2. for the Psychiatry Clerkship

3. is proud to present And Now Here Is The Host... Insert Name Here

4. The categories for today’s Jeopardy on Mood Stabilizers will be:

5. Lithium

6. Divalproex Sodium

7. Carbamazepine

8. Lamotrigine

9. Antipsychotics

10. 100 200 300 800 700 500 800 Lithium Carbamazepine Anitpsychotics 100 700 500 700 400 800 600 100 900 300 500 800 Lamotrigine 100 900 500 400 300 200 300 400 600 800 200 300 600 200 500 400 700 600 200 400 700 600 Divalproex Sodium

11. Row 1, Col 1 Blood levels should be drawn about this many hours after the last dose What is 12 hours? (Trough)

12. 1,2 For maintenance treatment of Bipolar disorder, lithium levels should generally be above this What is 0.6-0.8 mEq/L?

13. 1,3 Before starting a young male patient on lithium, labs that should routinely be done are these What is TSH & BUN/creatinine?

14. 1,4 In lithium maintenance treatment, ideally these labs are done 1-2 times per year What is lithium level, TSH, BUN/creatinine?

15. 1,5 This lithium side effect can be worsened by caffeine or improved with propranolol treatment What is tremor? (resting or postural?)

16. 1,6 Unlike any antidepressant or mood stabilizer, Lithium treatment decreases patient’s mortality risk from this What is suicide?

17. 1,7 Lithium toxicity with a lithium level greater than 4.0 mEq/L is treated with this What is dialysis?

18. 1,8 To confirm therapeutic levels after starting lithium or increasing the dose, a lithium level should be done after this number of days What is 5 days? (Lithium half life = ?)

19. 1,9 For patients taking lithium, renal impairment, sodium depletion, or dehydration all increase the risk of this What is lithium toxicity?

20. 2,1 Divalproex Sodium (Depakote) exposure during the first trimester of pregnancy increases the risk this serious congenital anomaly What is neural tube defect (spina bifida)?

21. 2,2 Before starting a male patient on Divalproex Sodium (Depakote), these two lab tests should be done What are LFT’s & platelets?

22. 2,3 If Divalproex Sodium (Depakote) is added to the medication regimen of a patient who is taking Lamotrigine (Lamictal) this should be done. What is decrease Lamotrigine dose by half?

23. 2,4 Propranolol 2-3x’s per day may be used to treat this common side effect of divalproex (depakote) What is tremor?

24. 2,5 The age range of patients most at risk for divalproex’s (depakote) side effect of serious, possibly fatal, hepatoxicity is this What is under 2 years old ?

25. 2,6 Patients on the generic form of valproic acid (depakene) are at greater risk of developing this side effect than those on the enteric coated divalproex (depakote) What are GI side effects? (N/V/D, GI discomfort)

26. 2,7 Ironically, divalproex (depakote) is indicated as prophylaxis for this condition, which is also one of divalproex (depakote)’s common side effects What is Headache? (indicated for migraine prophylaxis)

27. 2,8 For divalproex (depakote), while the trough level of the Immediate Release (IR) should be drawn 12 hrs after the last dose, the trough level of Extended Release (ER) should be drawn at this time What is 18 hour after the last dose? If IR-last dose 10pm, blood draw 10am If ER-last dose 10pm, blood draw 4 pm

28. 2,9 For a patient taking Divalproex Sodium (Depakote), taking aspirin increases the risk of this What is decreased platelets? Thrombocytopenia

29. 3,1 Over the first few weeks of taking carbamazepine (tegretol) its t 1/2 will decease to less than 50%of its initial t 1/2 due to this What is auto-induction?

30. 3,2 Exposure of the fetus during the 1 st trimester of pregnancy leads to an unacceptable risk of this What is neural tube defect?

31. 3,3 Carbamazepine (tegretol) has a black box warning for these two rare (~1/100,000 = 0.001%) but serious side effects on the hematopoietic system What is agranulocytosis & aplastic anemia?

32. 3,4 This electrolyte may be abnormally low in patients who are taking carbamazepine (tegretol) What is sodium?

33. 3,5 CYP: 3A4 2D6 2C9 Carbamazepine (Tegretol) is both a substrate & an inducer of this cytochrome p450 enzyme system which makes up ~55% of the cytochrome p450 enzymes What is CYP 3A4?

34. 3,6 Carbamazepine (tegretol)’s drug- drug interaction with hormonal birth control increases the risk of this What is pregnancy?

35. 3,7 Closely related structurally to carbamazepine (tegretol), this medication has far fewer side effects but is not FDA approved for treatment of bipolar disorder What is oxcarbamazepine (trileptal)?

36. 3,8 Patients who are getting long term treatment with divalproex (depakote) or carbamazepine (tegretol) need to have regular labs done to check their medication blood levels, platelets/blood count, and this What is liver function test?

37. 3,9 To  the risk of birth defects, a woman on carbemazepine (tegretol) who desires to become pregnant should also take this medication What is folate?

38. 4,1 Patients who start taking lamotrigine (lamictal) have a this % risk of developing a benign rash What is 10%?

39. 4,2 While the side effect of a benign rash is relatively common, the risk of a severe rash is about 0.3%, and the risk of this is about 0.02-0.1% What is Steven’s Johnson Syndrome?

40. 4,3 The 4 picture set shows this side effect of lamictal (lamotrigine) What is Steven’s Johnson Syndrome?

41. 4,4 The drug-drug interaction between lamotrigine (lamictal) & divalproex sodium (depakote) results in lamictal’s blood level doing this What is increasing? (doubles)

42. 4,5 Lamotrigine (lamictal), quetiapine (seroquel), lithium, olanzapine/fluoxetine (symbyax), & latuda (lurasidone) all have this in common regarding their usage in the treatment of pts with bipolar disorder What is FDA indication to treats bipolar depression

43. 4,6 Lamotrigine (lamictal), lithium, quetiapine (seroquel), olanzapine (zyprexa) & aripiprazole (abilify) all have this in common regarding their usage in treatment of pts with bipolar disorder What is FDA indication for use in maintenance treatment of bipolar disorder?

44. 4,7 Lithium, divalproex (depakote), carbamazepine ER (tegretol ER) quetiapine (seroquel), ziprasidone (geodon), & asenapine (saphris) are FDA indicated to treat this phase of bipolar disorder but lamotrigine (lamictal) is not What is an acute manic episode?

45. 4,8 Lithium, divalproex (depakote), quetiapine (seroquel), & olanzapine (zyprexa) with regard to these two common side effects are NOT side effects of lamotrigine (lamictal) What is weight gain and sedation?

46. 4,9 The common mechanism of action for the mood stabilizers carbamazepine (tegretol), divalproex (depakote), and lamotrigine (lamictal) is blocking these What is Sodium channels?

47. 5,1 This SGA has FDA indication to treat acute mania or for maintenance treatment of bipolar disorder, but of all the SGA’s it has the highest risk for weight gain, elevated lipids, and diabetes What is olanzapine (zyprexa)?

48. 5,2 This SGA has FDA indication to treat acute mania or for maintenance treatment of bipolar disorder, but must be taken with food or > 50% will not be absorbed in the digestive tract What is ziprasidone (geodon)?

49. 5,3 While this SGA has FDA indication to treat acute mania or for maintenance treatment of bipolar disorder, it has a particularly long half life of ~75 hours and takes nearly 2 weeks to reach steady state What is aripiprazole (abilify)?

50. 5,4 This SGA has FDA indication to treat acute mania or for maintenance treatment of bipolar disorder, but at high doses (> 6 mg) it acts more like a FGA and has a much higher rate of EPS side effects What is risperidone (risperdal)?

51. 5,5 This SGA has FDA indication to treat acute mania & must be taken sublingually because if it is swallowed only ~5% will be bioavailable due to 1 st pass liver metabolism What is asenapine (saphris)?

52. 5,6 These 2 SGA’s, in addition to being FDA indicated to treat acute mania or for maintenance treatment of bipolar disorder, are the least likely of the SGA’s to cause weight gain or metabolic syndrome What is ziprasidone (geodon) & aripiprazole (abilify)?

53. 5,7 This SGA is FDA indicated to treat acute mania or for maintenance treatment of bipolar disorder, but should not be used in patient’s with ECG’s that show an QTc > 500 milliseconds What is ziprasidone (geodon)?

54. 5,8 These three SGA’s are useful is FDA indicated for treating bipolar depression; two by themselves, the other in combination with fluoxetine (prozac) What are quetiapine (seroquel), latuda (lurasidone) & olanzapine (zyprexa)?

55. 5,9 Risperidone (risperdal consta), paliperidone (invenga sustenna), and these 2 SGA’s are available in a long acting injectable form What is aripiprazole (abilify maintena) & olanzapine (zyprexa relprevv)