricyclic antidepressant has been demonstrated to have higher toxicity compared to others?...

    Incorrect

    • Which tricyclic antidepressant has been demonstrated to have higher toxicity compared to others?

      Your Answer:

      Correct Answer: Dothiepin

      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.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 132 - In which group is the prevalence of dystonias caused by antipsychotic treatment the...

    Incorrect

    • In which group is the prevalence of dystonias caused by antipsychotic treatment the highest?

      Your Answer:

      Correct Answer: Young men

      Explanation:

      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 133 - What is a true statement about olanzapine pamoate / embonate? ...

    Incorrect

    • What is a true statement about olanzapine pamoate / embonate?

      Your Answer:

      Correct Answer: It is licenced only for gluteal administration

      Explanation:

      Although only gluteal injection is approved for olanzapine, deltoid injection is not as effective. Smoking and carbamazepine can induce the metabolism of olanzapine, resulting in lower concentrations. However, the increase in olanzapine clearance is only slight to moderate, and the clinical implications are likely limited. Clinical monitoring is recommended, and an increase in olanzapine dosage may be necessary. While test doses are not required for olanzapine embonate, the Summary of Product Characteristics (SPC) recommends treating patients with oral olanzapine before administering ZYPADHERA to establish tolerability and response.

      , coma, respiratory depression (rare)

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 134 - In an elderly patient with decreased kidney function, which substance is most likely...

    Incorrect

    • In an elderly patient with decreased kidney function, which substance is most likely to build up in their body?

      Your Answer:

      Correct Answer: Amisulpride

      Explanation:

      Patients with renal impairment should avoid taking amisulpride and sulpiride. This is because amisulpride is eliminated through the kidneys, and in cases of renal insufficiency, the dosage should be reduced, and intermittent treatment should be considered.

      Prescribing medication for elderly individuals requires consideration of their unique pharmacokinetics and pharmacodynamics. As the body ages, changes in distribution, metabolism, and excretion can affect how medication is absorbed and processed. For example, reduced gastric acid secretion and motility can impact drug absorption, while a relative reduction of body water to body fat can alter the distribution of lipid soluble drugs. Additionally, hepatic metabolism of drugs decreases with age, and the kidneys become less effective, leading to potential accumulation of certain drugs.

      In terms of pharmacodynamics, receptor sensitivity tends to increase during old age, meaning smaller doses may be needed. However, older individuals may also take longer to respond to treatment and have an increased incidence of side-effects. It is important to start with a lower dose and monitor closely when prescribing medication for elderly patients, especially considering the potential for interactions with other medications they may be taking.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 135 - For what purpose is Modafinil licensed? ...

    Incorrect

    • For what purpose is Modafinil licensed?

      Your Answer:

      Correct Answer: Obstructive sleep apnoea

      Explanation:

      Modafinil: A Psychostimulant for Wakefulness and Attention Enhancement

      Modafinil is a type of psychostimulant that is known to improve wakefulness, attention, and vigilance. Although it is similar to amphetamines, it does not produce the same euphoric effects and is not associated with dependence of tolerance. Additionally, it does not seem to cause psychosis. Modafinil is approved for the treatment of narcolepsy, obstructive sleep apnea, and chronic shift work. It is also suggested as an adjunctive treatment for depression by the Maudsley. Recently, it has gained popularity as a smart drug due to its potential to enhance cognitive functioning in healthy individuals.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 136 - Which medication is known to cause nephrogenic diabetes insipidus as a significant adverse...

    Incorrect

    • Which medication is known to cause nephrogenic diabetes insipidus as a significant adverse reaction?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      The exact reason for the development of polyuria and polydipsia (nephrogenic diabetes insipidus) as a side effect of lithium treatment is not fully understood, but it is believed to be linked to the impact of lithium on ion transportation.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 137 - What specific warnings should be given to patients who are prescribed tranylcypromine? ...

    Incorrect

    • What specific warnings should be given to patients who are prescribed tranylcypromine?

      Your Answer:

      Correct Answer: Hypertensive crisis

      Explanation:

      It is important to provide education to patients who are prescribed MAOIs regarding the dietary restrictions that must be followed in order to avoid a hypertensive crisis.

      MAOIs: A Guide to Mechanism of Action, Adverse Effects, and Dietary Restrictions

      First introduced in the 1950s, MAOIs were the first antidepressants introduced. However, they are not the first choice in treating mental health disorders due to several dietary restrictions and safety concerns. They are only a treatment option when all other medications are unsuccessful. MAOIs may be particularly useful in atypical depression (over eating / over sleeping, mood reactivity).

      MAOIs block the monoamine oxidase enzyme, which breaks down different types of neurotransmitters from the brain: norepinephrine, serotonin, dopamine, as well as tyramine. There are two types of monoamine oxidase, A and B. The MOA A are mostly distributed in the placenta, gut, and liver, but MOA B is present in the brain, liver, and platelets. Selegiline and rasagiline are irreversible and selective inhibitors of MAO type B, but safinamide is a reversible and selective MAO B inhibitor.

      The most common adverse effects of MAOIs occurring early in treatment are orthostatic hypotension, daytime sleepiness, insomnia, and nausea; later common effects include weight gain, muscle pain, myoclonus, paraesthesia, and sexual dysfunction.

      Pharmacodynamic interactions with MAOIs can cause two types of problem: serotonin syndrome (mainly due to SSRIs) and elevated blood pressure (caused by indirectly acting sympathomimetic amines releasers, like pseudoephedrine and phenylephrine). The combination of MAOIs and some TCAs appears safe. Only those TCAs with significant serotonin reuptake inhibition (clomipramine and imipramine) are likely to increase the risk of serotonin syndrome.

      Tyramine is a monoamine found in various foods, and is an indirect sympathomimetic that can cause a hypertensive reaction in patients receiving MAOI therapy. For this reason, dietary restrictions are required for patients receiving MAOIs. These restrictions include avoiding matured/aged cheese, fermented sausage, improperly stored meat, fava of broad bean pods, and certain drinks such as on-tap beer. Allowed foods include fresh cottage cheese, processed cheese slices, fresh packaged of processed meat, and other alcohol (no more than two bottled or canned beers of two standard glasses of wine, per day).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 138 - What is a true statement about clozapine? ...

    Incorrect

    • What is a true statement about clozapine?

      Your Answer:

      Correct Answer: It affects adrenergic receptors

      Explanation:

      Clozapine is an atypical antipsychotic drug that acts as an antagonist at various receptors, including dopamine, histamine, serotonin, adrenergic, and cholinergic receptors. It is mainly metabolized by CYP1A2, and its plasma levels can be affected by inducers and inhibitors of this enzyme. Clozapine is associated with several side effects, including drowsiness, constipation, weight gain, and hypersalivation. Hypersalivation is a paradoxical side effect, and its mechanism is not fully understood, but it may involve clozapine agonist activity at the muscarinic M4 receptor and antagonist activity at the alpha-2 adrenoceptor. Clozapine is also associated with several potentially dangerous adverse events, including agranulocytosis, myocarditis, seizures, severe orthostatic hypotension, increased mortality in elderly patients with dementia-related psychosis, colitis, pancreatitis, thrombocytopenia, thromboembolism, and insulin resistance and diabetes mellitus. The BNF advises caution in using clozapine in patients with prostatic hypertrophy, susceptibility to angle-closure glaucoma, and adults over 60 years. Valproate should be considered when using high doses of clozapine, plasma levels > 0.5 mg/l, of when the patient experiences seizures. Myocarditis is a rare but potentially fatal adverse event associated with clozapine use, and its diagnosis is based on biomarkers and clinical features. The mortality rate of clozapine-induced myocarditis is high, and subsequent use of clozapine in such cases leads to recurrence of myocarditis in most cases.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 139 - Which of the following is most strongly linked to delirium? ...

    Incorrect

    • Which of the following is most strongly linked to delirium?

      Your Answer:

      Correct Answer: Pethidine

      Explanation:

      Prescribing in the Elderly: Iatrogenic Consequences

      Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

      Medications Linked to Delirium and Other Cognitive Disorders

      Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

      According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

      Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

      Medications Linked to Mood Changes

      The following medications are well known to precipitate mood changes:

      – Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
      – Interferon-a is capable of inducing depressive symptoms.
      – Digoxin is capable of inducing depressive symptoms.
      – Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
      – Antidepressants can precipitate mania.

      Medications Linked to Psychosis

      The following medications are well known to precipitate psychosis:

      – Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
      – Corticosteroids

      Medications Linked to Anxiety

      The following medications are well known to precipitate anxiety:

      – Stimulants
      – β adrenergic inhalers

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 140 - Which drug is most likely to increase the likelihood of serious cardiac events?...

    Incorrect

    • Which drug is most likely to increase the likelihood of serious cardiac events?

      Your Answer:

      Correct Answer: Thioridazine

      Explanation:

      Which two medications have been associated with sudden death and subsequently removed from the UK market due to their effect on the QTc interval?

      Amantadine and QTc Prolongation

      Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 141 - What is a known outcome of using lithium for an extended period of...

    Incorrect

    • What is a known outcome of using lithium for an extended period of time?

      Your Answer:

      Correct Answer: Hypothyroidism

      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 142 - A 35-year-old woman has just started taking antipsychotic medication for the first time...

    Incorrect

    • 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:

      Correct 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
      0
      Seconds
  • Question 143 - Which of these medications experience substantial liver metabolism? ...

    Incorrect

    • Which of these medications experience substantial liver metabolism?

      Your Answer:

      Correct Answer: Trazodone

      Explanation:

      The majority of psychotropics undergo significant hepatic metabolism, with the exclusion of amisulpride, sulpiride, gabapentin, and lithium, which experience little to no hepatic metabolism.

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 144 - What was the amount of drug X ingested by a patient who has...

    Incorrect

    • What was the amount of drug X ingested by a patient who has overdosed, given that the drug has a volume of distribution of 4L and their blood concentration of X is 10 mg/L, assuming 100% bioavailability via the route of administration?

      Your Answer:

      Correct Answer: 40mg

      Explanation:

      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 145 - What is a suitable alternative for a patient who has lithium-induced diabetes insipidus...

    Incorrect

    • What is a suitable alternative for a patient who has lithium-induced diabetes insipidus and cannot be switched to a different medication?

      Your Answer:

      Correct Answer: Amiloride

      Explanation:

      It is not advisable to limit fluid intake in cases of lithium-induced DI as it can result in severe hypernatremia.

      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
      0
      Seconds
  • Question 146 - What option has the least likelihood of causing extrapyramidal side effects? ...

    Incorrect

    • What option has the least likelihood of causing extrapyramidal side effects?

      Your Answer:

      Correct Answer: Clozapine

      Explanation:

      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 147 - Acamprosate is believed to produce its positive effects in the treatment of alcohol...

    Incorrect

    • Acamprosate is believed to produce its positive effects in the treatment of alcohol dependence by targeting which type of receptors?

      Your Answer:

      Correct Answer: Metabotropic glutamate receptors

      Explanation:

      The exact way in which acamprosate helps maintain alcohol abstinence is not fully understood. However, it is believed that chronic alcohol exposure disrupts the balance between neuronal excitation and inhibition. Studies conducted on animals suggest that acamprosate may interact with the glutamate and GABA neurotransmitter systems in the brain, which may help restore this balance. Acamprosate is thought to inhibit glutamate receptors while activating GABA receptors, specifically GABA-A and metabotropic glutamate receptors. It should be noted that some sources suggest that acamprosate affects NMDA receptors, which are a type of ionotropic glutamate receptor. However, this is not entirely accurate and may not be reflected in exam questions.

      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 148 - What is the maximum duration of a normal QTc interval in a female...

    Incorrect

    • What is the maximum duration of a normal QTc interval in a female adult?

      Your Answer:

      Correct Answer: 470

      Explanation:

      Amantadine and QTc Prolongation

      Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 149 - A 45-year-old female with long-standing epilepsy experiences severe hyponatremia. What medication is the...

    Incorrect

    • A 45-year-old female with long-standing epilepsy experiences severe hyponatremia. What medication is the probable cause of this condition?

      Your Answer:

      Correct Answer: Carbamazepine

      Explanation:

      Carbamazepine is an anticonvulsant drug that is used to treat seizures and nerve pain. However, it can also cause some major systemic side effects. These include nausea, vomiting, and diarrhea, which can be quite severe in some cases. Another potential side effect is hyponatremia, which is a condition where the blood sodium levels become too low. This can cause symptoms such as confusion, seizures, and even coma in severe cases.

      Carbamazepine can also cause skin reactions such as rash and pruritus (itching). These can range from mild to severe and may require medical attention. Finally, fluid retention is another potential side effect of carbamazepine. This can cause swelling in the legs, ankles, and feet, and may also lead to weight gain.

      It is important to note that not everyone who takes carbamazepine will experience these side effects. However, if you do experience any of these symptoms, it is important to speak with your doctor right away. They may be able to adjust your dosage of switch you to a different medication to help alleviate these side effects.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 150 - What was the first SSRI to be introduced to the European market? ...

    Incorrect

    • What was the first SSRI to be introduced to the European market?

      Your Answer:

      Correct Answer: Zimeldine

      Explanation:

      Although fluoxetine was the first SSRI to be approved and marketed in the United States, it took over seven years of clinical trials (Phase I-Phase III) to do so. Meanwhile, Astra AB introduced zimeldine (Zelmid®), the first SSRI, to the European market in March 1982. However, zimeldine, which was derived from pheniramine, was taken off the European market in September 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome, an acute peripheral neuropathy. The hypersensitivity reactions were similar to a flu-like syndrome and included fever, joint/muscle pain, headaches, and hepatic effects.

      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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      Seconds
  • Question 151 - What is the lowest daily dose of moclobemide that is effective for treating...

    Incorrect

    • What is the lowest daily dose of moclobemide that is effective for treating depression in adults?

      Your Answer:

      Correct Answer: 300 mg

      Explanation:

      Antidepressants: Minimum Effective Doses

      According to the Maudsley 13th, the following are the minimum effective doses for various antidepressants:

      – Citalopram: 20 mg/day
      – Fluoxetine: 20 mg/day
      – Fluvoxamine: 50 mg/day
      – Paroxetine: 20 mg/day
      – Sertraline: 50 mg/day
      – Mirtazapine: 30 mg/day
      – Venlafaxine: 75 mg/day
      – Duloxetine: 60 mg/day
      – Agomelatine: 25 mg/day
      – Moclobemide: 300 mg/day
      – Trazodone: 150 mg/day

      Note that these are minimum effective doses and may vary depending on individual factors and response to treatment. It is important to consult with a healthcare professional before starting of changing any medication regimen.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 152 - Which drug does not belong to the category of NMDA antagonists? ...

    Incorrect

    • Which drug does not belong to the category of NMDA antagonists?

      Your Answer:

      Correct Answer: Rivastigmine

      Explanation:

      Rivastigmine inhibits cholinesterase in a reversible manner.

      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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      Seconds
  • Question 153 - Which type of depot injection is the most probable cause of the 23-year-old...

    Incorrect

    • Which type of depot injection is the most probable cause of the 23-year-old male's sedation, dysarthria, and ataxia that occurred 30 minutes after administration?

      Your Answer:

      Correct Answer: Olanzapine embonate

      Explanation:

      The presentation is indicative of post-injection syndrome related to olanzapine embonate.

      , coma, respiratory depression (rare)

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 154 - Which of the following is an uncommon feature of discontinuing SSRI medication? ...

    Incorrect

    • Which of the following is an uncommon feature of discontinuing SSRI medication?

      Your Answer:

      Correct Answer: Palpitations

      Explanation:

      The symptoms experienced during discontinuation can be similar to those of anxiety and depression, leading to the possibility of misinterpreting them as a relapse.

      Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 155 - For which medical conditions is Modafinil prescribed? ...

    Incorrect

    • For which medical conditions is Modafinil prescribed?

      Your Answer:

      Correct Answer: Narcolepsy

      Explanation:

      Modafinil: A Psychostimulant for Wakefulness and Attention Enhancement

      Modafinil is a type of psychostimulant that is known to improve wakefulness, attention, and vigilance. Although it is similar to amphetamines, it does not produce the same euphoric effects and is not associated with dependence of tolerance. Additionally, it does not seem to cause psychosis. Modafinil is approved for the treatment of narcolepsy, obstructive sleep apnea, and chronic shift work. It is also suggested as an adjunctive treatment for depression by the Maudsley. Recently, it has gained popularity as a smart drug due to its potential to enhance cognitive functioning in healthy individuals.

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 156 - A 32-year-old woman presents to the emergency department 2 days after receiving a...

    Incorrect

    • A 32-year-old woman presents to the emergency department 2 days after receiving a test dose of zuclopenthixol decanoate. She is experiencing confusion, sweating, fever, and significant muscle stiffness. What diagnostic tests would be useful in determining the cause of her symptoms?

      Your Answer:

      Correct Answer: Serum creatine kinase

      Explanation:

      The combination of the patient’s symptoms and medical history strongly suggests the presence of neuromuscular malignant syndrome. To confirm the diagnosis, a serum creatine kinase test would be the most beneficial investigation to conduct. Although creatine kinase is a highly sensitive marker for muscle tissue damage, it is not specific to this condition and may also be elevated in other conditions such as acute alcohol intoxication of acute psychosis.

      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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      Seconds
  • Question 157 - Which of the following is not a side-effect related to the extrapyramidal system?...

    Incorrect

    • Which of the following is not a side-effect related to the extrapyramidal system?

      Your Answer:

      Correct Answer: Myoclonus

      Explanation:

      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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      Seconds
  • Question 158 - A female client at your clinic has mentioned that she is using various...

    Incorrect

    • A female client at your clinic has mentioned that she is using various herbal and dietary supplements to manage her depression. Which of these supplements is most likely to interact with her SSRI antidepressant medication?

      Your Answer:

      Correct Answer: St John's wort

      Explanation:

      Omega 3 fatty acids, which are found in high amounts in oily fish, have been shown in some studies to improve depressive symptoms and can be safely combined with SSRIs. However, St John’s wort, which inhibits serotonin reuptake at nerve terminals, should not be taken with drugs that have a predominantly serotonergic action. Brewer’s yeast may cause a tyramine reaction with an MAOI, while evening primrose oil and ginkgo biloba have no interaction with SSRIs.

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 159 - What is an example of a biogenic amine? ...

    Incorrect

    • What is an example of a biogenic amine?

      Your Answer:

      Correct Answer: Histamine

      Explanation:

      Biogenic Amines: Understanding the Neurotransmitters

      Biogenic amines are a class of compounds that are derived from amino acids. These compounds play a crucial role in the functioning of the nervous system. Biogenic amine neurotransmitters include catecholamines (adrenaline, noradrenaline, and dopamine), serotonin, and histamine. A useful mnemonic to remember these neurotransmitters is HANDS (Histamine, Adrenaline, Noradrenaline, Dopamine, Serotonin).

      Catecholamines are involved in the body’s response to stress and are responsible for the fight or flight response. Adrenaline and noradrenaline are catecholamines that are released by the adrenal glands in response to stress. Dopamine is involved in the reward system of the brain and is associated with pleasure and motivation.

      Serotonin is a neurotransmitter that is involved in mood regulation, appetite, and sleep. It is also involved in the regulation of pain and the perception of pain.

      Histamine is involved in the immune response and is responsible for the symptoms of allergies. It is also involved in the regulation of sleep and wakefulness.

      Understanding the role of biogenic amines in the nervous system is crucial for the development of treatments for neurological and psychiatric disorders.

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 160 - During which decade was chlorpromazine first introduced into psychiatric clinical practice? ...

    Incorrect

    • During which decade was chlorpromazine first introduced into psychiatric clinical practice?

      Your Answer:

      Correct Answer: 1950s

      Explanation:

      Charpentier synthesised Chlorpromazine in 1950, and it was subsequently introduced into clinical practice in the 1950s.

      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
      0
      Seconds
  • Question 161 - What is a true statement about the QTc interval? ...

    Incorrect

    • What is a true statement about the QTc interval?

      Your Answer:

      Correct Answer: The Bazett formula over corrects the QTc at heart rates > 100 bpm

      Explanation:

      To obtain an accurate measurement of the QT interval, it is recommended to measure it in lead II of leads V5-6. The Bazett formula may not provide accurate corrections for heart rates above 100 bpm of below 60 bpm, but it can be used to estimate the QT interval at a standard heart rate of 60 bpm through the corrected QT interval (QTc).

      QTc Prolongation: Risks and Identification

      The QT interval is a measure of the time it takes for the ventricles to repolarize and is calculated from the beginning of the QRS complex to the end of the T wave. However, the QT interval varies with the heart rate, making it difficult to use a single number as a cut-off for a prolonged QT. Instead, a corrected QT interval (QTc) is calculated for each heart rate using various formulas. A QTc over the 99th percentile is considered abnormally prolonged, with approximate values of 470 ms for males and 480 ms for females.

      Prolonged QT intervals can lead to torsade de pointes (TdP), a polymorphic ventricular tachycardia that can be fatal if it degenerates into ventricular fibrillation. TdP is characterized by a twisting of the QRS complexes around an isoelectric line and is often asymptomatic but can also be associated with syncope and death. An accurate diagnosis requires an ECG to be recorded during the event. It is important to note that an increase in the QT interval due to a new conduction block should not be considered indicative of acquired LQTS and risk for TdP.

    • This question is part of the following fields:

      • Psychopharmacology
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      Seconds
  • Question 162 - Which TCA is commonly linked to discontinuation symptoms? ...

    Incorrect

    • Which TCA is commonly linked to discontinuation symptoms?

      Your Answer:

      Correct Answer: Imipramine

      Explanation:

      Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

    • This question is part of the following fields:

      • Psychopharmacology
      0
      Seconds
  • Question 163 - Who were the pioneers in publishing clinical reports that showcased the efficacy of...

    Incorrect

    • Who were the pioneers in publishing clinical reports that showcased the efficacy of chlorpromazine as a valuable medication for psychiatric treatment?

      Your Answer:

      Correct Answer: Delay and Deniker

      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
      0
      Seconds
  • Question 164 - The Maudsley Guidelines recommend certain approaches for managing akathisia. ...

    Incorrect

    • The Maudsley Guidelines recommend certain approaches for managing akathisia.

      Your Answer:

      Correct Answer: Propranolol

      Explanation:

      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).

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      • Psychopharmacology
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  • Question 165 - Which of the options below is not a symptom commonly associated with antidepressant...

    Incorrect

    • Which of the options below is not a symptom commonly associated with antidepressant withdrawal syndrome?

      Your Answer:

      Correct Answer: Agomelatine

      Explanation:

      Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 166 - A senior citizen with an extensive mental health history shares with you about...

    Incorrect

    • A senior citizen with an extensive mental health history shares with you about a medication they were previously prescribed. They are unable to recall the name of it, but recollect that it resulted in swollen ankles, constant thirst, and worsened psoriasis. What medication do you suspect they were administered?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      The symptoms reported by the patient are likely caused by the side-effects of lithium. Increased thirst is a common occurrence when starting lithium treatment. Patients with psoriasis may not be suitable candidates for lithium use. Although the mechanism behind pedal edema is not fully understood, it is a well-known side-effect of lithium treatment, as reported in a case study by Paravathypriya (2016) in the International Journal of Pharmacy and Pharmaceutical Sciences.

      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.

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      • Psychopharmacology
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  • Question 167 - What is the preferred medication for treating alcohol withdrawal in a patient who...

    Incorrect

    • What is the preferred medication for treating alcohol withdrawal in a patient who has significant liver damage?

      Your Answer:

      Correct Answer: Lorazepam

      Explanation:

      Sedatives and Liver Disease

      Sedatives are commonly used for their calming effects, but many of them are metabolized in the liver. Therefore, caution must be taken when administering sedatives to patients with liver disease. The Maudsley Guidelines recommend using low doses of the following sedatives in patients with hepatic impairment: lorazepam, oxazepam, temazepam, and zopiclone. It is important to note that zopiclone should also be used with caution and at low doses in this population. Proper management of sedative use in patients with liver disease can help prevent further damage to the liver and improve overall patient outcomes.

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      • Psychopharmacology
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  • Question 168 - A client is referred with depression and is eager to begin medication. You...

    Incorrect

    • A client is referred with depression and is eager to begin medication. You find out that they have hypertension. What would be the most suitable treatment option?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      Antidepressants and Diabetes

      Depression is a prevalent condition among patients with diabetes. It is crucial to select the appropriate antidepressant as some may have negative effects on weight and glucose levels. The first-line treatment for depression in diabetic patients is selective serotonin reuptake inhibitors (SSRIs), with fluoxetine having the most supporting data. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also likely to be safe, but there is less evidence to support their use. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided. These recommendations are based on the Maudsley Guidelines 10th Edition.

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      • Psychopharmacology
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  • Question 169 - What is the mechanism of action of bupropion? ...

    Incorrect

    • What is the mechanism of action of bupropion?

      Your Answer:

      Correct Answer: Nicotinic acetylcholine receptor antagonist

      Explanation:

      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.

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      • Psychopharmacology
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  • Question 170 - A woman in her 60s with type II diabetes and established renal impairment...

    Incorrect

    • A woman in her 60s with type II diabetes and established renal impairment presents with symptoms of depression. Her GP is concerned about the use of psychotropics due to her kidney disease and refers her for a psychiatric opinion. Her blood pressure is within normal limits, and her ECG shows a QTc of 450 ms but is otherwise normal.

      After assessing the patient, you determine that antidepressant medication is necessary. What would be the most appropriate medication to prescribe in this case?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      Renal Impairment and Psychotropic Drugs

      The following table provides recommendations for drug treatment in patients with renal impairment, based on the Maudsley 14th guidelines. When a new drug treatment is required, the suggestions below should be followed.

      Drug Group Recommendation

      Antipsychotics: It is recommended to avoid sulpiride and amisulpride. Otherwise, no agent is clearly preferable to another. For first-generation antipsychotics, haloperidol (2-6 mg/day) is the best choice. For second-generation antipsychotics, olanzapine (5mg/day) is the best choice.

      Antidepressants: No agent is clearly preferable to another. Reasonable choices include sertraline (although there is poor efficacy data in renal disease), citalopram (with care over QTc prolongation), and fluoxetine (with care over long half-life).

      Mood stabilizers: Lithium is nephrotoxic and contraindicated in severe renal impairment. Otherwise, no agent is clearly preferable to another. Valproate of lamotrigine are suggested.

      Anxiolytics: No agent is clearly preferable to another. Lorazepam and zopiclone are suggested.

      Anti-dementia drugs: No agent is clearly preferable to another. Rivastigmine is suggested.

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      • Psychopharmacology
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  • Question 171 - A male patient in his 40s has been tried on several oral antipsychotics...

    Incorrect

    • A male patient in his 40s has been tried on several oral antipsychotics but has been non-compliant. He remains psychotic and the team feel a depot antipsychotic is indicated. He has had a number of EPSE's whilst on oral medication. Which of the following options would be the most sensible choice bearing in mind his history of EPSEs?:

      Your Answer:

      Correct Answer: Aripiprazole depot

      Explanation:

      , coma, respiratory depression (rare)

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      • Psychopharmacology
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  • Question 172 - What antihistamine medication is prescribed to treat extrapyramidal side effects? ...

    Incorrect

    • What antihistamine medication is prescribed to treat extrapyramidal side effects?

      Your Answer:

      Correct Answer: Diphenhydramine

      Explanation:

      Diphenhydramine is a type of antihistamine that belongs to the first generation. It is commonly used to alleviate extrapyramidal side effects (EPSE). Unlike second generation antihistamines, first generation antihistamines have anticholinergic properties and can penetrate the blood-brain barrier, resulting in sedative effects. The anticholinergic effects of first generation antihistamines are beneficial for treating EPSE, which is believed to be caused by excessive acetylcholine due to reduced dopamine activity. Dopamine normally inhibits acetylcholine, but when dopamine activity is reduced, acetylcholine levels increase, leading to EPSE.

      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).

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      • Psychopharmacology
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  • Question 173 - What is the beverage with the highest caffeine content per serving size? ...

    Incorrect

    • What is the beverage with the highest caffeine content per serving size?

      Your Answer:

      Correct Answer: Brewed coffee

      Explanation:

      The caffeine content in brewed coffee is relatively high, with approximately 100 mg per cup. In comparison, tea has a lower caffeine content. Black tea has around 45 mg per cup, while green tea has approximately 25 mg per cup. Instant coffee contains about 60 mg per cup, and a can of Red Bull contains 80 mg of caffeine.

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      • Psychopharmacology
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  • Question 174 - Which of the following findings would provide the strongest evidence for a diagnosis...

    Incorrect

    • Which of the following findings would provide the strongest evidence for a diagnosis of lithium toxicity in a man who has just started taking lithium and is reporting feeling unwell during a clinic visit?

      Your Answer:

      Correct Answer: Ataxia

      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.

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      • Psychopharmacology
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  • Question 175 - What strategies can be implemented to decrease alcohol intake in individuals who continue...

    Incorrect

    • What strategies can be implemented to decrease alcohol intake in individuals who continue to consume alcohol?

      Your Answer:

      Correct Answer: Nalmefene

      Explanation:

      In the treatment of harmful alcohol use, Nalmefene is a novel medication that can help reduce the desire for alcohol. After successful withdrawal, NICE recommends the use of acamprosate, disulfiram, and naltrexone (which is approved for use in opioid dependence) to manage alcohol dependence. Bupropion is utilized to manage nicotine dependence.

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      • Psychopharmacology
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  • Question 176 - Which of the options experiences the lowest level of metabolism in the liver?...

    Incorrect

    • Which of the options experiences the lowest level of metabolism in the liver?

      Your Answer:

      Correct Answer: Gabapentin

      Explanation:

      Gabapentin, lithium, and topiramate require minimal of no hepatic metabolism, allowing them to be excreted without undergoing significant liver alteration.

      Drug Clearance: Understanding the Rate of Drug Removal from the Body

      Drug clearance refers to the efficiency of drug removal from the plasma, and is measured as the volume of plasma cleared of a drug over a specific time period. The unit of measurement for drug clearance is volume per time. Clearance of a drug involves both metabolism and excretion. When drug intake equals clearance, it is referred to as a steady state, which is usually achieved by 4.5 half-lives. The time taken to reach steady state depends on the half-life of the drug.

      There are two main types of clearance: hepatic and renal. Hepatic clearance involves the conversion of the parent drug into a different chemical entity by the liver enzymes, while renal clearance involves the removal of the drug from the plasma into the urine. The clearance of a drug can take one of two forms: zero and first-order kinetics. In zero-order reactions, the clearance of a drug is constant and not related to the concentration of the drug in the plasma. This type of reaction is typically found when the material needed for the reaction to proceed (e.g. enzyme) is saturated. Ethanol and Phenytoin are good examples of this.

      Most drugs tend to follow first-order reactions, where the clearance is related to the concentration of the drug in the plasma. The half-life of a drug is the time taken for its concentration to fall by half. In first-order reactions, this is constant. In zero-order reactions, it gets progressively shorter.

      It is important to note that elimination and clearance are not the same. Elimination is the irreversible removal of the drug from the body, while clearance is a theoretical volume of blood that is cleared of the drug per unit of time, which is independent of the drug dose of concentration. Understanding drug clearance is crucial in determining the appropriate dosing regimen for a drug.

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      • Psychopharmacology
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  • Question 177 - A client complains of feeling ill after abruptly discontinuing paroxetine. What symptom is...

    Incorrect

    • A client complains of feeling ill after abruptly discontinuing paroxetine. What symptom is most indicative of discontinuation syndrome associated with selective serotonin reuptake inhibitors?

      Your Answer:

      Correct Answer: Diarrhoea

      Explanation:

      Discontinuation syndrome of selective serotonin reuptake inhibitors may manifest with diverse symptoms such as abdominal pain, vomiting, and diarrhea.

      Antidepressants can cause discontinuation symptoms when patients stop taking them, regardless of the type of antidepressant. These symptoms usually occur within 5 days of stopping the medication and can last up to 3 weeks. Symptoms include flu-like symptoms, dizziness, insomnia, vivid dreams, irritability, crying spells, and sensory symptoms. SSRIs and related drugs with short half-lives, such as paroxetine and venlafaxine, are particularly associated with discontinuation symptoms. Tapering antidepressants at the end of treatment is recommended to prevent these symptoms. TCAs and MAOIs are also associated with discontinuation symptoms, with amitriptyline and imipramine being the most common TCAs and all MAOIs being associated with prominent discontinuation symptoms. Patients at highest risk for discontinuation symptoms include those on antidepressants with shorter half-lives, those who have been taking antidepressants for 8 weeks of longer, those using higher doses, younger people, and those who have experienced discontinuation symptoms before. Agomelatine is not associated with any discontinuation syndrome. If a discontinuation reaction occurs, restarting the antidepressant of switching to an alternative with a longer half-life and tapering more slowly may be necessary. Explanation and reassurance are often sufficient for mild symptoms. These guidelines are based on the Maudsley Guidelines 14th Edition and a study by Tint (2008).

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      • Psychopharmacology
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  • Question 178 - What is the current licensing of asenapine, a psychotropic medication that was introduced...

    Incorrect

    • What is the current licensing of asenapine, a psychotropic medication that was introduced in the UK in 2012?

      Your Answer:

      Correct Answer: Moderate to severe manic episodes related to bipolar affective disorder

      Explanation:

      Asenapine is an unconventional antipsychotic that binds to D2, 5HT2A, 5HT2C, and alpha 1 and 2 adrenergic receptors. Originally intended for individuals with schizophrenia and bipolar affective disorder, it is presently authorized in the UK solely for managing moderate to severe manic episodes.

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      • Psychopharmacology
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  • Question 179 - A patient in their 60s taking an antipsychotic is found to have a...

    Incorrect

    • A patient in their 60s taking an antipsychotic is found to have a QTc of 490ms. What would be the most appropriate alternative to their current antipsychotic medication?

      Your Answer:

      Correct Answer: Aripiprazole

      Explanation:

      Amantadine and QTc Prolongation

      Amantadine is a medication used to treat Parkinson’s disease and influenza. It has been associated with QTc prolongation, which can increase the risk of Torsades de points. Therefore, caution should be exercised when prescribing amantadine to patients with risk factors for QT prolongation. If a patient is already taking amantadine and develops a prolonged QTc interval, the medication should be discontinued and an alternative treatment considered. It is important to monitor the QTc interval in patients taking amantadine, especially those with risk factors for QT prolongation.

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      • Psychopharmacology
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  • Question 180 - In comparison to conventional antipsychotics, which side-effect is more frequently observed with atypical...

    Incorrect

    • In comparison to conventional antipsychotics, which side-effect is more frequently observed with atypical antipsychotics?

      Your Answer:

      Correct Answer: Weight gain

      Explanation:

      Antipsychotic drugs are known to cause weight gain, but some more than others. The reason for this is not due to a direct metabolic effect, but rather an increase in appetite and a decrease in activity levels. The risk of weight gain appears to be linked to clinical response. There are several suggested mechanisms for this, including antagonism of certain receptors and hormones that stimulate appetite. The risk of weight gain varies among different antipsychotics, with clozapine and olanzapine having the highest risk. Management strategies for antipsychotic-induced weight gain include calorie restriction, low glycemic index diet, exercise, and switching to an alternative antipsychotic. Aripiprazole, ziprasidone, and lurasidone are recommended as alternative options. Other options include aripiprazole augmentation, metformin, orlistat, liraglutide, and topiramate.

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      • Psychopharmacology
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  • Question 181 - What factor is associated with an increased likelihood of developing torsade de pointes?...

    Incorrect

    • What factor is associated with an increased likelihood of developing torsade de pointes?

      Your Answer:

      Correct Answer: Citalopram

      Explanation:

      In December 2011, the MHRA (Medicines and Healthcare products Regulatory Agency) issued guidance regarding citalopram and escitalopram. These medications have been found to cause QT interval prolongation, which can lead to torsade de pointes, ventricular fibrillation, and sudden death. Therefore, they should not be used in individuals with congenital long QT syndrome, pre-existing QT interval prolongation, of in combination with other medications that prolong the QT interval. Patients with cardiac disease should have ECG measurements taken, and any electrolyte imbalances should be corrected before starting treatment. Additionally, new restrictions on the maximum daily doses of citalopram have been put in place: 40 mg for adults, 20 mg for patients over 65 years old, and 20 mg for those with hepatic impairment.

      Antidepressants and Their Cardiac Effects

      SSRIs are generally recommended for patients with cardiac disease as they may protect against myocardial infarction (MI). Untreated depression worsens prognosis in cardiovascular disease. Post MI, SSRIs and mirtazapine have either a neutral of beneficial effect on mortality. Sertraline is recommended post MI, but other SSRIs and mirtazapine are also likely to be safe. However, citalopram is associated with Torsades de pointes (mainly in overdose). Bupropion, citalopram, escitalopram, moclobemide, lofepramine, and venlafaxine should be used with caution of avoided in those at risk of serious arrhythmia (those with heart failure, left ventricular hypertrophy, previous arrhythmia, of MI).

      Tricyclic antidepressants (TCAs) have established arrhythmogenic activity which arises as a result of potent blockade of cardiac sodium channels and variable activity at potassium channels. ECG changes produced include PR, QRS, and QT prolongation and the Brugada syndrome. Lofepramine is less cardiotoxic than other TCAs and seems to lack the overdose arrhythmogenicity of other TCAs. QT changes are not usually seen at normal clinical doses of antidepressants (but can occur, particularly with citalopram/escitalopram). The arrhythmogenic potential of TCAs and other antidepressants is dose-related.

      Overall, SSRIs are recommended for patients with cardiac disease, while caution should be exercised when prescribing TCAs and other antidepressants, especially in those at risk of serious arrhythmia. It is important to monitor patients closely for any cardiac effects when prescribing antidepressants.

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  • Question 182 - Which class of antidepressants share a molecular structure similar to carbamazepine? ...

    Incorrect

    • Which class of antidepressants share a molecular structure similar to carbamazepine?

      Your Answer:

      Correct Answer: Tricyclics

      Explanation:

      Carbamazepine mechanism of action involves decreasing the metabolism of dopamine and noradrenaline, which is similar to tricyclic antidepressants due to their comparable molecular structure.

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      • Psychopharmacology
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  • Question 183 - Out of the options provided, which one is the least probable cause of...

    Incorrect

    • Out of the options provided, which one is the least probable cause of delirium?

      Your Answer:

      Correct Answer: Lansoprazole

      Explanation:

      Prescribing in the Elderly: Iatrogenic Consequences

      Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

      Medications Linked to Delirium and Other Cognitive Disorders

      Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

      According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

      Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

      Medications Linked to Mood Changes

      The following medications are well known to precipitate mood changes:

      – Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
      – Interferon-a is capable of inducing depressive symptoms.
      – Digoxin is capable of inducing depressive symptoms.
      – Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
      – Antidepressants can precipitate mania.

      Medications Linked to Psychosis

      The following medications are well known to precipitate psychosis:

      – Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
      – Corticosteroids

      Medications Linked to Anxiety

      The following medications are well known to precipitate anxiety:

      – Stimulants
      – β adrenergic inhalers

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  • Question 184 - Which drug interacts with a G-coupled receptor to exert its effects? ...

    Incorrect

    • Which drug interacts with a G-coupled receptor to exert its effects?

      Your Answer:

      Correct Answer: Heroin

      Explanation:

      The mechanism of action of heroin involves attaching to opiate receptors, which are G-coupled. This attachment results in the suppression of cellular activity through stimulation.

      Mechanisms of action for illicit drugs can be classified based on their effects on ionotropic receptors of ion channels, G coupled receptors, of monoamine transporters. Cocaine and amphetamine both increase dopamine levels in the synaptic cleft, but through different mechanisms. Cocaine directly blocks the dopamine transporter, while amphetamine binds to the transporter and increases dopamine efflux through various mechanisms, including inhibition of vesicular monoamine transporter 2 and monoamine oxidase, and stimulation of the intracellular receptor TAAR1. These mechanisms result in increased dopamine levels in the synaptic cleft and reuptake inhibition.

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      • Psychopharmacology
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  • Question 185 - Which substances are metabolized by the enzyme CYP1A2? ...

    Incorrect

    • Which substances are metabolized by the enzyme CYP1A2?

      Your Answer:

      Correct Answer: Clozapine

      Explanation:

      The Cytochrome P450 system is a group of enzymes that metabolize drugs by altering their functional groups. The system is located in the liver and small intestine and is involved in drug interactions through enzyme induction of inhibition. Notable inducers include smoking, alcohol, and St John’s Wort, while notable inhibitors include grapefruit juice and some SSRIs. CYP2D6 is important due to genetic polymorphism, and CYP3A4 is the most abundant subfamily and is commonly involved in interactions. Grapefruit juice inhibits both CYP1A2 and CYP3A4, while tobacco smoking induces CYP1A2. The table summarizes the main substrates, inhibitors, and inducers for each CYP enzyme.

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      • Psychopharmacology
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  • Question 186 - When is it inappropriate to use cholinesterase inhibitors? ...

    Incorrect

    • When is it inappropriate to use cholinesterase inhibitors?

      Your Answer:

      Correct Answer: Frontotemporal dementia

      Explanation:

      The use of cholinesterase inhibitors may worsen behaviour in individuals with frontotemporal dementia. However, these inhibitors are approved for treating Alzheimer’s dementia and Parkinson’s disease dementia (rivastigmine). While NICE guidelines do not recommend their use for non-cognitive symptoms in dementia with Lewy bodies, they can be prescribed for mixed dementia with a primary Alzheimer’s pathology.

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      • Psychopharmacology
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  • Question 187 - Which statement about drug distribution in the elderly is incorrect? ...

    Incorrect

    • Which statement about drug distribution in the elderly is incorrect?

      Your Answer:

      Correct Answer: Water soluble drugs show increased volumes of distribution in the elderly

      Explanation:

      Prescribing medication for elderly individuals requires consideration of their unique pharmacokinetics and pharmacodynamics. As the body ages, changes in distribution, metabolism, and excretion can affect how medication is absorbed and processed. For example, reduced gastric acid secretion and motility can impact drug absorption, while a relative reduction of body water to body fat can alter the distribution of lipid soluble drugs. Additionally, hepatic metabolism of drugs decreases with age, and the kidneys become less effective, leading to potential accumulation of certain drugs.

      In terms of pharmacodynamics, receptor sensitivity tends to increase during old age, meaning smaller doses may be needed. However, older individuals may also take longer to respond to treatment and have an increased incidence of side-effects. It is important to start with a lower dose and monitor closely when prescribing medication for elderly patients, especially considering the potential for interactions with other medications they may be taking.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 188 - Which symptom is the strongest indicator of neuroleptic malignant syndrome? ...

    Incorrect

    • Which symptom is the strongest indicator of neuroleptic malignant syndrome?

      Your Answer:

      Correct Answer: Increased muscle tone

      Explanation:

      NMS can be identified by three primary symptoms: hyperthermia, rigidity, and elevated creatine phosphokinase concentration. If these symptoms are not present, the diagnosis of NMS should be reconsidered as other symptoms may be present in patients taking neuroleptics without having NMS. This information was reported by P Adnet in the British Journal of Anaesthesia in 2000.

      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 189 - Antipsychotic drugs are known to cause hypotension, and it is believed that this...

    Incorrect

    • Antipsychotic drugs are known to cause hypotension, and it is believed that this effect is mediated by a specific type of receptor. Which receptor is thought to be responsible for this?

      Your Answer:

      Correct Answer: Alpha 1

      Explanation:

      Postural hypotension is a known side effect of alpha-1-blockade.

      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 190 - What is the truth about medication absorption in elderly individuals? ...

    Incorrect

    • What is the truth about medication absorption in elderly individuals?

      Your Answer:

      Correct Answer: The first pass metabolism tends to be reduced

      Explanation:

      The circulation of blood to the organs of the abdominal gastrointestinal system, such as the stomach, liver, spleen, pancreas, small intestine, and large intestine, is referred to as the splanchnic circulation.

      Prescribing medication for elderly individuals requires consideration of their unique pharmacokinetics and pharmacodynamics. As the body ages, changes in distribution, metabolism, and excretion can affect how medication is absorbed and processed. For example, reduced gastric acid secretion and motility can impact drug absorption, while a relative reduction of body water to body fat can alter the distribution of lipid soluble drugs. Additionally, hepatic metabolism of drugs decreases with age, and the kidneys become less effective, leading to potential accumulation of certain drugs.

      In terms of pharmacodynamics, receptor sensitivity tends to increase during old age, meaning smaller doses may be needed. However, older individuals may also take longer to respond to treatment and have an increased incidence of side-effects. It is important to start with a lower dose and monitor closely when prescribing medication for elderly patients, especially considering the potential for interactions with other medications they may be taking.

    • This question is part of the following fields:

      • Psychopharmacology
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  • Question 191 - Which diuretic can be used safely in combination with lithium? ...

    Incorrect

    • Which diuretic can be used safely in combination with lithium?

      Your Answer:

      Correct Answer: Amiloride

      Explanation:

      Loop diuretics and potassium sparing diuretics have been found to have no significant impact on lithium levels, unlike other diuretics. While acetazolamide can decrease lithium levels by increasing excretion, loop diuretics may initially increase excretion followed by a rebound phase of enhanced reabsorption, resulting in no significant effect on lithium levels over a 24-hour period.

      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.

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      • Psychopharmacology
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  • Question 192 - What is a true statement about pregabalin? ...

    Incorrect

    • What is a true statement about pregabalin?

      Your Answer:

      Correct Answer: The euphoric effects of pregabalin disappear with prolonged use

      Explanation:

      Pregabalin: Pharmacokinetics and Mechanism of Action

      Pregabalin is a medication that acts on the alpha-2-delta subunit of voltage-gated calcium channels in the central nervous system. It is known for its anticonvulsant, analgesic, and anxiolytic properties. By decreasing presynaptic calcium currents, it reduces the release of excitatory neurotransmitters that contribute to anxiety. Despite being a GABA analogue, it does not affect GABA receptors of metabolism.

      Pregabalin has predictable and linear pharmacokinetics, making it easy to use in clinical practice. It is rapidly absorbed and proportional to dose, with a time to maximal plasma concentration of approximately 1 hour. Steady state is achieved within 24-48 hours, and efficacy can be observed as early as day two in clinical trials. It has a high bioavailability and a mean elimination half-life of 6.3 hours.

      Unlike many medications, pregabalin is not subject to hepatic metabolism and does not induce of inhibit liver enzymes such as the cytochrome P450 system. It is excreted unchanged by the kidneys and does not bind to plasma proteins. This means that it is unlikely to cause of be affected by pharmacokinetic drug-drug interactions.

      While there is some potential for abuse of pregabalin, the euphoric effects disappear with prolonged use. Overall, pregabalin is a safe and effective medication for the treatment of various conditions, including anxiety and neuropathic pain.

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      • Psychopharmacology
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  • Question 193 - You are evaluating a 56-year-old patient with depression that has not responded to...

    Incorrect

    • You are evaluating a 56-year-old patient with depression that has not responded to previous treatments. The patient inquires about the potential use of phenelzine. However, they have a pertinent medical history.
      What medical condition would prohibit the prescription of phenelzine in this patient?

      Your Answer:

      Correct Answer: Phaeochromocytoma

      Explanation:

      Phenelzine belongs to a class of antidepressants called Monoamine Oxidase Inhibitors (MAOIs). However, it is contraindicated in patients with phaeochromocytoma, a rare tumor that secretes catecholamines, as MAOIs inhibit the breakdown of catecholamines and can lead to hypertensive crises, brain hemorrhage, and even death in such patients.

      While antidepressants are generally considered to have a negligible effect on seizure activity in epileptics, caution should be exercised when using MAOIs in patients with thyroid disease. Additionally, as with all antidepressants, MAOIs may precipitate mania and should be used with caution in bipolar disorder, although they are not contraindicated.

      Hyponatremia, a condition characterized by low sodium levels, is a potential side effect of most antidepressants, including MAOIs. However, MAOIs are not considered high risk compared to other antidepressant drugs. If sodium levels fall below 125 mmol/L, antidepressants should be stopped.

      Reference:
      Taylor, D., Paton, C., & Kapur, S. (2018). The Maudsley Prescribing Guidelines in Psychiatry (13th ed.). John Wiley & Sons.

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      • Psychopharmacology
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  • Question 194 - Which medication should be avoided by patients who are taking phenelzine? ...

    Incorrect

    • Which medication should be avoided by patients who are taking phenelzine?

      Your Answer:

      Correct Answer: Broad bean pods

      Explanation:

      There is conflicting information regarding whether people should avoid only the pods of broad beans of both the beans and their pods.

      MAOIs: A Guide to Mechanism of Action, Adverse Effects, and Dietary Restrictions

      First introduced in the 1950s, MAOIs were the first antidepressants introduced. However, they are not the first choice in treating mental health disorders due to several dietary restrictions and safety concerns. They are only a treatment option when all other medications are unsuccessful. MAOIs may be particularly useful in atypical depression (over eating / over sleeping, mood reactivity).

      MAOIs block the monoamine oxidase enzyme, which breaks down different types of neurotransmitters from the brain: norepinephrine, serotonin, dopamine, as well as tyramine. There are two types of monoamine oxidase, A and B. The MOA A are mostly distributed in the placenta, gut, and liver, but MOA B is present in the brain, liver, and platelets. Selegiline and rasagiline are irreversible and selective inhibitors of MAO type B, but safinamide is a reversible and selective MAO B inhibitor.

      The most common adverse effects of MAOIs occurring early in treatment are orthostatic hypotension, daytime sleepiness, insomnia, and nausea; later common effects include weight gain, muscle pain, myoclonus, paraesthesia, and sexual dysfunction.

      Pharmacodynamic interactions with MAOIs can cause two types of problem: serotonin syndrome (mainly due to SSRIs) and elevated blood pressure (caused by indirectly acting sympathomimetic amines releasers, like pseudoephedrine and phenylephrine). The combination of MAOIs and some TCAs appears safe. Only those TCAs with significant serotonin reuptake inhibition (clomipramine and imipramine) are likely to increase the risk of serotonin syndrome.

      Tyramine is a monoamine found in various foods, and is an indirect sympathomimetic that can cause a hypertensive reaction in patients receiving MAOI therapy. For this reason, dietary restrictions are required for patients receiving MAOIs. These restrictions include avoiding matured/aged cheese, fermented sausage, improperly stored meat, fava of broad bean pods, and certain drinks such as on-tap beer. Allowed foods include fresh cottage cheese, processed cheese slices, fresh packaged of processed meat, and other alcohol (no more than two bottled or canned beers of two standard glasses of wine, per day).

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      • Psychopharmacology
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  • Question 195 - Which of the following is classified as a phenothiazine? ...

    Incorrect

    • Which of the following is classified as a phenothiazine?

      Your Answer:

      Correct Answer: Pipotiazine

      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.

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      • Psychopharmacology
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  • Question 196 - Which medication does not create a significant active metabolite? ...

    Incorrect

    • Which medication does not create a significant active metabolite?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      There is no active metabolite produced by lithium.

      The Significance of Active Metabolites in Drug Discovery and Development

      Certain drugs are classified as prodrugs, which means that they are inactive when administered and require metabolism to become active. These drugs are converted into an active form, which is referred to as an active metabolite. Some drugs have important active metabolites, such as diazepam, dothiepin, fluoxetine, imipramine, risperidone, amitriptyline, and codeine, which are desmethyldiazepam, dothiepin sulfoxide, norfluoxetine, desipramine, 9-hydroxyrisperidone, nortriptyline, and morphine, respectively.

      The role of pharmacologically active metabolites in drug discovery and development is significant. Understanding the active metabolites of a drug can help in the development of more effective and safer drugs. Active metabolites can also provide insights into the pharmacokinetics and pharmacodynamics of a drug, which can aid in the optimization of dosing regimens. Additionally, active metabolites can have different pharmacological properties than the parent drug, which can lead to the discovery of new therapeutic uses for a drug. Therefore, the study of active metabolites is an important aspect of drug discovery and development.

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      • Psychopharmacology
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  • Question 197 - Which atypical antipsychotic has the most extended half-life? ...

    Incorrect

    • Which atypical antipsychotic has the most extended half-life?

      Your Answer:

      Correct Answer: Aripiprazole

      Explanation:

      Knowing the half life of a drug is important in determining the steady state concentration, which occurs when absorption and elimination reach an equilibrium after repeated doses. This equilibrium depends on factors such as dose, time between doses, and the drug’s elimination half life. Typically, steady state is achieved after four to five half lives. The following are the half lives of some atypical antipsychotics: Aripiprazole – 90 hours, Clozapine – 16 hours, Olanzapine – 30 hours, Risperidone – 15 hours, and Quetiapine – 6 hours.

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      • Psychopharmacology
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  • Question 198 - What is the truth about hyperprolactinemia that is linked to the use of...

    Incorrect

    • What is the truth about hyperprolactinemia that is linked to the use of antipsychotic medication?

      Your Answer:

      Correct Answer: It is often asymptomatic

      Explanation:

      Hyperprolactinemia is frequently without symptoms, and determining whether treatment is necessary involves weighing the present symptoms, potential long-term risks, and perceived advantages of maintaining the antipsychotic. It is frequently discovered by chance and does not typically necessitate altering the medication regimen.

      Hyperprolactinemia is a potential side effect of antipsychotic medication, but it is rare with antidepressants. Dopamine inhibits prolactin, so dopamine antagonists, such as antipsychotics, can increase prolactin levels. The degree of prolactin elevation is dose-related, and some antipsychotics cause more significant increases than others. Hyperprolactinemia can cause symptoms such as galactorrhea, menstrual difficulties, gynecomastia, hypogonadism, and sexual dysfunction. Long-standing hyperprolactinemia in psychiatric patients can increase the risk of osteoporosis and breast cancer, although there is no conclusive evidence that antipsychotic medication increases the risk of breast malignancy and mortality. Some antipsychotics, such as clozapine and aripiprazole, have a low risk of causing hyperprolactinemia, while typical antipsychotics and risperidone have a high risk. Monitoring of prolactin levels is recommended before starting antipsychotic therapy and at three months and annually thereafter. Antidepressants rarely cause hyperprolactinemia, and routine monitoring is not recommended. Symptomatic hyperprolactinemia has been reported with most antidepressants, except for a few, such as mirtazapine, agomelatine, bupropion, and vortioxetine.

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      • Psychopharmacology
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  • Question 199 - Which of the following is classified as a tertiary amine? ...

    Incorrect

    • Which of the following is classified as a tertiary amine?

      Your Answer:

      Correct Answer: Clomipramine

      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 200 - What is the closest estimate for the frequency of dystonia linked to the...

    Incorrect

    • What is the closest estimate for the frequency of dystonia linked to the usage of typical antipsychotics?

      Your Answer:

      Correct Answer: 10%

      Explanation:

      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).

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      • Psychopharmacology
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