NAPLEX Bipolar/ADHD/Anxiety/Sleep

Mania diagnosis: exhibits >= _____ symptoms or, if mood is only irritable, exhibits >= 4 symptoms

3

Mania diagnosis: exhibits >= 3 symptoms or, if mood is only irritable, exhibits >= ____ symptoms

4

Traditional mood stabilizers for Bipolar Disorder include Lithium and antiseizure meds (______)

valproate, lamotrigine, carbamazepine

______ can induce or exacerbate a manic episode when used as monotherapy, so they should only be used in combination with a mood stabilizer

antidepressants

Acute treatment for Bipolar Disorder for Manic Episode: first-line treatment is ________

antispychotic, lithium, valproate

Acute treatment for Bipolar Disorder for Depressive Episode: first-line treatment is ________

antispychotic, lithium, valproate, lamotrigine

Maintenance treatment for Bipolar Disorder: meds that were effective for acute episodes should be continued as maintenance treatment to prevent relapse. This include ________

lithium, antiseizure drugs, SGAs

Antiseizure meds used to treat Bipolar Disorder

lamotrigine, carbamazepine, valproate

Common SGAs used alone or in combo with mood stabilizers for acute mania and/or maintenance treatment

aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone, lurasidone, olanzapine/fluoxetine

What is the therapeutic range for Lithium (trough level)? _____ mEq/L

0.6 - 1.2

Side effects of Lithium (within therapeutic range)

GI upset, cognitive effects, cogwheel rigidity, tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism

Warnings for Lithium

serotonin syndrome, renal impairment, hyponatremia, dehydration

Lithium toxicity side effects (> 1.5 mEq/L)

ataxia, coarse hand tremor, vomiting, diarrhea, sedation

Lithium toxicity side effects (> 2.5 mEq/L)

CNS depression, arrhythmia, seizure, coma

What to monitor for Lithium?

lithium levels, renal function, thyroid function

Lithium levels increase with ________

decreased salt intake, NSAIDs

Lithium levels decrease with _________, caffeine, or theophylline

increased salt intake

5 mL lithium citrate syrup = _____ mEq lithium ion = 300 mg lithium carbonate tabs/caps

8

___ mL lithium citrate syrup = 8 mEq lithium ion = 300 mg lithium carbonate tabs/caps

5

5 mL lithium citrate syrup = 8 mEq lithium ion = ____ mg lithium carbonate tabs/caps

300

Which common mood stabilizers are teratogenic and should be avoided in pregnancy?

valproate, carbamazepine, lithium

______ or SGAs are safer choices than Valproate, Carbamazepine, and Lithium for pregnancy

lamotrigine

Which SGA has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for Bipolar depression

lurasidone

______ meds are the primary treatment for ADHD, because they raise DA + NE levels

stimulant

For diagnosis of ADHD, several sx MUST be present before age ____ years, sx MUST be present in >= 2 settings (e.g. home, school, work), sx MUST be inerfering with functioning and are not caused by another disorder

12

In patients age >= _____ years, ADHD meds are first-line. First-line treatment for ages 4-5 years is behavioral therapy

6

For diagnosis of ADHD, several sx MUST be present before age 2 years, sx MUST be present in >= ____ settings (e.g. home, school, work), sx MUST be inerfering with functioning and are not caused by another disorder

2

What are the non-stimulant meds that are 2nd-line for ADHD?

atomoxetine, viloxazine

What are the add-on meds for ADHD? (or can be used alone)

clonidine ER, guanfacine ER

What are the meds that can be added to help with sleep at night for ADHD?

clonidine IR, diphenhydramine, melatonin

Stimulant doses can be titrated up every ____ days as needed. Stimulants do not need to be tapered off

7

Ritalin

methylphenidate IR tablet

Concerta

methylphenidate ER tablet with OROS delivery

Ritalin LA

methylphenidate ER capsule

Daytrana

methylphenidate patch

Daytrana patch is applied QAM; apply to the hip ___ hrs before the desired effect; remove after 9 hrs; alternate hips daily; discard by flushing down the toilet

2

Daytrana patch is applied QAM; apply to the hip 2 hrs before the desired effect; remove after __ hrs; alternate hips daily; discard by flushing down the toilet

9

Jornay PM

Methylphenidate formulation that has an outer coating that delays drug release 10 hrs to allow evening dosing

Adderall

dextroamphetamine + amphetamine

Vyvanse

lisdexamphetamine

Which ADHD med is a prodrug for dextroamphetamine and has a low abuse potential

lisdexamfetamine

Focalin

dexmethylphenidate

What is the active isomer of methylphenidate?

dexmethylphenidate (focalin)

Strattera

atomoxetine

Strattera

atomoxetine

Viloxazine (Qelbree) drug class + indication

SNRI for ADHD

Kapvay

clonidine ER for ADHD

Intuniv

guanfacine ER for ADHD

Which ADHD med is a CYP2D6 substrate?

atomoxetine

Which ADHD med is a strong CYP1A2 inhibitor and a weak CYP2D6 and CYP3A4 inhibitor? (significant DDIs)

viloxazine

Which med for ADHD is a CYP3A4 subtrate and should have the dose be adjusted if used with strong CYP3A4 inducers (double dose) or inhibitors (1/2 dose)?

guanfacine ER

Which med for ADHD should not be discontinued abruptly?

clonidine ER, guanfacine ER

Which ADHD med can cause a ghost tablet in stool

Concerta

Which natural products can be used for anxiety?

St. John’s Wort, valerian, passionflower, kava

Which natural product can be used for both depression and anxiety?

St. John’s Wort

Which natural product can be used for anxiety, but is not recommended due to liver damage?

kava

Which natural product can be used for anxiety and sleep?

valerian

Which SSRIs are used for anxiety?

escitalopram, sertraline, paroxetine, fluoxetine

Which SNRIs are used for anxiety?

duloxetine, venlafaxine

Which meds are first-line for anxiety? (most anxiety is due to depression, so which antidepressants are preferred?)

selective SSRIs and SNRIs

Which meds are second-line for anxiety?

buspirone, TCAs, hydroxyzine, pregabalin, gabapentin

Which meds can be used for anxiety in special situations? (not FDA-approved but can reduce sx of stage fright or performance anxiety)

propanolol

Vistaril

hydroxyzine

Lyrica

pregabalin

Neurotin

gabapentin

Which meds for anxiety will not provide immediate relief?

SSRIs, SNRIs, buspirone

BZDs enhance _____ which is an inhibitory NT

GABA

Which meds can be useful for short-term treatment of acute anxiety since they provide fast relief (antidepressants have a longer onset of action)?

BZD

BZD should only be used for ____ weeks and then discontinued due to risk of dependence

1-2

Which BZDs are preferred in elderly or patients with liver impairment (LOT drugs) (they undergo glucuronidation)

lorazepam, oxazepam, temazepam

Xanax

alprazolam

Klonopin

clonazepam

Valium

diazepam

Ativan

lorazepam

If BZDs are used regularly for > ____ days, do not stop suddenly, they should be tapered off slowly

10

Which meds are use to help falling asleep?

eszopiclone, zolpidem, ramelteon, zalepton

Which meds are use to help staying asleep?

eszopiclone, zolpidem, doxepin, suvorexant

Which meds are use to help with falling AND staying asleep?

eszopiclone, zolpidem

Which OTC antihistamines can patients use to self-treat their insomnia?

diphenhydramine, doxylamine

The American Academy of Sleep Medicine (AASM) guidelines state that the following treatments are not recommended for chronic use: _____

diphenhydramine, melatonin, trazodone, valerian

Lunesta

eszopiclone

Edular

zolpidem SL tabs

Non-BZD hynotics (Eszopiclone, Zolpidem) act selectively at BZD receptors to increase ______

GABA

MOA of Buspirone is unknown, but its effect may be due to its affinity for _______ receptors

5-HT1A, 5-HT2

Ramelteon + Tasimelteon drug class

metatonin receptor agonists

Which TCA can be used for insomnia (staying asleep) —> TCAs also block Ach and Histamine receptors which contributes to side effects of somnolence

doxepin

Suvorexant (Belsomra) drug class

orexin receptor antagonist

Suvorexant (Belsomra) indication

insomnia (staying asleep)

What is the treatment for Restless Legs Syndrome? (urge to move the lower legs, worse at night, can impact sleep)

iron supplementation, gabapentin enacarbil (Horizant), pregabalin, dopamine agonists (pramiprexole, ropinirole, rotigotine)

Modafinil drug class

stimulant

Modafinil indication

narcolepsy

Sodium oxybate drug class

derived from GABA

Sodium oxybate indication

narcolepsy

Which meds are used to treat narcolepsy?

modafinil, armodafinil, sodium oxybate, dextroamphetamine, dextroamphetamine/amphetamine, methylphenidate

Pitolisant (Wakix) indication (Histamine-3 receptor antagonist/inverse agonist)

narcolepsy

Solriamfetol (Sunosi) indication (DA + NE reuptake inhibitor)

narcolepsy