ISST 11 Exam

What is target carbamazepine level?

4-12

What is the half life of VPA?

12 hours

What is target VPA level?

50-125

What VPA levels are associated with more weight gain?

>125

IN patients with no recent history of manic episodes what is the VPA target range?

50-100

In acute mania what is the VPA target range?

85-125

What is the half life of lithium?

24 hours

What needs to be done in lithium clearance calc?

Multiply CrCl by 0.25

What is the target lithium level?

0.6-1

After day 1 of extrapolated lithium what is the expected level%?

50%

After day 2 of extrapolated lithium what is the expected level%?

75%

After day 3 of extrapolated lithium what is the expected level%?

87.5%

What is the calculation for extrapolated steady state level?

12h level/87.5%

In patients with no history of manic episodes with is the range of lithium?

0.6-0.8

In acute mania what is the lithium target?

0.8-1

What is the dosing for lithium?

Once daily to preserve renal function

What makes lithium levels go up?

Salt

Thiazides

ACEi/ARB

NSAIDS

Dehydration

What is the range for nortriptyline target?

50-150

Where is there a higher prevalance in insomnia?

Unemployed

Divorced, widowed

Lower socioeconomic status

Psychiatric disorder

What comorbidities does insomnia have a relationship with?

Hypertension

CVD

T2DM

Mortality

Psych disorder

What counts as chronic insomnia per ICSD-3?

>3 times per week for >3 months

What is diagnostic criteria for Chronic insomnia?

One in A(difficulty sleeping) and one in B(tiredness)

What are screening questionares for insomnia?

Epworth

ISI

Pittsburgh

What medications may induce insomnia?

Oral contraceptives

Thyroid supplements

Beta blockers

Anti-convulsants

Nicotine

What are non-pharm therapy for insomnia?

Cognitive-behavioral therapy(ikr)

Light therapy

Paradoxical intention

Relaxation

Sleep hygiene

What is the first line treatment for all insomnias?

CBT-I

What temperature leads to increased awakenings and reduced REM and SWS?

>75

What temperature leads to unpleasant and emotional dreams?

<54

What meds can be used for insomnia?

Orexin

• “rexant”

GABA

What can be used as a sedative, anti-anxiety, muscle relaxant, and anticonvulsive?

Benzos

Which benzos are long acting?

Flurazepam

Quazepam

What needs to be counseled with Z-drugs?

High-fat meals will delay absorption

Females get half the dose

What is the other name for sonata?

Zaleplon

What is the other name for lunesta?

Eszopiclone

What is a spray that helps with insomnia?

Zolpmist

What is the MOA of valerian?

Bind to GABA-A receptors and increase GABA release

Similar to benzos

Can valerian be given with benzos?

NO

How is melatonin released?

Pineal gland is turned on by the suprachiasmatic nucelus when dark

What is the best tx choice for sleep-onset insomnia and does not cause dependence?

Rozarem

What are SE of rozarem?

SI

Depression

Complex sleep related behavior

Headache

Somnolence

What are counseling points in Rozarem?

Do not eat with high fat meal

Care in hepatic

What MT1 and MT2 receptor agonist has greater affinity for MT2?

Hetlioz

What is the other name of tasimelteon?

Hetlioz

What MT1 and MT2 receptor agonist cannot be taken with food?

Hetlioz

What is unique about tasimelton?

Cannot take with food

MT2 greater affinity

Effect takes weeks-months

Only approved to treat sleep-wake disorder

UTI

URI

Abnormal dreams

What do orexin receptor antagonists do?

Keep people awake

Promote sleep induction and maintenance by blocking orexin in hypothalamus

What are orexin receptor antagonists metabolized by?

CYP3A4

What is the CI of orexin receptor antagonists?

Insomnia

What are counseling points of orexin receptor antagonists?

Take within 30 mins of bedtime more than 7 hours before planned time of awakening

Delayed if taken with food

Which antidepressant is FDA approved for insomnia?

Doxepin

What needs to be cautioned in Doxepin?

Do not take with high fat meals

What is the other name for doxepin?

Silenor

What are SE of mirtazapine?

Drowsiness

Dry mouth

Weight gain

Are OTCs recommended for sleep aid?

no

What drugs are recommended in sleep onset?

Eszopiclone

Ramelteon

Temazepam

Triazolam

Zaleplon

Zolpidem

What drugs are recommended in sleep maintenence?

Doxepin

Eszopiclone

Suvorexant

Temazepam

Zolpidem

What drugs are ONLY recommended in sleep maintenance and not onset?

Doxepin

Suvorexant

What drugs are ONLY recommended in sleep onset and not maintanence?

Ramelteon

Triazolam

Zaleplon

What may help with obstructive sleep disorder and other risk factors?

Losing weight

Menopause

Endocrine

Down syndrome

Neurological

Alcohol

Rhinitis

What meets the criteria for OSA?

Five or more predominantly obstructive respiratory events per hour of sleep or >1 in list A(sleepiness, waking up breathless, habitual snoring, HTN mood disorder CAD stroke CHF afib DM2)

What are tx options for OSA?

Avoid sleeping on back

Weight loss

CPAP

Nasal splints

Chin straps

Surgery

What can be used to promote wakefullness for OSA, shift work disorder, and narcolepsy?

Modafinil(provigil)

R-enantiomer armodafinil(Nuvigil)

Solriamfetol(Sunosi)

Take w/ or w/o food

Major CYP3A4

What is a crazy FDA drug for OSA?

Tirzapetide(Zepbound)

What are consequences of untreated OSA?

Cardiovascular risk

HTN risk

due to increased inflammatory mediators and oxygen desaturation

What part of the brain is positvely correlated with psychotic symptoms with D2 receptor activation?

Striatum

How do traditional antispychotic drugs work?

Inhibit cAMP production and block D1 receptors

What tract is responsible for cognitive control and executive function and is midbrain to cortex?

Mesocortical

What tract is responsible for motivation and emotion and is midbrain to basal ganglia(striatum, N. accumbens)?

Mesolimbic

What tract regulates prolactin release and is from hypothalamus to pituitary?

Tuberoinfundibular

What tract is responsible for motor control and dysfunction causes parkinsons disease?

Nigrostriatal

What are the first generation typical antipsychotic drugs (D2 antagonism)?

Chlorpomazine

Haloperidol

Fluphenazine

Thioridazinie

Trifuluoperazine

What are the 2nd generation atypical antipsychotic drugs(5HT2 antangonism)?

Clozapine

Quetiapine

Risperidone

Olanzapine

ZIprasidone
Aripiprazole

What AP does not block D4?

Chlorpromazine

• phenothiazines

What AP does not block D2 and H1?

Clozapine

What gen blocks all 5H2A receptors?

2nd gen

What AP has exceptional D2 blockade?

Haloperidol

Which drugs have D4 blockade?

Haloperidol

Aripiprazole

Clozapine

Asenapine

What hypothesis talks about blocking 5HT to increase DA release and prevent motor AE and negative sx?

Stahl’s

What gen APs have greater metabolic symptoms?

Second gen

What should gen AP is cheaper?

First gen

What are characteristics of clozapine?

More effective for patients who did not respond to earlier drugs but have more serious AE

What may blocking of DA lead to in AP drugs?

Lower mesolimbic motivation and may lead to anhedona, lack of motivation, and “secondary” negative symptoms

What is unique about clozapine?

No D2 blockade

5HT2 blockade

Agranulocytosis and neutropenia

Low risk of EPS

What are SE of clozapine?

Agranulocytosis

Neutropenia

Weight gain

High burden of care

What SE may be caused by an inhibition of nigrostriatal DA tract?

EPS

What 2nd gen APs have the lowest muscarininc sx?

Aripiprazole

Ziprasidone

What are more likely to cause postural hypotension?

Clozapine

Ziprasidone

What are the endocrine effects of APs?

Block of DA in pituitary

Inhibit prolactin

Galactorrhea

Gyno

Reduced libido

What is catagonia, stupor, high gever, muscle rigidity, autonomic instability, rapid changing BP, sweating, tachy, a sign of?

Neuroleptic malignant syndrome

• First gen AP bc of D2R block

Which gen AP has the most weight gain?

Second gen

Can second gen antipsychotics benefit negative symptoms?

Lack of evidence

What is a long term effect of anti-psychotics?

Tardive dyskinesia

Which bipolar is more severe and manic?

Bipolar 1

What bipolar has hypomania and major depression?

Bipolar 2

What is alternating mild depression and mid mania(hypomania)?

Cyclothymia

What are the proposed mechanisms of bipolar disorder?

Increased DA and NE and Glutamate

Lower GABA

Neuroinflammation

What are considered “mood stabalizers”?

Lithium

2nd gen AP
Anticonvulsants

What happens if antidepressants are used in bipolar disorder?

May trigger manic episodes

What are first line tx for mania in bipolar disorder?

Lithium

Quetiapine

Risperidone

Paliperidone

Aripiprazole

Asenapine

Divalproex

Cariprazine

What antidepressants can be used in combination for manic phase?

Olanzapine

Fluoxetine