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

Lithium

Divalproex Sodium

Carbamazepine

Lamotrigine

Antipsychotics

Lithium Carbamazepine Anitpsychotics Lamotrigine Divalproex Sodium

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

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

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

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

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

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

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

1,8 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 = ?)

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

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)?

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

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

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

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 ?

2,6 Because divalproex (depakote) is enteric coated this side effect is less likely, or at least less severe, than in the generic form of valproic acid (depakene) What are GI side effects? (N/V/D, GI discomfort)

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)

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? IR-last dose 10pm, blood draw 10am ER-last dose 10pm, blood draw 4 pm

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

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?

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?

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?

3,4 This electrolyte that may be abnormally low in patient’s who are taking carbamazepine (tegretol) What is sodium?

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

3,6 Sexually active women taking carbamazepine (tegretol) & hormonal birth control are at risk of this What is becoming pregnant?

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)?

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?

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?

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

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 % What is Steven’s Johnson Syndrome?

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

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

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 treats bipolar depression

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 use in maintenance treatment of bipolar disorder?

4,7 Lithium, divalproex (depakote), carbamazepine ER (tegretol ER) quetiapine (seroquel), ziprasidone (geodon), & asenapine (saphris) can treat this phase of bipolar disorder but lamotrigine (lamictal) cannot What is an acute manic episode?

4,8 Two common side effects of lithium, divalproex (depakote), quetiapine (seroquel), & olanzapine (zyprexa) are this & this which are NOT side effects of lamotrigine (lamictal) What is weight gain and sedation?

4,9 Similar to mood stabilizers such as carbamazepine (tegretol), and divalproex (depakote), lamotrigine’s (lamictal) mechanism of action includes blocking these What is Sodium channels?

5,1 This SGA is used 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)?

5,2 This SGA is used 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)?

5,3 While this SGA is used 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)?

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

5,5 This SGA is used 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)?

5,6 These 2 SGA’s, in addition to being used 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)?

5,7 This SGA is used 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)?

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

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)