Psychotropics
Item Number: 11667 correct answer: 4 category: Psychotropics
1. The symptoms of tardive dyskinesia will acutely improve with:
1. administration of diphenhydramine
2. administration of amantadine
3. administration of bromocriptine
4. increase of neuroleptic dose
5. All of the above

Item Number: 8777 correct answer: 5 category: Psychotropics
2. Psychopharmacology includes the judicious of all the following EXCEPT:
1. haloperidol
2. lithium carbonate
3. imipramine
4. chlordiazepoxide
5. selegiline

Item Number: 11641 correct answer: 2 category: Psychotropics
3. Major tranquilizers of the phenothiazine group produce all of the following
EXCEPT:
1. autonomic effects
2. anesthesia
3. extrapyramidal effects
4. control of psychotic behavior
5. prevention of vomiting

Item Number: 11652 correct answer: 4 category: Psychotropics
4. Neuroleptic malignant syndrome is characterized by all of the following
EXCEPT:
1. hyperpyrexia
2. increase in serum creatine phosphokinase
3. catatonia
4. akathisia
5. All of the above

Item Number: 10533 correct answer: 5 category: Psychotropics
5. Pigment deposits in the anterior lens capsule and posterior surface of the
cornea can be seen by slit-lamp examination in one third to one half of some
groups receiving certain phenothiazine tranquilizers. Phenothiazine
tranquilizers which have caused this state include:
1. chlorpromazine
2. promazine
3. thioridazine
4. All of the above
5. 1,3

Item Number: 11754 correct answer: 4 category: Psychotropics
6. Pharmacologic effects of thioridazine include all of the following EXCEPT:
1. control of psychotic behavior
2. orthostatic hypotension
3. antiemesis
4. hypoprolactinemia
5. All of the above

Item Number: 10699 correct answer: 2 category: Psychotropics
7. A substance which decreases or inhibits the metabolism of benzodiazepines
metabolized to active metabolites in the liver is:
1. ranitidine
2. cimetidine
3. rifampin
4. carbamazepine
5. phenytoin

Item Number: 10484 correct answer: 5 category: Psychotropics
8. Systems on which antipsychotic agents exhibit pharmacologic action include all
of the following EXCEPT:
1. central nervous system
2. autonomic nervous system
3. cardiovascular
4. endocrine system
5. pulmonary

Item Number: 10645 correct answer: 5 category: Psychotropics
9. Pharmacologic effects of cyclic antidepressants include all of the following
EXCEPT:
1. sedation
2. flattened or inverted T waves on EKG
3. urinary retention and mydriasis
4. mood elevation
5. raise the seizure threshold

Item Number: 10486 correct answer: 4 category: Psychotropics
10. Uses for antipsychotics include all of the following EXCEPT:
1. Gilles de la Tourette syndrome
2. hiccups
3. schizophrenia
4. Parkinson’s disease
5. manic phase of manic depression

Item Number: 5262 correct answer: 5 category: Psychotropics
11. The pharmacological agent which is useful as an antiemetic is:
1. tetracycline
2. naloxone
3. caffeine
4. epinephrine
5. chlorpromazine

Item Number: 10663 correct answer: 4 category: Psychotropics
12. All of the following are monoamine oxidase inhibitors EXCEPT:
1. phenelzine
2. isocarboxazid
3. tranylcypromine
4. maprotiline
5. All of the above

Item Number: 10666 correct answer: 2 category: Psychotropics
13. The pharmacologic action of monoamine oxidase inhibitors is:
1. block the reuptake of monoamine neurotransmitter into the presynaptic cleft
2. blocks the metabolism of monoamine neurotransmitters
3. decreases 5HT and NE monoamines
4. enhances REM sleep
5. selective MAO-B inhibitors may be useful in psychosis

Item Number: 10687 correct answer: 5 category: Psychotropics
14. Effects of benzodiazepines include all of the following EXCEPT:
1. paradoxical stimulation
2. tolerance
3. dependence and withdrawal
4. respiratory depression in patients with obstructive lung disease
5. lower seizure threshold

Item Number: 10681 correct answer: 1 category: Psychotropics
15. Pharmacologic effects of lorazepam include:
A. sedation/hypnosis
B. anterograde amnesia
C. increased seizure threshold
D. inhibition of prolactin secretion
1. A,B,C
2. A,C
3. B,D
4. D only
5. All of the above

Item Number: 10682 correct answer: 4 category: Psychotropics
16. The elimination of all of the following benzodiazepines are influenced by
liver disease or advanced aging EXCEPT:
1. alprazolam
2. midazolam
3. chlordiazepoxide
4. lorazepam
5. diazepam

Item Number: 10648 correct answer: 4 category: Psychotropics
17. The appropriately matched tricyclic antidepressant and metabolite is:
1. amitriptyline – desipramine
2. imipramine – nortriptyline
3. imipramine – trimipramine
4. imipramine – desipramine
5. fluoxetine – protriptyline

Item Number: 6702 correct answer: 2 category: Psychotropics
18. A recognized side effect of  lithium carbonate is:
1. hypermagnesemia
2. polyuria and polydipsia
3. transient fall in BUN and serum creatinine
4. hypochloremia
5. proximal tubular degeneration

Item Number: 11648 correct answer: 5 category: Psychotropics
19. Endocrine effects of chlorpromazine include all of the following EXCEPT:
1. decrease in adrenocorticotropins
2. decrease in gonadotropins
3. decrease in release of pituitary growth hormone
4. increase in prolactin secretion
5. decrease in thyroid hormone production

Item Number: 3750 correct answer: 1 category: Psychotropics
20. Cholestasis is the principle derangement observed in hepatotoxicity
associated with:
1. phenothiazines
2. monoamine oxidase inhibitors
3. para-aminosalicylic acid
4. carbon tetrachloride
5. None of the above

Item Number: 11758 correct answer: 4 category: Psychotropics
21. Phenelzine can result in a hypertensive crisis when coadministered with all of
the following EXCEPT:
1. pickled herring (tyramine)
2. amphetamines
3. phenylpropanolamine
4. diazepam
5. ephedrine

Item Number: 10680 correct answer: 4 category: Psychotropics
22. The neurotransmitter through which benzodiazepines exert their action is:
1. norepinephrine
2. epinephrine
3. dopamine
4. gamma amino butyric acid
5. serotonin

Item Number: 10612 correct answer: 1 category: Psychotropics
23. The neuroleptic available as ester salts for intramuscular injection with slow
absorption characteristics is:
1. haloperidol
2. prochlorperazine
3. thioridazine
4. perphenazine
5. All of the above

Item Number: 10500 correct answer: 2 category: Psychotropics
24. Anticholinergic side effects are most common with:
1. haloperidol
2. thioridazine
3. fluphenazine
4. trifluoperazine
5. All of the above

Item Number: 11642 correct answer: 5 category: Psychotropics
25. Reserpine normally has a tranquilizing effect. However, prior administration
of some drugs can produce excitement in a patient taking reserpine. Classes
of drugs which will produce this paradoxical effect include:
1. anticholinesterases
2. antihistamines
3. atropine-type muscarinic blockers
4. alpha-adrenergic blockers
5. monoamine oxidase inhibitors

Item Number: 11697 correct answer: 4 category: Psychotropics
26. Fluoxetine is FDA-approved to treat:
1. schizophrenia
2. mania
3. anxiety
4. depression
5. obesity

Item Number: 11659 correct answer: 2 category: Psychotropics
27. Compliance with neuroleptics medications can be increased by the
administration of depot injections of:
1. loxapine hydrochloride
2. fluphenazine enanthate
3. molindone hydrochloride
4. chlorpromazine hydrochloride
5. All of the above

Item Number: 11766 correct answer: 5 category: Psychotropics
28. Drugs that reduce the renal clearance of lithium include all of the following
EXCEPT:
1. ibuprofen
2. hydrochlorothiazide
3. indomethacin
4. chlorothiazide
5. theophylline

Item Number: 11617 correct answer: 2 category: Psychotropics
29. The potential central nervous system effects of haloperidol is:
1. monoamine oxidase inhibition
2. blockade of dopamine in the chemoreceptor trigger zone
3. cholinesterase inhibition
4. blockade of serotonin in the basal ganglia
5. blockade of dopamine reuptake

Item Number: 10497 correct answer: 2 category: Psychotropics
30. The correct statements regarding extrapyramidal effects of antipsychotics is:
1. acute dystonic reactions occur most commonly with low potency agents
2. excess dopaminergic activity is hypothesized to be a mechanism of
tardive dyskinesia
3. akathisia is characterized by oral facial dyskinesia
4. cholinergic agents are useful in the management of neuroleptic-induced
Parkinsonism
5. tardive dyskinesia occurs early on in therapy and is reversible upon
discontinuation of therapy

Item Number: 10625 correct answer: 1 category: Psychotropics
31. Agents which are tricyclic or atypical cyclic antidepressants include all of
the following EXCEPT:
1. imipramine
2. fluoxetine
3. trazodone
4. bupropion
5. All of the above

Item Number: 1362 correct answer: 1 category: Psychotropics
32. You treat a 40-year-old female for neurotic depression. After a few visits
you prescribe amitriptyline to relieve her depression. After 4 days she calls
you to say the pills are having no effect and she still feels depressed. The
best course of action would be to advise her to:
1. continue on the medication as prescribed, as the drug often takes up to
2-6 weeks to have its antidepressant, effect
2. double the dose
3. stop the pills and you will order other treatment from the pharmacist
4. continue on the same dose and you will call in an order for a second
drug to use in combination with it
5. take the pills with an alcoholic drink to increase their effect

Item Number: 11709 correct answer: 4 category: Psychotropics
33. All of the following benzodiazepines are metabolized to active products
EXCEPT:
1. alprazolam
2. chlordiazepoxide
3. midazolam
4. lorazepam
5. diazepam

Item Number: 11705 correct answer: 4 category: Psychotropics
34. The cyclic antidepressants which selectively block serotonin reuptake is:
1. imipramine
2. doxepin
3. amoxapine
4. fluoxetine
5. maprotiline

Item Number: 10669 correct answer: 5 category: Psychotropics
35. Adverse effects of monoamine oxidase inhibitors include all of the following
EXCEPT:
1. dry mouth, constipation, urinary retention
2. hyperreflexia, fatigue, muscle twitching
3. hypertensive reactions if administered with tyramine containing substances
4. orthostatic hypotension
5. raise seizure threshold

Item Number: 10499 correct answer: 5 category: Psychotropics
36. Adverse effects of antipsychotic agents include all of the following EXCEPT:
1. orthostatic hypotension
2. mydriasis
3. gynecomastia
4. jaundice
5. hypothyroidism

Item Number: 10639 correct answer: 3 category: Psychotropics
37. A patient on medication develops severe hypertension after eating some cheese.
The combination of substances found in the cheese and medication,
respectively, which is the most likely cause of this reaction is:
1. ergotamine and amphetamine
2. acetylcholine and reserpine
3. tyramine and phenelzine
4. angiotensin and propranolol
5. dopamine and phentolamine

Item Number: 10622 correct answer: 4 category: Psychotropics
38. The correct statement which describes the dopamine theory of schizophrenia is:
1. schizophrenia is due to a relative lack of the neurotransmitter dopamine
2. schizophrenia is due to a relative decrease in sensitivity of
postsynaptic CNS dopamine receptors
3. schizophrenia is a result of a deficiency in the decarboxylase enzyme
necessary for dopamine synthesis
4. schizophrenia is due to a functional excess of the neurotransmitter
dopamine or to a hypersensitivity of dopamine receptors or a global
imbalance in dopaminergic function within the area A-10 of the brain
5. All of the above

Item Number: 10657 correct answer: 5 category: Psychotropics
39. Indications for and/or uses of cyclic antidepressants include all of the
following EXCEPT:
1. major depression
2. eating disorders
3. chronic pain
4. obsessive-compulsive disorders
5. epilepsy

Item Number: 10483 correct answer: 2 category: Psychotropics
40. Correct pairs of pharmacologic action with CNS region of dopamine blockade
include:
A. extrapyramidal effects – basal ganglia
B. increase prolactin secretion – limbic
C. antiemetic – chemoreceptor trigger zone
D. antipsychotic – basal ganglia
1. A,B,C
2. A,C
3. B,D
4. D only
5. All of the above

Item Number: 11749 correct answer: 4 category: Psychotropics
41. The predominant action of the demethylated biotransformation product of
imipramine is inhibition of:
1. serotonin synthesis
2. serotonin uptake
3. dopamine release
4. norepinephrine uptake
5. dopamine reuptake

Item Number: 10076 correct answer: 2 category: Psychotropics
42. Lithium carbonate is used as an alternative to the major tranquilizers in
the control of manic-depressive illness. After the drug is started, how many days
elapse before the antimanic effect is reached?
1. 1-5 days
2. 7-10 days
3. 11-15 days
4. 16-20 days
5. 21-25 days

Item Number: 10621 correct answer: 5 category: Psychotropics
43. Drug interactions with neuroleptics include all of the following EXCEPT:
1. opioids
2. guanethidine
3. phenobarbital
4. levodopa
5. furosemide

Item Number: 6923 correct answer: 3 category: Psychotropics
44. An attempted suicide with chlorpromazine is admitted to the hospital in a
semi-comatose state. Blood pressure is low. An injection of epinephrine is
given to restore the cardiovascular system and the patient immediately goes
into shock. Blood pressure is now unobtainable. The responsible factor is:
1. chlorpromazine depresses the respiratory center
2. epinephrine has a positive inotropic effect on the heart
3. chlorpromazine is an alpha-adrenergic blocking agent
4. chlorpromazine causes hypertension in toxic doses
5. epinephrine slows the heart rate

Item Number: 8220 correct answer: 3 category: Psychotropics
45. Compared to other major tranquilizers, thioridazine appears to produce
significantly fewer instances of:
1. ventricular dysrhythmias
2. retinopathy
3. Parkinsonism
4. All of the above
5. 1,3

Item Number: 11761 correct answer: 1 category: Psychotropics
46. Adverse effects of lithium that may persist with chronic therapy include all
of the following EXCEPT:
1. severe nausea and vomiting
2. fine tremor
3. leukopenia
4. polyuria
5. hypothyroidism

Item Number: 10673 correct answer: 4 category: Psychotropics
47. Adverse effects of lithium include all of the following EXCEPT:
1. tremors
2. polyuria
3. sedation
4. tardive dyskinesia
5. hypothyroidism

Item Number: 10489 correct answer: 4 category: Psychotropics
48. Extrapyramidal side effects is most common with which of the following
neuroleptics?
1. thioridazine
2. triflupromazine
3. mesoridazine
4. haloperidol
5. All of the above

Item Number: 11651 correct answer: 2 category: Psychotropics
49. Cholestatic jaundice is a rare hypersensitivity reaction which reportedly
occurs with:
1. amitriptyline
2. chlorpromazine
3. lithium
4. chlordiazepoxide
5. alprazolam

Item Number: 5700 correct answer: 5 category: Psychotropics
50. Overdosage of lithium carbonate prescribed for psychiatric disorders may be
serious. Correct statements include:
1. hemodialysis is an effective means of lithium removal and is helpful in
severe overdoses
2. activated charcoal binds lithium in the GI tract and prevents absorption
3. symptoms include edema, tremor, polyuria, and disturbed consciousness
4. All of the above
5. 1,3

Send comments to willoughby@cctr.umkc.edu.

Reducing risk of overdose with midazolam injection in adults

Issue

Some adult patients are being overdosed with midazolam injection when used for conscious sedation. The presentation of high strength midazolam as 5mg/ml (2ml and 10ml ampoules) or 2mg/ml (5ml ampoule) exceeds the dose required for most patients. There is a risk that the entire contents of high strength ampoules are administered to the patient when only a fraction of this dose is required. Doses often exceed that required, are not titrated to the patient’s individual needs, do not take into account concurrent medication (e.g. opioids) and may involve high risk groups for example, the frail or the elderly. There is frequent reliance on injectable flumazenil (antagonist/reversing agent) for reversal of sedation in patients that have been over sedated.

Patient Safety Incidents

The NPSA has received 498 midazolam patient safety incidents between November 2004 and November 2008 where the dose prescribed or administered to the patient was inappropriate. Three midazolam related incidents have resulted in death.
Incident data suggests that the reversing agent, flumazenil, is frequently used to treat inadvertent benzodiazepine overdose and, on occasion, no account is taken for the shorter half life of flumazenil (compared to midazolam) leading to residual re-sedation.
For IMMEDIATE ACTION by all organisations in the NHS and independent sector where midazolam is used for adult conscious sedation.
The deadline date for ACTION COMPLETE is 9 June 2009
An executive director, nominated by the Chief Executive, working with the lead pharmacist and relevant medical/nursing staff should:
011/1 Ensure that the storage and use of high strength midazolam (5mg/ml in 2ml and 10 ml ampoules; or 2mg/ml in 5ml ampoules) is restricted to general anaesthesia, intensive care, palliative medicine and clinical areas/situations where its use has been formally risk assessed, for example, where
syringe drivers are used.
011/2 Ensure that in other clinical areas, storage and use of high strength midazolam, is replaced with low strength midazolam (1mg/ml in 2ml or 5ml ampoules).
011/3 Review therapeutic protocols to ensure that guidance on use of midazolam is clear and that the risks, particularly for the elderly or frail, are fully assessed.
011/4 Ensure that all healthcare practitioners involved directly or participating in sedation techniques have the necessary knowledge, skills and competences required.
011/5 Ensure that stocks of flumazenil are available where midazolam is used and that the use of flumazenil is regularly audited as a marker of excessive dosing of midazolam.
011/6 Ensure that sedation is covered by organisational policy and that overall responsibility is assigned to a senior clinician which, in most cases, will be an anaesthetist.

Source: Rapid response report : reducing risk of overdose with midazolam injection in adults.  National Patient Safety Agency. PDF file

Benzodiazepines: ones not metabolized by the liver (safe to use in liver failure)
LOT:
Lorazepam
Oxazepam
Temazepam

Thanks to MedExcel

Remember to check the animation on the mechanism of action of benzodiazepines.

Hypnotic hazards and effects of z-drugs immeasurable

“It is difficult to know the extent of use and adverse effects of zolpidem and other z-drugs (zopiclone and zaleplon) because they have never been listed on the Australian Pharmaceutical Benefits Scheme, senior Sleep Disorders Physician Dr Les Olson writes in the latest edition of Australian Prescriber.

Following the media attention given to side effects in patients taking zolpidem, Dr Olson reviews the known adverse reactions of the z-drugs.

“Although the media have been impressed with the outlandish adverse events reported with zolpidem, these events are not unprecedented. Amnesia, hallucinations and bizarre behaviour were also seen frequently in patients taking the short-acting benzodiazepine, triazolam, for insomnia,” Dr Olson writes.

“All of the bizarre behaviours reported, such as sleep eating, sleep sex and sleep driving, are more likely to represent ‘wakeful behaviour with amnesia’ than behaviour while asleep.”

“Z-drugs have few advantages over benzodiazepines, and there is no good reason for their use in insomnia. It is possible to manage insomnia without ever using hypnotic drugs and this approach should be the rule rather than the exception.”

“If patients are prescribed z-drugs they should be made aware that sedation, confusion and disinhibition may occur. They should be advised to avoid alcohol, and the hypnotic should always be taken once the patient is in bed, not on the way to bed.”

“Evidence that z-drugs, especially zolpidem, commonly cause adverse effects, not predictable from their pharmacology, is weak. Zolpidem may cause hallucinations relatively frequently (as triazolam did), but reports of ‘abnormal behaviour with amnesia’ probably reflect predictable effects.”

Dr Olson says these adverse effects are not unique to z-drugs and could be limited by reduced prescribing.
“If there were fewer prescriptions for zolpidem and other z-drugs there would be fewer adverse events,” Dr Olson writes.

Non-medicine strategies for managing insomnia and guidance for counselling patients are available from the National Prescribing Service Limited (NPS) website www.nps.org.au.
For all hypnotics, NPS advises that doctors use the lowest dose for the shortest time possible (ideally for less than two weeks and no longer than four weeks) and re-evaluate within seven to 14 days of starting therapy.

For the complete article visit the Australian Prescriber website www.australianprescriber.com

Source: Australian Prescriber media releases. Hypnotic hazards and effects of z-drugs immeasurable

Gamma amino butyric acid (GABA) is an inhibiting neurotransmitter that is present on human brains. As shown in the animation, gamma amino butyric acid promotes opening of a postsynaptic receptor, the GABA-A receptor.

This opening leads to a increased conductance to cloride ions, which produces membrane hiperpolarization, this induces a neuronal inhibition.

The binding of benzodiazepines to the GABA-A receptor increases the affinity of gamma amino butyric acid (GABA) and its receptor, thereby increasing the opening frecuency of GABA-A receptor.As a consequence of this, benzodiazepines potentiate GABAergic neurotransmission.

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Drug list:

Some of the drugs included under the benzodiazepine class are:

• Alprazolam
• Diazepam
• Flurazepam
• Lorazepam
• Midazolam
• Oxazepam
• Prazepam
• Temazepam
• Triazolam

References:

• Modern Pharmacology with Clinical Applications, Sixth Edition by Charles Craig
• Principles of Pharmacology: The Pathophysiologic Basis of Drug Therapy, Second Edition
  by David E Golan