Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
15 Cards in this Set
- Front
- Back
|
Refer to Case 4
PA is diagnosed with major depressive disorder (MDD) but is not interested in psychotherapy at the present time. She is amenable to pharmacotherapy. What first-line therapy, titration schedule and maximum effective dose is most appropriate this patient? a. Nortriptyline (Pamelor) 50 mg at bedtime; titrate every week to the maximum dose of 150 mg daily b. Venlafaxine ER (Effexor XR) 150 mg daily; titrate every week to a maximum dose of 225 mg daily c. Fluoxetine (Prozac) 20 mg daily; titrate every week to the maximum dose of 100 mg daily d. Paroxetine (Paxil) 20 mg daily; titrate every week to the maximum dose of 50 mg daily e. Bupropion SR (Wellbutrin SR) 75 mg daily for 3 days, titrate every 3 days to a maximum dose of 300 mg bid |
d. Paroxetine (Paxil) 20 mg daily; titrate every week to the maximum dose of 50 mg daily
A. Not considered first-line therapy due to AE’s and potential toxicities B. Incorrect initial dose C. Incorrect titration schedule (should be qmonth) D. Correct answer See objective 5 E. Incorrect maximum dose |
|
|
Refer to Case 4
PA presents for her first follow-up visit after 4 weeks. She is still experiencing some bothersome depressive symptoms, but they have subsided in severity as indicated by a HAM-D score of 10. She is currently taking sertraline (Zoloft) 100 mg daily without adverse effects and states perfect compliance. What is the most appropriate action to take to induce remission in this patient? a. Continue sertraline (Zoloft) 100 mg daily and reassess in 4 weeks b. Discontinue sertraline (Zoloft); initiate citalopram (Celexa) 20 mg daily and reassess in 4 weeks c. Continue sertraline (Zoloft) 100 mg daily; add bupropion XR (Wellbutrin XL) 150 mg daily, titrate every week to a maximum effective dose of 450 mg daily; reassess in 4 weeks d. Continue sertraline (Zoloft) 100 mg daily; add mirtazipine (Remeron) 15 mg daily, titrate every 4-7 days to a maximum effective dose of 45 mg; reassess in 4 week e. Increase sertraline (Zoloft) dose to 150 mg daily, then to 200 mg daily after 1 week; reassess in 4 weeks |
e. Increase sertraline (Zoloft) dose to 150 mg daily, then to 200 mg daily after 1 week; reassess in 4 weeks
a. See treatment algorithm. This would not be an option for a partial response (reduction in symptoms by 26-49%) b. Sertraline is not at the maximum dose. Failure cannot be determined until max dose is met for at least 4 weeks c. See B d. See B; also mirtazipine may be a poor choice in this patient due to potential weight gain e. Correct. Please see objective 5 |
|
|
TK is a 59 year old Caucasian male who is initiating citalopram (Celexa) 20 mg daily due to a diagnosis of depression. Past Medical History also includes Gastroesophageal reflux disease for which he takes omeprazole (Prilosec OTC) every morning and osteoarthritis for which he takes naproxen 550 mg prn.
The diagnosing physician asks for you to counsel TK on possible adverse effects that TK may expect from citalopram. Which of the following adverse effects is most likely to occur with this medication? a. Sexual dysfunction b. Orthostatic hypotension c. Hypertensive crisis d. Seizures e. Increase in blood pressure |
a. Sexual dysfunction
A. Correct answer: increased 5HT postsynaptic ally has the ability to bind to theta receptors; thus, causing sexual dysfunction. Please see objective 5. B. Common to antidepressants that block 1 receptors (TCAs) and MAO-If’s C. May occur if tramline is consumed while a patient takes an MAO-I D. Rare adverse effects of bupropion E. May occur with agents that potentiate norepinephrine (Venlafaxine, Duloxetine) |
|
|
22. TK returns to his primary care physician for a follow-up visit 3 weeks after initiating citalopram. He was instructed to increase the dose to 40 mg after 1 week, but was unable to do so due to intolerable adverse effects. Symptoms of depression have slightly improved, but he states it is difficult to tell due to “feeling so bad” after initiating citalopram. After a thorough discussion, you theorize that TK may have a polymorphism of 2D6, which would make him a poor metabolizes (PM). What first-line antidepressant medication may TK change to that is not a substrate for 2D6?
a. Bupropion XR (Wellbutrin XL) 150 mg daily b. Fluoxetine (Prozac) 20 mg daily c. Sertraline (Zoloft) 50 mg daily d. Venlafaxine (Effexor XR) 75 mg daily e. Duloxetine (Cymbalta) 40 mg daily |
a. Bupropion XR (Wellbutrin XL) 150 mg daily
Correct answer- A. Only bupropion is not a substrate of 2D6. It utilizes 2B6. See objective 5. |
|
|
Refer to Case 5
AK is diagnosed with depression (MDD) but does not want a referral to a psychotherapist yet. She is willing to take medication. Which of the following is most appropriate for this patient at this time? a. Fluoxetine (Prozac) 20 mg daily; titrate every week to the maximum dose of 100 mg daily b. Citalopram (Celexa) 20 mg daily; titrate every week to the maximum dose of 40 mg daily c. Amitriptyline (Elavil) 50 mg at bedtime; titrate every week to the maximum dose of 200 mg daily d. Venlafaxine ER (Effexor XR) 150 mg daily; titrate every week to a maximum dose of 225 mg daily e. Bupropion SR (Wellbutrin SR) 75 mg daily for 3 days, titrate every 3 days to a maximum dose of 300 mg bid |
b. Citalopram (Celexa) 20 mg daily; titrate every week to the maximum dose of 40 mg daily
A, Incorrect titration: should be every month B, Correct answer C, Not first-line therapy due to AEs D, Incorrect starting dose E, Incorrect maximum effective dose |
|
|
AK presents for her first follow-up visit after 4 weeks. She is still experiencing some depressive symptoms, but they have subsided in severity as indicated by a HAM-D score of 10. She is currently taking sertraline (Zoloft) 100 mg daily without adverse effects and states perfect compliance. What is the MOST appropriate action to take to induce remission in the acute treatment phase?
a. Continue sertraline (Zoloft) 100 mg daily and reassess in 4 weeks b. Discontinue sertraline (Zoloft); initiate escitalopram (Lexapro) 10 mg daily and reassess in 4 weeks c. Increase sertraline (Zoloft) dose to 150 mg daily, then to 200 mg daily after 1 week; reassess in 4 weeks d. Continue sertraline (Zoloft) 100 mg daily; add bupropion XR (Wellbutrin XL) 150 mg daily, titrate every week to a maximum effective dose of 450 mg daily; reassess in 4 weeks e. Continue sertraline (Zoloft) 100 mg daily; add lithium extended-release (Lithobid) 150 mg bid, titrate every 3 to 4 days to a achieve a serum concentration of 0.5-0.8 mmol/L; reassess in 4 weeks |
A, See treatment algorithm. This would NOT be an option for a partial response (reduction in symptoms by 26-49%)
B, Sertraline is not at the maximum dose. Failure cannot be determined until max dose is met for at least 4 weeks C, Correct D, See B E, See B |
|
|
22. JA is a 46 year old white male who is initiating paroxetine (PaxilCR) 25 mg daily for depression. The patient’s medical history also includes gastroesophageal reflux disease for which he takes omeprazole (Prilosec OTC) every morning. The diagnosing physician asks for you to counsel JA on possible adverse effects that JA may experience from paroxetine. Which of the adverse effects listed below is most likely to occur?
a. Orthostatic hypotension b. Hypertensive crisis c. Seizures d. Increase in blood pressure e. Sexual dysfunction |
e. Sexual dysfunction
A, Common to antidepressants that block alpha-1 receptors (TCAs) and MAOIs B, May occur if tyramine is consumed while a patient takes an MAOI C, Rare adverse effect of bupropion D, May occur with agents that potentiate norepinephrine (Venlafaxine, duloxetine) E, Correct answer: increased 5HT postsynaptically has the ability to bind to 5HT2a receptors; thus, causing sexual dysfunction. |
|
|
JA (same patient as in previous question) returns to his primary care physician for a follow-up visit 2 weeks after initiating paroxetine. He was instructed to increase the dose to 37.5 mg after 1 week, but did not due to intolerable adverse effects. Symptoms of depression have slightly improved, but he states it is difficult to tell due to “feeling so bad” after initiating paroxetine. After a thorough discussion, the physician and you theorize that JA may have a polymorphism of 2D6; thus, rendering him a poor metabolizer (PM). What first-line antidepressant medication may JA change to that is not a substrate for 2D6?
a. Bupropion XR (Wellbutrin XL) 150 mg daily b. Fluoxetine (Prozac) 20 mg daily c. Sertraline (Zoloft) 50 mg daily d. Venlafaxine (Effexor XR) 75 mg daily e. Duloxetine (Cymbalta) 40 mg daily |
a. Bupropion XR (Wellbutrin XL) 150 mg daily
Only bupropion is not a substrate of 2D6. It utilizes 2B6. |
|
|
LPG is a 40 year old woman with no past medical history whose 12 year old daughter passed away 6 months ago. She presents today to her primary care physician with a number of non-specific somatic complaints (e.g. headaches, abdominal pain, difficulty sleeping). Her physician is unable to find any physical abnormalities and is considering the possibility that she has clinical depression.
Which of the following would be most consistent with a diagnosis of depression in this patient? a. alogia, flat affect, anhedonia, avolition b. anhedonia, weight loss or gain, depressed mood c. chest pain, tremulousness, hyperventilation d. since she is still grieving, diagnosis of clinical depression is unlikely |
Selection b is correct. Selection a and c describe negative symptom of schizophrenia and anxiety, respectively. Selection d is possible but unlikely due to the duration of time
(i.e. >2 months) that has passed since the loss of her child. |
|
|
Which of the following most correctly describes the pathogenesis of depression?
a. norepinephrine plays no role b. drugs that increase concentration of serotonin my precipitate or exacerbate depression c. drugs that increase activity of dopamine my precipitate or exacerbate depression d. drugs that increase norepinephrine activity, such as amitriptyline and venlafaxine, may improve depression |
d. drugs that increase norepinephrine activity, such as amitriptyline and venlafaxine, may improve depression
Selection d is correct. Please see slides 42 thru 48. |
|
|
Ms. LPG begins therapy with sertraline 50 mg po qd and returns two weeks later for follow-up. Based on her observations at this clinic visit, the physician feels that Ms LPG has not improved. Which of the following is the best next step?
a. increase dose of sertraline to 100 mg po qd and re-evaluate in two weeks. b. discontinue sertraline, begin paroxetine 50 mg po qd, and re-evaluate in two weeks. c. obtain a sertraline concentration to assess dose and compliance d. continue this dose and re-evaluate in two weeks |
a. increase dose of sertraline to 100 mg po qd and re-evaluate in two weeks.
Selection a is correct. Please see paragraphs 1 and 2 in column 2 page 1250 of required reading and slides 52, 68, and 69. Selection b is incorrect for two reasons: 1) too early to discontinue sertraline; 2 weeks at the starting dose does not constitute an adequate trial; 2) initial dose of paroxetine is incorrect. Selection c is incorrect since this information is not yet routinely available. Selection d is incorrect since the patient should have had even a minimal response within that time period. |
|
|
Ms. DA is a 35 year old white female who presents to her primary care physician
with complaints of depressed mood. After a complete physical exam, mental status exam, laboratory assessment, and medication review, the physician diagnoses Ms DA with major depressive disorder (MDD) of moderate severity. PMH: None Medications: Desogen® (ethinyl estradiol;desogestrel) 1 tablet daily for 21 days, off for 7 days, then repeat Multivitamin daily Mood disorder questionnaire: negative HAM-D score: 17 What is the most appropriate initial therapy for MDD in this patient? a. Phenelzine (Nardil®) 15 mg tid b. Amitriptyline (Elavil®) 50 mg at bedtime c. Psychotherapy d. Citalopram (Celexa®) 20 mg daily e. Bupropion extended-release (Wellbutrin XL®) 150 mg daily |
e. Bupropion extended-release (Wellbutrin XL®) 150 mg daily
Correct answer is selection “e”. May be used as a first-line option due to good safety, tolerability, and efficacy profile. Reduced adverse effects with bupropion compared to SSRIs (sexual dysfunction, weight gain) make this drug the best choice in a young patient that may be sexually active without CI to bupropion, such as a hx of seizure disorder. Wrong Answers: a. Not an appropriate option for first-line therapy due to adverse effects, dietary restrictions, and drug interactions. b. Not an appropriate first-line option due to adverse effects and toxicity in overdose. c. Not an appropriate first-line option in moderate depression. May be used as monotherapy in mild depression or used in combination with pharmacotherapy in moderate-severe depression. d. May be used as a first-line option due to good safety, tolerability, and efficacy profile. Increased incidence of sexual side effects renders this drug a second option. |
|
|
A patient returns to a pharmacist-managed mood disorder clinic for follow-up. He
was diagnosed 4 weeks ago with MDD (HAM-D score = 20) and was placed on paroxetine (Paxil) 20 mg daily. His HAM-D score at this visit is 9 and he is not experiencing any adverse effects. What option/s is/are most appropriate for the pharmacist at this visit? a. Continue with current therapy and assess in 2 to 4 weeks b. Increase dose of paroxetine (Paxil) to 40 mg daily and assess in 2 to 4 weeks c. Switch from paroxetine to sertraline (Zoloft) 50 mg daily and assess in 2 to 4 weeks d. All of the above e. Either a or b |
e. Either a or b
Correct answer is selection “e”. These are appropriate options for a partial remission defined as a decrease in sx of greater than 50% - see algorithm discussed in acute treatment. “c”. This patient has experienced a partial remission and switching the drug at this time is not appropriate. Switching medication may be an option if response is less than 50% or the drug is intolerable – see acute treatment algorithm |
|
|
A patient returns to a pharmacist-managed mood disorder clinic for follow-up. She was diagnosed 5 weeks ago with MDD (HAM-D score = 17) and was placed on
sertraline (Zoloft®) 50 mg daily with titration to 150 mg daily. Her HAM-D score at this visit is 12. She experienced nausea at treatment onset, but has since resolved. What option/s is/are most appropriate for the pharmacist at this visit? a. Continue with current therapy and assess in 2 to 4 weeks b. Increase dose of sertraline (Zoloft®) 200 mg daily and assess in 2 to 4 weeks c. Switch from sertraline (Zoloft®) 150 mg daily to fluoxetine (Prozac®) 20 g daily and assess in 4 weeks. d. Both a and b e. Both b and c |
e. Both b and c
Correct answer is selection “e”. This patient has experienced a partial response. There are three options available to the pharmacist at this time: increase the dose, switch the drug, and augmentation – see acute treatment algorithm. “a”. Not appropriate for a partial response defined as a reduction in symptoms of 26-49%. Addendum: since the typographical error in selection “c” (i.e. fluoxetine 20 g daily instead of fluoextine 20 mg daily) actually renders it an incorrect selection, it is highly likely that selections “e” and “b” will be accepted as correct. |
|
|
AH is a 55 year old African American male who presents to his primary care physician with complaints of depressed mood, anhedonia, and insomnia. After a
complete physical exam, mental status exam, laboratory assessment, and medication review, the physician diagnoses AH with mild major depressive disorder (MDD). PMH: hypertesnion Medications: Amlodipine (Norvasc®) 5 mg daily Mood disorder questionnaire: negative HAM-D score: 13 What is the most appropriate initial therapy for MDD in this patient? a. Venlafaxine ER (Effexor XR®) 75 mg daily b. Mirtazapine (Remeron®) 15 mg daily c. St. John’s wort (0.3% hypericin) 300 mg tid d. Escitalopram (Lexapro®) 10 mg daily e. Bupropion SR (Wellbutrin SR®) 150 mg daily |
b. Mirtazapine (Remeron®) 15 mg daily
Correct answer is selection “b”. May be used as a first-line agent due to limited drug interactions, equally efficacious to other agents, available as a generic. Major side effect of this drug is sedation, which may be beneficial in this patient. Wrong Answers: a. Has been shown to increase diastolic blood pressure. An alternative option is more appropriate c. Not recommended due to drug interactions, disparate efficacy data, and additional adverse effects (phototoxicity) d. All SSRIs may cause/worsen insomnia e. Highest rate of insomnia compared to other first-line agents |
