Mood Stabilizers Jeopardy: Lithium, Divalproex Sodium, Carbamazepine, Lamotrigine, Antipsychotics

1. Jeopardy for the Psychiatry Clerkship

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

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

4. Lithium

5. Divalproex Sodium

6. Carbamazepine

7. Lamotrigine

8. Antipsychotics

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

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

11. 1,2 What is 0.6-0.8 mEq/L? For maintenance treatment of Bipolar disorder, lithium levels should generally be above this

12. 1,3 What is TSH & BUN/creatinine? Before starting a young male patient on lithium, labs that should routinely be done are these

13. 1,4 What islithium level, TSH, BUN/creatinine? In lithium maintenance treatment, ideally these labs are done 1-2 times per year

14. 1,5 What is tremor? (resting or postural?) This lithium side effect can be worsened by caffeine or improved with propranolol treatment

15. 1,6 What is suicide? Unlike any antidepressant or mood stabilizer, Lithium treatment decreases patient’s mortality risk from this

16. 1,7 What is dialysis? Lithium toxicity with a lithium level greater than 4.0 mEq/L is treated with this

17. 1,8 What is 5 days? (Lithium half life = ?) To confirm therapeutic levels after starting lithium or increasing the dose, a lithium level should be done after this number of days

18. 1,9 What is lithium toxicity? For patients taking lithium, renal impairment, sodium depletion, or dehydration all increase the risk of this

19. 2,1 What is neural tube defect (spina bifida)? Divalproex Sodium (Depakote) exposure during the first trimester of pregnancy increases the risk this serious congenital anomaly

20. 2,2 What are LFT’s & platelets? Before starting a male patient on Divalproex Sodium (Depakote), these two lab tests should be done

21. 2,3 What is decrease Lamotrigine dose by half? If Divalproex Sodium (Depakote) is added to the medication regimen of a patient who is taking Lamotrigine (Lamictal) this should be done.

22. 2,4 What is tremor? Propranolol 2-3x’s per day may be used to treat this common side effect of divalproex (depakote)

23. 2,5 What is under 2 years old ? The age range of patients most at risk for divalproex’s (depakote) side effect of serious, possibly fatal, hepatoxicity is this

24. 2,6 What are GI side effects? (N/V/D, GI discomfort) 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)

25. 2,7 What is Headache? (indicated for migraine prophylaxis) Ironically, divalproex (depakote) is indicated as prophylaxis for this condition, which is also one of divalproex (depakote)’s common side effects

26. 2,8 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 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

27. 2,9 What is decreased platelets? Thrombocytopenia For a patient taking Divalproex Sodium (Depakote), taking aspirin increases the risk of this

28. 3,1 What is auto-induction? Over the first few weeks of taking carbamazepine (tegretol) its t1/2 will decease to less than 50%of its initial t1/2 due to this

29. 3,2 What is neural tube defect? Exposure of the fetus during the 1st trimester of pregnancy leads to an unacceptable risk of this

30. 3,3 What is agranulocytosis & aplastic anemia? Carbamazepine (tegretol) has a black box warning for these two rare (~1/100,000 = 0.001%) but serious side effects on the hematopoietic system

31. 3,4 What is sodium? This electrolyte may be abnormally low in patients who are taking carbamazepine (tegretol)

32. 3,5 What is CYP 3A4? 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

33. 3,6 What is pregnancy? Carbamazepine (tegretol)’s drug-drug interaction with hormonal birth control increases the risk of this

34. 3,7 What is oxcarbamazepine (trileptal)? Closely related structurally to carbamazepine (tegretol), this medication has far fewer side effects but is not FDA approved for treatment of bipolar disorder

35. 3,8 What is liver function test? 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

36. 3,9 What is folate? To  the risk of birth defects, a woman on carbemazepine (tegretol) who desires to become pregnant should also take this medication

37. 4,1 What is 10%? Patients who start taking lamotrigine (lamictal) have a this % risk of developing a benign rash

38. 4,2 What is Steven’s Johnson Syndrome? 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%

39. 4,3 What is Steven’s Johnson Syndrome? The 4 picture set shows this side effect of lamictal (lamotrigine)

40. 4,4 What is increasing? (doubles) The drug-drug interaction between lamotrigine (lamictal) & divalproex sodium (depakote) results in lamictal’s blood level doing this

41. 4,5 What is FDA indication to treats bipolar depression 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

42. 4,6 What is FDA indication for use in maintenance treatment of bipolar disorder? Lamotrigine (lamictal), lithium, quetiapine (seroquel), olanzapine (zyprexa) & aripiprazole (abilify) all have this in common regarding their usage in treatment of pts with bipolar disorder

43. 4,7 What is an acute manic episode? 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

44. 4,8 What is weight gain and sedation? Lithium, divalproex (depakote), quetiapine (seroquel), & olanzapine (zyprexa) with regard to these two common side effects are NOT side effects of lamotrigine (lamictal)

45. 4,9 What is Sodium channels? The common mechanism of action for the mood stabilizers carbamazepine (tegretol), divalproex (depakote), and lamotrigine (lamictal) is blocking these

46. 5,1 What is olanzapine (zyprexa)? 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

47. 5,2 What is ziprasidone (geodon)? 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

48. 5,3 What is aripiprazole (abilify)? 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

49. 5,4 What is risperidone (risperdal)? 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

50. 5,5 What is asenapine (saphris)? 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 1st pass liver metabolism