Updates in Therapeutics® 2012:

The Pharmacotherapy Preparatory Review and Recertification Course

Conflict of Interest Disclosures

Melody Ryan –no conflicts of interest to

disclose

Updates in Therapeutics® 2012:

The Pharmacotherapy Preparatory Review &
Recertification Course
Neurology
Melody Ryan, PharmD, MPH
University of Kentucky College of Pharmacy

Learning Objectives Patient Case # 1

„ Differentiate between various antiepileptic drugs based on use and
adverse effects TM is an 18-year-old new patient in the
„ Develop a treatment strategy for status epilepticus pharmacy where you work. He presents a
„ Identify appropriate treatment strategies for primary and secondary prescription for carbamazepine 100 mg 1 PO
stroke prevention
BID with instructions to increase to 200 mg 1
„ Determine the appropriateness of treatment with tissue plasminogen
activator for acute stroke PO TID. Currently, he does not take any
„ Examine common adverse effects associated with treatment of medications and does not have any drug
Parkinson disease allergies. During your counseling session, TM
Differentiate between regimens for acute and prophylactice treatment
„
of migraine, tension, and cluster headaches
tells you he must have blood drawn for a test in
„ Identify common adverse effects of disease-modifying therapies for 3 weeks.
multiple sclerosis

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Patient Case # 1
Which of the following common potential adverse
Carbamazepine Adverse Effects
effects of carbamazepine is best assessed through a
blood draw? „ Rash
„ SIADH
A. Leukopenia „ Aplastic anemia
B. Renal failure „ Th
Thrombocytopenia
b t i
„ Anemia
C. Congestive heart failure
„ Leukopenia
D. Hypercalcemia

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© 2012 American College of Clinical Pharmacy 1

 Updates in Therapeutics® 2012:
The Pharmacotherapy Preparatory Review and Recertification Course

Patient Case # 2 Patient Case # 2

Which one of the following choices should be your response?
A. The rash is likely caused by carbamazepine because
One month later, TM returns to your carbamazepine rash often has delayed development
pharmacy with a new prescription for
lamotrigine 25 mg with instructions to take 1 B. The rash is unlikely caused by carbamazepine because
tablet daily for 2 weeks, then 1 tablet PO BID carbamazepine rash usually presents after the first dose
for 2 weeks
weeks, then 2 tablets PO BID for 2
C. The rash is unlikely caused by carbamazepine because
weeks, then 3 tablets PO BID thereafter. He it is probably attributable to carbamazepine-induced liver
tells you that the carbamazepine is being failure
discontinued because he developed a rash a
few days ago. D. The rash is unlikely caused by carbamazepine because
it is probably attriubutable to carbamazepine-induced
renal failure
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Dermatologic Adverse Effects Patient Case # 3

„ Dermatologic reactions to anticonvulsants
occur after a delay of 2-8 weeks
„ May include rash, Stevens-Johnson
syndrome, anticonvulsant hypersensitivity TM wants to know why it is necessary to
syndrome increase the dose of lamotrigine so
„ Recommendation for testing for the HLA-
HLA slowly.
B*1502 allele in patients of Asian,
including South Asian Indians, ancestry
have a 10-time increased risk of rash
„ Patients with HLA-A*3101 (usually
Caucasian) are also at increased risk for
rash
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Patient Case # 3 Lamotrigine Rash

Which one of the following replies is best?

A. It causes dose-related psychomotor slowing „ Related to starting dose

„ Particular caution necessary in children
B. It causes dose-related renal stones
„ Valproic
p acid inhibits lamotrigine
g
C. It causes dose-related paresthesias metabolism and increases rash risk
„ May be mild to serious in nature
D. It causes dose-related rash

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© 2012 American College of Clinical Pharmacy 2

 Updates in Therapeutics® 2012:
The Pharmacotherapy Preparatory Review and Recertification Course

Patient Case # 4 Patient Case # 4

Which one of the following drugs is best to use first?

JG is a 34-year-old patient who has been A. Diazepam

maintained on carbamazepine extended-
B. Lorazepam
release 400 mg orally 2 times/day for the
past 2 years. She has had no seizures
C. Phenytoin
for the past 4 years. She presents to the
emergency department in status D. Phenobarbital
epilepticus.

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Status Epilepticus Status Epilepticus

„ Always give a rapidly acting medication to „ Lorazepam is the drug of choice for first line
stop seizures immediately therapy
(benzodiazepine)
„ Lorazepam is less lipophilic than diazepam
„ Follow with a longer-acting medication to ‰ Stays in the CNS longer rather than being re-
prevent recurrence of seizures (phenytoin, distributed to other areas of the body
fosphenytoin, phenobarbital, valproic acid)
„ All medications for status epilepticus
should be given parenterally
„ Do not use a neuromuscular blocker
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Patient Case # 5 Patient Case # 5

Today, which of the following best represents his
expected serum concentration?
SR is a 37-year-old patient who began taking
phenytoin 100 mg 3 capsules PO QHS 6 A. 10 mcg/mL
months ago. He has experienced several
seizures since that time;; the most recent B 14 mcg/mL
B.
occurred this past week. At that time, his
phenytoin serum concentration was 8 C. 16 mcg/mL
mcg/mL. The treating physician increased
his dose to phenytoin 100 mg 3 capsules PO D. 20 mcg/mL
BID.
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© 2012 American College of Clinical Pharmacy 3

 Updates in Therapeutics® 2012:
The Pharmacotherapy Preparatory Review and Recertification Course

Phenytoin Pharmacokinetics Patient Case # 6

„ Non-linear (Michaelis-Menton) kinetics
„ Highly protein bound SS is a 22-year-old woman who has always
had episodes of “zoning out.” Recently, one
of these episodes occurred after an
examination while she was driving home.
She had a non
non-injury
injury accident,
accident but it
prompted a visit to a neurologist. She is
given a diagnosis of absence seizures.

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Patient Case # 6 Medications for Absence Seizures

Which of the following drugs is best to treat this type of
epilepsy?
„ First-line
A. Phenytoin ‰ Ethosuximide
‰ Valproic acid
B Tiagabine
B. „ Second-line
‰ Clonazepam
C. Carbamazepine ‰ Lamotrigine

D. Ethosuximide

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Patient Case # 7 Patient Case # 7

Which of the following adverse effects is JB most likely to
experience related to the dose increase?
JB is a 25-year-old man with a history of
seizure disorder. He has been treated
with phenytoin 200 mg orally 2 times/day A. Drowsiness
for 6 months and his current phenytoin
concentration is 6
6.3
3 mcg/mL.
mcg/mL His B Acne
B.
neurologist decides to increase his
phenytoin dose to 300 mg 2 times/day. C. Gingival hyperplasia

D. Rash

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 Updates in Therapeutics® 2012:
The Pharmacotherapy Preparatory Review and Recertification Course

Phenytoin Adverse Effects Patient Case # 8

Dose-related Non-Dose-related MG is a 15-year-old male with a diagnosis of

„ Nystagmus „ Gingival hyperplasia juvenile myoclonic epilepsy. He has been
„ Ataxia „ Hirsutism prescribed sodium divalproate.
„ Drowsiness „ Acne

„ Cognitive impairment „ Rash

„ Hepatotoxicity

„ Coarsening of facial
features

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Patient Case # 8 Valproic Acid Adverse Effects

On which of the following adverse effects is it best to
counsel MG?
„ Hepatotoxicity
A. Oligohidrosis „ Nausea/vomiting
„ Weight gain
B Renal stones
B. „ I t f
Interference with
ith platelet
l t l t aggregation
ti
C. Alopecia
„ Pancreatitis
„ Alopecia
D. Word-finding difficulties

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Patient Case # 9
Patient Case # 9 Which one of the following is the most accurate comparison of
carbamazepine and oxcarbazepine?
GZ, a 26-year-old woman, presents with a 6-
month history of “spells.” The spells are all
the same, and all of them start with a feeling A. Oxcarbazepine causes more liver enzyme induction
in the abdomen that is difficult for her to than carbamazepine
describe. This feeling rises toward the head.
The patient believes that she will then loose B Oxcarbazepine
B. O b i does
d nott cause rash
h
awareness. After a neurologic work-up, she
is given a diagnosis of focal seizures evolving
to a bilateral, convulsive seizure. The C. Oxcarbazepine does not cause hyponatremia
neurologist is considering starting either
carbamazepine or oxcarbazepine. D. Oxcarbazepine does not form an epoxide intermediate
in its metabolism

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© 2012 American College of Clinical Pharmacy 5

 Updates in Therapeutics® 2012:
The Pharmacotherapy Preparatory Review and Recertification Course

Oxcarbazepine Patient Case # 10

„ Does not form an epoxide intermediate in its When you see GZ 6 months later for follow-
metabolism up, she tells you that she is about 6 weeks
„ Enzyme inducer, but no autoinduction pregnant. She has had no seizures since
„ Hyponatremia more common than with g
beginningg drugg therapy.
py
carbamzepine
„ Blood dyscrasias less common than with
carbamazepine

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Patient Case # 10 Pregnancy Recommendations

Which one of the following is the best strategy for GZ?

„ Women of childbearing potential

A. Immediately discontinue her antiepileptic drug
‰ Have the best medication for their seizure type
‰ Be treated with monotherapy, if possible
B. Immediately discontinue her antiepileptic drug
‰ Discuss the possible decrease in oral
and give folic acid contraceptive
t ti effectiveness
ff ti with
ith enzyme-inducing
i d i
antiepileptic medicines
C. Continue her antiepileptic drug „ 50 mcg of ethinyl estradiol or mestranol
‰ Folic acid supplementation of at least 0.4 mg/day
D. Change her antiepileptic drug to phenobarbital

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Pregnancy Recommendations Patient Case # 11

LR is a 78-year-old man who presents to
„ During/after pregnancy the emergency department for symptoms
‰ Medications optimized before conception of right-sided paralysis. He states these
Withdrawals accomplished at least 6 months before
„
symptoms began about 5 hours ago and
‰ Avoid valproic acid have not improved since then. He also
‰ Avoid
o d po
polytherapy,
yt e apy, if poss
possible
be has hypertension
hypertension, benign prostatic
‰ Allow breastfeeding hypertrophy, diabetes mellitus, erectile
‰ Monitor serum concentrations dysfunction, and osteoarthritis.
„ Before, at the beginning of each trimester, last
month, during first 8 weeks post-partum
„ Lamotrigine, carbamazepine, phenytoin,
levetiracetam, oxcarbazepine

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 Updates in Therapeutics® 2012:
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Patient Case # 11 Stroke Risk Factors

Which of the following is the most accurate assessment of LR’s risk
factors for stroke? Non-modifiable Modifiable
„ Age „ Hypertension
„ Race
„ Smoking
A. Erectile dysfunction, age, osteoarthritis
„ Estrogens
„ Male sex
„ Atrial fibrillation
B. Sex,, diabetes
b mellitus,, osteoarthritis „ Low birth weight
„ Coronary artery disease
„ Family history „ Carotid stenosis
C. Benign prostatic hypertrophy, diabetes mellitus,
age, sex Somewhat modifiable „ Dyslipidemia
„ Diabetes mellitus „ Obesity
D. Age, diabetes mellitus, sex, hypertension „ Physical inactivity
„ Sickle cell anemia
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Stroke Risk Factors Patient Case # 12

Modifiable Less well documented

„ Peripheral artery disease „ Alcohol abuse Is LR a candidate for tissue plasminogen
„ Pregnancy „ Hyperhomocysteinemia activator for treatment of stroke?
„ Patent foramen ovale „ Drug abuse
„ Depression „ Hypercoagulability
„ Periodontal disease
„ Acute systemic inflammation
and infection
„ Sleep disordered breathing
„ Metabolic syndrome
„ Migraine with aura

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Patient Case # 12 Tissue Plasminogen Activator

Which one of the following options is the best response?

A. Yes „ Within 3 hours of symptoms

„ 3 month outcome significantly improved
B. No, he is too old „ Intracerebral hemorrhage increased, but no
increase in mortality or disability
C. No, his stroke symptoms began too long ago
„ Dose 0.9 mg/kg IV (max 90 mg with 10% as
D. No, his diabetes mellitus is a contraindication
a bolus, remainder over 1 hr)
for tissue plasminogen activator

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© 2012 American College of Clinical Pharmacy 7

 Updates in Therapeutics® 2012:
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TPA Exclusion Criteria Time Window for TPA

„ Intracranial or subarachnoid bleeding or hx
„ Other active internal bleeding „ Expanded to 4.5 hours with additional
„ Recent intercranial surgery, head trauma, exclusion criteria
stroke ‰ Taking any oral anticoagulant
„ Blood pressure > 185/110 mm Hg ‰ Baseline NIHSS score greater than 25
‰ Previous stroke combined with diabetes
„ Seizure at stroke onset
‰ Age older than 80
„ Intracranial neoplasm, AV malformation,
aneurysm
„ Active treatment with warfarin, heparin,
platelets < 100,000
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Patient Case # 13 Patient Case # 13

Which one of the following choices is the best secondary stroke
prevention therapy for this patient?

He was previously taking no drugs at A. Sildenafil

home.
B. Celecoxib

C. Aspirin

D. Warfarin

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Secondary Stroke Prevention Patient Case # 14

You are the pharmacist at a community
„ Reduction of risk factors pharmacy and receive a call from MW, a 64-
year-old man recently given a diagnosis of
„ Carotid endarterectomy atrial fibrillation. He is concerned about his
„ Aspirin risk for having a stroke because his friend,
„ A i i /di id
Aspirin/dipyridamole
l who also has atrial fibrillation
fibrillation, asked him
what dose of warfarin he is taking. MW
„ Ticlopidine called you because he is not taking warfarin
„ Clopidogrel and he wants to know if he should. He has
„ Warfarin no other medical conditions and takes
atenolol 50 mg/day orally for ventricular rate
control.
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 Updates in Therapeutics® 2012:
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Patient Case # 14
After encouraging him to discuss this with his doctor, which one of the
CHADS2 Score
following choices best describes what you should tell him?

Congestive heart failure, hypertension, age >75

A. You need warfarin treatment to prevent a stroke years, diabetes mellitus, and prior stroke or
transient ischemic attack stratification scheme
B. You do not need warfarin, but you should take aspirin
‰ Assign 1 point each for CHF, HTN, age ≥ 75 years, or
and clopidogrel
diabetes
C. You do not need drug therapy at this time ‰ Assign 2 points for previous stroke or TIA
‰ If total=0, no therapy or aspirin 75-325 mg/day
D. Because you have atrial fibrillation, nothing can reduce ‰ If total≥1, give either oral anticoagulant (alternative
your risk of stroke aspirin 75-325 mg/day and clopidogrel 75 mg BID)
‰ Dabigatran 150 mg BID recommended over warfarin

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CHADS2 Score Patient Case # 15

L.S. is a 72-year-old woman with a medical
Congestive heart failure, hypertension, age >75 history of hypertension, type 2 diabetes
years, diabetes mellitus, and prior stroke or mellitus, renal failure, and atrial fibrillation.
transient ischemic attack stratification scheme She presents to the anticoagulation clinic for
her initial visit.
‰ Assign 1 point each for CHF, HTN, age ≥ 75 years, or
diabetes
‰ Assign 2 points for previous stroke or TIA
‰ If total=0, no therapy or aspirin 75-325 mg/day
‰ If total≥1, give either oral anticoagulant (alternative
aspirin 75-325 mg/day and clopidogrel 75 mg BID)
‰ Dabigatran 150 mg BID recommended over warfarin

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Patient Case # 15 Patient Case # 16

Which one of the following best reflects her target INR?

SF is a 64-year-old woman who presents

A. 1.5
to the ED complaining of numbness in
her left hand and face for about 2 hours.
B. 2.0
The ED doctor suspects a stroke.
C. 2.5

D. 3.0

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© 2012 American College of Clinical Pharmacy 9

 Updates in Therapeutics® 2012:
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Patient Case # 16
Which one of the following choices best describes why streptokinase is or
Acute Stroke Treatment
is not an appropriate choice for acute therapy in this patient?
A. Streptokinase is not appropriate; steptokinase should
not be used in stroke treatment
„ Heparin
‰ Good outcome data not available
B. Streptokinase is not appropriate; streptokinase must be ‰ Avoid in hemorrhagic stroke
used within 1 hour of symptom onset ‰ aPTT 1.5
1.5-2.0
2.0 times control
C. Streptokinase is appropriate; streptokinase must be „ Streptokinase
used within 3 hours of symptom onset ‰ Avoid due to excess mortality
„ Tissue plasminogen activator
D. Streptokinase is appropriate; it is the drug of choice
for the treatment of stroke not involving paralysis

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Patient Case # 17 Patient Case # 17

You work as the clinical pharmacist in a small ASA + Placebo + RRR (95% CI)
hospital. Several of the physicians with Clopidogrel (n) Clopidogrel (n)
Primary 596 636 6.4% (-4.6-6.3)
whom you work want to use aspirin and outcome
p g together
clopidogrel g after stroke,, similar to Secondary outcomes
what they are doing for MI. You access the
MI 73 68 -7.7% (-8.5-
MATCH study and obtain the following 20.4)
results: Ischemic stroke 309 333 7.1% (-8.5-20.4)

Death, all cause 201 201 0.1% (-21.5-

17.8)

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Patient Case # 17
Which one of the following is the best interpretation of this information?
Relative Risk Reduction

A. Aspirin plus clopidogrel is more effective than placebo „ RRR of 1 indicates no difference between
plus clopidogrel only for the primary outcome
groups
B. Aspirin plus clopidogrel is more effective than placebo plus „ The 95% CI also cannot contain 1
clopidogrel
p g for all the secondaryy outcomes.

C. Aspirin plus clopidogrel is more effective than placebo plus

clopidogrel for prevention of myocardial infarction.

D. Aspirin plus clopidogrel is no more effective than

placebo plus clopidogrel for any of the listed outcomes.

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© 2012 American College of Clinical Pharmacy 10

 Updates in Therapeutics® 2012:
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Patient Case # 18 Patient Case # 18

Which one of the following changes is best to resolve these
symptoms?
LS is taking levodopa/carbidopa 25 A. Increase carbidopa/levodopa
mg/100 mg orally 4 times/day and
trihexyphenidyl 2 mg orally 3 times/day B. Increase trihexyphenidyl
for his Parkinson disease. LS’s wife C. Decrease carbidiopa/levodopa
reports that he is often confused and
experiences constipation; he has trouble D. Decrease trihexyphenidyl

talking because of his dry mouth.

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Anti-Parkinson Adverse Effects Patient Case # 19

„ Dopaminergic „ Anticholinergic
‰ Nausea/vomiting ‰ Dry mouth Six months later, LS returns to the clinic
‰ Orthostatic ‰ Urinary retention concerned that his levodopa/carbidopa
hypotension ‰ Dry eyes dose is wearing off before his next dose
‰ Hallucinations ‰ Constipation is due.
‰ Confusion

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Patient Case # 19 Anti-Parkinson Adverse Effects

Which one of the following is best to suggest?

A. Increase the dose of carbidopa/levodopa „ Levodopa/carbidopa

B. Decrease the dose of carbidiopa/levodopa ‰ Wearing off
„ Use controlled release formulation
C. Increase the dosing interval „ Give doses more frequently
„ Add COMT inhibitor
D. Decrease the dosing interval
„ Add dopamine agonist
‰ On-off
„ Add COMT inhibitor, selegiline, rasagaline,
pramipexole, ropinirole, apomorphine
„ Redistribute dietary protein
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Handout Page 1-356; Answer Page 1-372

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 Updates in Therapeutics® 2012:
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Patient Case # 20 Patient Case # 20

Which, if any, of his drugs is the most likely cause of this condition?

PJ is a 57-year-old man with an 8-year

history of Parkinson disease. His current A. Carbidopa/levodopa
drugs include carbidopa/levodopa 50/200 B. Entacapone
orally 4 times/day, entacapone 200 mg
orally 4 times/day
times/day, and amanatadine 100 C. Amantadine
mg orally 3 times/day. He presents to the
D. None; likely represents venous stasis
clinic with a reddish blue discoloration on
his lower arms and legs.

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Anti-Parkinson Adverse Effects Patient Case # 21

„ Dopamine agonists „ Amantadine

‰ Ergot derived agents ‰ Livedo reticularis LL is a 47-year-old man with Parkinson
(bromocriptine and COMT inhibitors
pergolide) rarely have
„
disease. He takes carbidopa/levodopa
Diarrhea
retroperitoneal, ‰

Urine discoloration
50/200 orally 4 times/day. He recently
pleuropulmonary or
pleuropulmonary, ‰

cardiac fibrosis (entacapone) noticed an involuntary twitching

‰ Pergolide is movement of his left foot.
associated with
valvular heart
disease

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Patient Case # 21 Anti-Parkinson Adverse Effects

Which one of the following is the best therapy to treat LL’s
dyskinesia?

A. Add ropinirole „ Levodopa/carbidopa

B. Add selegiline ‰ Dyskinesias
„ Decrease dopaminergics
C. Increase carbidopa/levodopa „ Add amantadine

D. Decrease carbidopa/levodopa

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© 2012 American College of Clinical Pharmacy 12

 Updates in Therapeutics® 2012:
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Patient Case # 22 Patient Case # 22

Which one of the following is the best treatment for this man?

CA, a 57-year-old white man who just retired A. Trihexyphenidyl

from the NYC Fire Department, has been
experiencing tremors in his right hand that B. Entacapone
have become progressively worse for the
C. Apomorphine
past 6 months
months. He has difficulty walking
walking. He
also has backaches and no longer plays golf. D. Ropinirole
In addition, he is losing his sense of taste.
He is given a diagnosis of Parkinson disease.

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Treatment Choice in Parkinson Disease Patient Case # 23

MR, a 34-year-old pharmacist, has
throbbing right-sided headache. She
„ Anticholinergics work best for tremor experiences nausea, sonophobia, and
„ COMT inhibitors currently available do not photophobia with these headaches, but no
aura. She usually has headaches 2 times/
cross the blood-brain barrier and must be month. She is hypertensive and morbidly
given with carbidopa/levodopa obese. She takes an ethinyly estradiol/
progestin combination oral contraceptive
„ Apomorphine is only for severe on-off daily and hydrochlorothiazide 25 mg/day
symptoms orally. She has a diagnosis of migraine
headaches.

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Patient Case # 23 When to Use Prophylactic Agents

Which one of the following medications is best for prophylaxis of
her headaches?

A. Propranolol „ Recurrent migraines that interfere with

B. Valproic acid
daily routine
„ Frequent migraines
C. Amitriptyline
„ Inefficacy or inability to use acute therapy
D. Lithium „ Patient preference
„ Cost of acute medications problematic
„ Adverse effects with acute therapies
„ Uncommon migraine presentation

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 Updates in Therapeutics® 2012:
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Prophylactic Agents Migraine Treatment

„ Use lowest effective dose „ Prophylaxis page 1-357-8

„ Give adequate trial (2-3 months) ‰ Amitriptyline
„ Consider other disease states ‰ Propranolol
‰ Additional treatment ‰ Timolol
‰ Contraindications ‰ Valproic acid
‰ Topiramate
„ Acute treatment pages 1-358-9

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Patient Case # 24 Patient Case # 24

Which one of the following drugs is best for prophylaxis of her
headaches?
SR is a 54-year-old female homemaker with
squeezing, bandlike headaches that occur 3 A. Propranolol
or 4 times/week. She rates the pain of
B. Valproic acid
these headaches as 7 of 10 and finds
p
acetaminophen, , aspirin,
p , ibuprofen,
p , C. Amitriptyline
naproxen, ketoprofen, and piroxicam only
partially effective. She wishes to take a D. Lithium

prophylactic medication to prevent these

tension headaches.

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Tension Headache Treatment Patient Case # 25

DS is a 49-year-old male computer
„ Prophylaxis programmer who describes lancinating right
‰ Tricyclic antidepressants eye pain and tearing several times a day for
‰ Botulinum toxin 2-3 days in a row. He will then have no
episodes for 2-3 weeks but then will have
„ Acute treatment
recurrent episodes. In the office, he
‰ Acetaminophen
receives oxygen by nasal cannula during an
‰ NSAIDs episode, and his pain is relieved. He has a
diagnosis of cluster headaches.

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 Updates in Therapeutics® 2012:
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Patient Case # 25 Cluster Headache Treatment

Which one of the following drugs is best for prophylaxis of his
headaches?

A. Propranolol „ Prophylaxis „ Acute Treatment

‰ Verapamil ‰ Triptans
B. Valproic acid ‰ Melatonin ‰ Oxygen
C. Amitriptyline ‰ Suboccipital injection ‰ Intranasal lidocaine
of betamethasone
D. Lithium ‰ Lithium

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Patient Case # 26 Patient Case # 26

Which one of the following triptans is best to treat MK’s migraine
headaches?

A. Almotriptan
MK is a 44-year-old woman with right-
sided headaches of moderate intensity B. Naratriptan
that are accompanied by severe nausea C. Rizatriptan
and vomiting.
D. Sumatriptan

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Patient Case # 27 Patient Case # 27

Drug NNT
One of the neurologists you work with „ Ergotamine + caffeine 6.6
recently read a meta-analysis of migraine
„ Eletriptan 80 mg 2.8
treatments. He is most interested in the
outcome of sustained relief at 24 hours, „ Rizatriptan
Ri t i t 10 mg 56
5.6
but he is confused by the number „ Sumatriptan 50 mg 6.0
needed to treat analyses. He shows you
the following table:

Page Number 1-362 Page Number 1-362

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 Updates in Therapeutics® 2012:
The Pharmacotherapy Preparatory Review and Recertification Course

Patient Case # 27 Number Needed to Treat

Which one of the following is the best interpretation of these data?

A. Eletriptan 80 mg is the most effective agent „ Way to express the number of patients it
would be necessary to treat to have one
B. Ergotamine plus caffeine is the most effective drug
patient with benefit/adverse effect
C. Eletriptan has the most adverse effects

D. Ergotamine plus caffeine has the most adverse effects

1
NNT =
% improved on active therapy - % improved on placebo

Page Number 1-373

Handout Page 1-362; Answer Page 1-373

Patient Case # 28 Patient Case # 28

Which one of the following is the best method for treating SF’s
exacerbation?
SF is a 33-year-old African American woman of A. Interferon beta-1a
Cuban descent living in the Miami area. This
B. Glatiramer acetate
morning, her right leg became progressively
weaker over about 3 hours. She was C. Mitoxantrone
previously healthy except for a broken radius
D. Methylprednisolone
when she was 13 years old and a case of optic
neuritis when she was 25 years old.

Page Number 1-367

Handout Page 1-367; Answer Page 1-373

Treatment of Acute Relapses Patient Case # 29

Which one of the following therapies is best for SF to prevent
further exacerbations?
„ Intravenous methylprednisolone: The usual A. Interferon beta-1a
dose is 1 g/day as one or divided doses for
B. Interferon beta-1b
3–5 days
„ Oral prednisone: The usual dose is 1250 C. Glatiramer acetate
mg/day given every other day for five doses D. Any of the above
„ Intravenous adrenocorticotropic hormone
„ Neurologic recovery is the same with or
without an oral prednisone taper

Page Number 1-363

Handout Page 1-367; Answer Page 1-373

© 2012 American College of Clinical Pharmacy 16

 Updates in Therapeutics® 2012:
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Patient Case # 30 Patient Case # 30

Which one of the following is the best advice?

S.F. elects to start beta interferon-1b and wants A. Always give the injection at the same time of day
to know whether there is any way she can
B. Lie down for 2 hours after the injection
prevent or minimize some of the adverse
effects. C. Rotate injection sites

D. Use a heating pad on the injection sites

Page Number 1-367

Handout Page 1-367; Answer Page 1-373

Injection Site Reactions

„ More common with subcutaneous products

„ Bring medication to room temperature before
injection
„ Ice injection site
Updates in Therapeutics® 2012:
„ Rotate injection sites
The Pharmacotherapy Preparatory Review &
Recertification Course
General Psychiatry
Kelly C. Lee, Pharm.D., BCPP, FCCP
University of California, San Diego
Page Number 1-363

Conflict of Interest Learning Objectives and/or Agenda

Disclosures
1. Describe pharmacotherapeutic options for managing
the following psychiatric disorders: major depression,
bipolar disorder, schizophrenia, anxiety disorders,
insomnia, and alcohol withdrawal/dependence.
2
2. Describe the drugs used to treat the above disorders
N conflict
No fli t off iinterest
t t tto disclose.
di l with respect to unique pharmacologic properties,
therapeutic uses, adverse effects, and cognitive and
behavioral effects.
3. Formulate a pharmacotherapeutic treatment plan when
presented with a patient having depression, bipolar
disorder, schizophrenia, anxiety disorder, insomnia, and
alcohol withdrawal/dependence.
Page Number (Page number that the answer to
Patient Case is located if applicable)

© 2012 American College of Clinical Pharmacy 17

 Updates in Therapeutics® 2012:
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Outline Major Depression

Patient Case Page 1-380
„ Major Topics „ A.Z. is a 45-year-old woman with sleep
‰ Major Depression apnea, hypertension, diabetes mellitus type
‰ Bipolar Disorder 2, and chronic pain.
‰ Schizophrenia „ She endorses sad mood
mood, poor appetite (lost
„ Minor Topics 15 lb), poor concentration, and feelings of
‰ Anxiety Disorders hopelessness and worthlessness for the past
‰ Insomnia 3 weeks.
‰ Alcohol Dependence

103

Major Depression Patient Case # 1

Which of the following SSRIs would most likely
Patient Case Page 1-380 interact with her current medications?
„ Also stopped going to her book club due to
lack of motivation to get out of the house, and
A. Citalopram
has frequent mid-nocturnal awakening.
„ Denies SI/HI
SI/HI, ETOH,
ETOH tobacco,
tobacco or illicit drugs.
drugs B Fluvoxamine
B.
„ Currently taking HCTZ, metformin,
hydrocodone/acetaminophen, and aspirin. C. Paroxetine
You decide that A.Z. should receive a
selective serotonin reuptake inhibitor (SSRI) D. Sertraline
to treat her depressive symptoms.
Handout Page 1-380 ; Answer Page 1-415

Patient Evaluation DSM-IV Diagnostic Criteria

„ Target symptoms „ Depressed mood or anhedonia (loss of interest or

pleasure) and four (4) or more target symptoms (below)
„ Comorbidities, past medical history for at least two (2) weeks
„ Family and personal psychiatric history „ Weight change (loss or gain)
„ Sleep disturbance ((insomnia or hypersomnia)
y )
„ Rating Scales (patient-rated,
(patient rated clinician-rated)
clinician rated) „ Decreased energy
‰ Hamilton Rating Scale for Depression (HAM-D) „ Feelings of worthlessness or guilt
‰ Quick Inventory of Depressive Symptoms (QIDS) „ Decreased concentration
‰ Beck Depression Inventory (BDI) „ Psychomotor agitation or retardation
‰ Clinical Global Impression (CGI) „ Recurrent thoughts of death or suicide

„ Laboratory findings
107 108

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 Updates in Therapeutics® 2012:
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DSM-IV Diagnostic Criteria Patient Case # 2

Which one of the following antidepressants would
„ Rule out medical conditions or medications that be most appropriate for A.Z.’s depressive
could contribute to symptoms symptoms?
‰ Medical conditions A. Bupropion
„ Hypothyroidism, Cushing’s disease, pregnancy/postpartum,
diabetes mellitus,, Parkinson’s,, MS,, Alzheimer’s disease,, CVA,,
MI, CHF, AIDS, menopause, RA, FM, IBS B Fl
B. i
Fluoxetine
‰ Medications
„ High probability: Benzodiazepines, barbiturates, ETOH, C. Mirtazapine
corticosteroids, contraceptive implants, interferon alpha,
interleukin-2, mefloquine, GnRHA, stimulant withdrawal
„ Low probability/uncertain: Reserpine, BB (propranolol), D. Venlafaxine
interferon beta, tamoxifen, digitalis

109
Handout Page 1-380; Answer Page 1-415

Selecting an Antidepressant Patient Case # 3

A.Z. has been treated with citalopram 20 mg/day QAM x4 weeks.
Still has sad mood, but her insomnia, concentration and appetite
have improved. Still has feelings of hopelessness and worthlessness,
„ Indication
lack of motivation, and anhedonia. At this point, which one of the
„ Previous response or familial response following is the best recommendation to optimize her therapy?
„ Severity and type of depression and symptoms A. Continue at current dose of 20 mg/day
„ Patient preference
„ Financial consideration B. Increase the current dose to 40 mg/day.
„ Side effect profile
„ Suicidal ideation or risk of overdose C. Add bupropion 150 mg twice daily
„ Comorbidities (medical/psychiatric disorders,
substance abuse history) D. Switch to a different SSRI.
„ Demographics: age, ethnicity
111
Handout Page 1-380; Answer Page 1-415

Major Depression Black Box/Serious Warnings/ADR

Clinical Pearls Guess the Antidepressant!
Warning Antidepressant
„ Antidepressant are equally efficacious „ Suicidality
„ Selection is dependent on multiple patient „ Insomnia/irritability
and drug-related factors (next slide) „ Sedation
„ Remission is primary goal of therapy
„ Hepatotoxicity
„ Pharmacotherapy and psychotherapy
„ Seizures
produce best outcomes
„ Hypertension
„ Onset of effect may take 4-6 weeks
„ Single episode requires at least 7-12 months „ Eating Disorders
of antidepressant treatment „ Withdrawal Syndrome
113 114

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 Updates in Therapeutics® 2012:
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Bipolar Disorder Bipolar Disorder

Patient Case Page 1-389 Patient Case Page 1-389
„ J.L. is a 26-year-old man with bipolar disorder „ He has a history of nonadherence to
I, who presents with delusions that the FBI is medications and is currently not taking any
tracking his movements and that his thoughts medications. J.L.’s last hospitalization was 2
are being g recorded in a secret g
governmental g , when he had significant
months ago, g
database. He believes he has special powers depressive symptoms and suicidal ideation.
to hide from the FBI by making himself „ He has 3-4 hospitalizations per year, and his
invisible. medication trials include carbamazepine,
„ He is hyperverbal and has not slept in the olanzapine, and lamotrigine (may be helpful
past 48 hours. He is placed on a 72-hour hold but uncertain because of nonadherence). He
for control of his manic symptoms.. has also received a diagnosis of hepatitis C.
115

Patient Case # 5 Bipolar Disorder

Which of the following statements is most
applicable regarding selecting J.L.’s mood stabilizer
at this time? „ Cyclical disorder with recurrences of
depressive episode and manic episode
A. Carbamazepine should be tried again because it is
effective for preventing rehospitalization.
during patient’s lifetime
„ Episodic long
Episodic, long-term
term illness with variable
B. Divalproex should be tried because it is good for
maintenance treatment.
course
„ Bipolar disorder should be considered in
C. Lithium should be tried because it can effectively treat the
manic phase and prevent future episodes. differential diagnosis in patients presenting
with depression
D. Lamotrigine should be tried again because it is effective
for bipolar maintenance.

Handout Page 1-389; Answer Page 1-415 118

DSM-IV Diagnostic Criteria Bipolar Disorder Life Cycle

„ Manic episode
‰ Distinct period of abnormally and persistently
elevated, expansive or irritable mood, lasting at least 1 Mania
week (or any duration if hospitalization necessary)
‰ Three or more* of following sx during mood
disturbance: 1) inflated self-esteem
self esteem or grandiosity
grandiosity, 2)
decreased need for sleep, 3) more talkative than usual Euthymic
or pressured speech, 4) flight of ideas or racing
thoughts (subjective), 5) distractibility, 6) increase in
goal-directed activity (either socially, occupationally,
sexually) or psychomotor agitation, 7) excessive
involvement in pleasurable activities that have
negative consequences (gambling, spending $$,
sexual activity) Depression

*Four or more sx required if only irritable mood 119 120

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 Updates in Therapeutics® 2012:
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Mood Stabilizers: Uses Mood Stabilizers

Therapeutic Efficacy
„ Lithium „ Mania, depression, maintenance
„ Lithium „ 1-2 weeks
„ Valproic acid „ Mania, maintenance
„ Valproic acid „ 3-5 days
„ Lamotrigine „ Maintenance, depression
„ Lamotrigine „ 5 weeks to reach target
„ Carbamazepine „ Mania, maintenance dose
„ Oxcarbazepine „ Mania, maintenance 4 weeks for autoinduction
„ Carbamazepine „
„ Antipsychotics „ Olanz: mania, maintenance 1-2 weeks
„ Oxcarbazepine „
„ Quet: mania, depression, maint* Few days
„ Antipsychotics „
„ Aripip: mania, maintenance
„ Risp, zipras, asenapine: mania

*As adjunct 121 122

Patient Case # 6 Bipolar Disorder

Which of the following adverse effects would be of
„ Lithium
most concern and would require immediate
‰ Excreted 95% unchanged by glomerular filtration
evaluation if J.L. were prescribed lithium?
‰ Initial workup: CBC, electrolytes, renal function
A. Hyperthyroidism.
‰ Serum conc: 0.8-1.2 mEq/L (acute mania), 0.6-1.0
mEq/L
E /L (maintenance)
( i t )
B. Coarse tremor. ‰ Other labs: thyroid function, urinalysis, poss. EKG,
pregnancy test
C. Severe acne. ‰ Factors that ↑ Li: Drugs (discussed later), ↓ renal
function, dehydration, salt restriction
D. Weight gain ‰ Factors that ↓ Li: Drugs, pregnancy, aging

Handout Page 1-389; Answer Page 1-415 124

Patient Case # 7 Adverse Effects

J.L. has been stable on lithium 900 mg/day x 3mo. During a
clinic visit, J.L. is confused and slurring his words. His other
medications include lisinopril, ibuprofen, atorvastatin, and
„ Lithium
zolpidem. Which one of the following is best to recommend
immediately?
A. Discontinue lisinopril because it interacts with lithium. „ Valproic acid

B. Discontinue zolpidem because it may increase confusion. „ Lamotrigine

C. Obtain a lithium level because J.L. may have „ Carbamazepine
supratherapeutic levels.

„ Oxcarbazepine
D. Discontinue ibuprofen because it interacts with lithium.
„ Antipsychotics
Handout Page 1-389; Answer Page 1-415 126

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 Updates in Therapeutics® 2012:
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Drug Interactions Bipolar Disorder

Table 5, Page 1-391, 1-392 Clinical Pearls
„ Lithium „ Selection of treatment depends on acute
phase vs maintenance phase
„ Mood stabilizers are not equally efficacious
„ Valproic acid „ Selection is dependent on efficacy and drug
drug-
related factors
„ Lamotrigine „ Euthymic state and avoidance of
„ Carbamazepine hospitalization are goal of therapy
„ Oxcarbazepine „ Onset of effect may occur within 1-2 weeks
„ Patients may need life-long treatment
127 128

Schizophrenia Schizophrenia
Patient Case Page 1-393 Patient Case Page 1-393
„ L.M. is a 25-year-old man with recent „ He was given haloperidol in the psychiatry
diagnosis of schizophrenia, paranoid type. He unit and now presents with neck stiffness and
frequently hears voices telling him that he is feelings of extreme restlessness.
p and worthless” and that he should
“stupid „ Up to this point,
point he has not taken medications
“just jump off his apartment building.” His because he felt that he could control his
parents became very concerned over his symptoms on his own with vitamins and Red
isolative behavior and brought him to the Bull drinks.
hospital.

129

Patient Case # 8 Antipsychotic Agents

Which one of the following is the most appropriate
treatment of L.M.’s symptoms at this time? „ Conventional “first generation”, “typical”
‰ Block postsynaptic D2 receptors (mainly), α1, M1, H1
A. Benztropine ‰ Alleviate positive symptoms of schizophrenia
‰ Blockade of DA in nigrostriatal tract Æ movement d/o
‰ Blockade of DA in tuberoinfundibular tract Æ ↑prolactin
B H
B. Haloperidol.
l id l „ Atypical (“novel”, “second generation”)
‰ Block D2 and 5HT2, α1, M1, H1 receptors
C. Olanzapine. ‰ Alleviate positive and negative symptoms, cognitive
dysfunction
‰ Minimal ↑ in serum prolactin, minimal risk of EPS, TD
D. Quetiapine.
„ In each class, efficacy most likely similar for first
episode schizophrenia; Exception: clozapine
Handout Page 1-393; Answer Page 1-415 132

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 Updates in Therapeutics® 2012:
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Patient Case # 9 Patient Case # 11

You and the psychiatric team decide to recommend One year later, L.M. is no longer responding to risperidone, and you
decide to switch him to another medication. He is only interested in
risperidone for L.M. Which one of the following is oral medications. Which one of the following agents is most
the most likely reason for this selection? appropriate at this time?
A. Risperidone has less risk of causing EPS than A. Clozapine.
haloperidol.
B Fluphenazine.
B. Fluphenazine
B. Risperidone is available in a long-acting injection for
increasing adherence.
C. Olanzapine.
C. Risperidone is effective for decreasing L.M.’s negative
symptoms. D. Quetiapine.
D. Risperidone can be dosed once daily after titration to
target dose.

Handout Page 1-393 ; Answer Page 1-415 Handout Page 1-393; Answer Page 1-416

First Generation Antipsychotics Second Generation Antipsychotics

Table 8, Page 1-396 Table
Generic Name Trade Name Chemical Class Dose
Equivalence*
Generic Name Trade Name Chemical Class Dose Equivalence
Clozapine Clozaril Dibenzodiazepine 50

Low Potency
Risperidone Risperdal Benzisoxazole 2
Chlorpromazine Thorazine Aliphatic phenothiazine 100 Olanzapine Zyprexa Thienobenzodiazepine 5
Thioridazine Mellaril Piperidine phenothiazine 100 Quetiapine Seroquel Dibenzothiazepine 75
Mid-Potency Ziprasidone Geodon Benzothizolylpiperazine 60
Perphenazine Trilafon Piperazine phenothiazine 10
Aripiprazole Abilify Quinolinone derivative 7.5
Loxapine Loxitane Dibenzoxazepines 10
Paliperidone Invega Benzisoxazole --
High Potency
Asenapine Saphris Dibenzo-oxepino pyrroles --
Haloperidol Haldol Butyrophenone 2
Fluphenazine Prolixin Piperazine phenothiazine 2
Iloperidone Fanapt Piperidinyl-benzisoxazole --
Thiothixene Navane Thioxanthenes 4 Lurasidone Latuda Benzoisothiazole --

*Woods SW. Chlorpromazine equivalent doses for the newer atypical antipsychotics.
135 136
J Clin Psychiatry 2003;64(6):663-7

Adverse Effects Adverse Effects

Table 9, Page 1-400 Guess the antipsychotic!
Anticholinergic Sedation EPS Orthostasis
„ Agranulocytosis
Clozapine 4 4 1 4 „ Metabolic syndrome
Risperidone 1 2 2-3 3
„ QT prolongation
Olanzapine 3 3 1 1
Quetiapine 1 3 1 3 „ Cardiomyopathy
Ziprasidone 1 1 1 1 „ Hepatitis
Aripiprazole 1 1 1 1
Paliperidone 1 1 2-3 1
„ Seizures
Asenapine 2 4 1 4 „ Ophthalmic
Iloperidone 1 1 1 4
Lurasidone 1 1 1 1

1=none to minimal, 4=high; EPS=extrapyramidal symptoms 137 138

© 2012 American College of Clinical Pharmacy 23

 Updates in Therapeutics® 2012:
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Management of Adverse Effects Schizophrenia

Clinical Pearls
„ Dystonia „ Anticholinergic „ All antipsychotics are equally efficacious
„ Akathisia „ Anticholinergic, β-blockers except clozapine
„ Parkinsonism „ Anticholinergic, amantadine „ Second generation antipsychotics have better
„ Tardive dyskinesia „ Prevention reduce dose
Prevention, negative symptom control and less EPS
„ Anticholinergic „ Symptomatic „ Selection is dependent on multiple patient
„ Sedation „ Move dose to bedtime and drug-related factors
„ Orthostasis „ Hydration, split dose „ Remission may never be achieved and
„ Neuroleptic „ Dantrolene, hydration, primary goal is to control symptoms and
malignant syndrome symptomatic minimize adverse
139 140

Schizophrenia Anxiety Disorders

Clinical Pearls Patient Case Page 1-402
„ Positive and negative symptoms, functional „ C.P. is a recent Iraq war veteran who has
outcomes and cognitive impairment are key been treated successfully with paroxetine for
target areas for treatment his major depression for the past 3 weeks.
„ Avoidance of hospitalization is critical He ppresents to the clinic with nightmares,
g ,
„ Onset of effect may take 4-6 weeks “feeling on edge all the time,” and flashbacks
of his time in the war. He is evaluated for and
„ Most patients require life-long treatment given a diagnosis of posttraumatic stress
disorder (PTSD). He has no history of
substance dependence and has no
significant medical history.
141

Patient Case # 12 Guess the Anxiety Disorder

Which one of the following recommendations is
most appropriate at this time?
A. Continue paroxetine because it treats both PTSD
„ Patient who is often labeled as a worrywart
and major depression. „ Patient who spends 2 hours every day
making sure her towels are neatly folded
B. Discontinue paroxetine and start sertraline,
which treats both PTSD and major depression.
„ Patient who startles easily and complains of
nightmares about her time in combat
C. Continue paroxetine and add lorazepam for the „ Patient who has moments where she feels
anxiety symptoms.
like she’s dying and afraid to drive
D. Discontinue paroxetine and start buspirone for „ Patient who is afraid of snakes and can’t go
the anxiety symptoms. to the zoo
Handout Page 1-402; Answer Page 1-416 144

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 Updates in Therapeutics® 2012:
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Patient Case # 13 Patient Case # 15

C.P. has been adherent to the medication you recommended C.P. returns to the clinic and states that his depressive and anxiety
above, but he still feels very irritable and has been aggressive symptoms have much improved. How-ever, he is concerned that his
girlfriend, who has obsessive-compulsive disorder, is not doing well
at times at work toward others. Which one of the following
on her treatment with lorazepam. If you were also treating the
adjunctive medications is most appropriate in this patient? girlfriend, which one of the following would be the most appropriate
A. Buspirone. medication you would initiate?
A. Clomipramine.
B. Clonazepam.
B. Amitriptyline.
C. Divalproex.
C. Imipramine.
D. Lithium.
D. Nortriptyline.
Handout Page 1-402; Answer Page 1-416 Handout Page ; Answer Page

Which agent is effective for Insomnia

different anxiety disorders? Patient Case Page 1-405
„ SSRI „ C.D. is a 38-year-old kindergarten teacher
„ Venlafaxine who presents to clinic today with noticeable
„ Buspirone dark circles under her eyes. She has difficulty
with sleep, mainly with staying asleep. It
„ Benzodiazepines
takes her about 20 minutes to fall asleep, but
„ Duloxetine
after about 2 hours, she wakes up and
„ Mood stabilizers cannot fall asleep again for several hours.
„ MAOIs This pattern has taken a toll on her job, and
„ Beta blockers she feels tired all the time.

147 148

Insomnia Patient Case # 16

Which one of the following agents is most likely
Patient Case Page 1-405 contributing to C.D.’s insomnia?
„ She once took diphenhydramine for sleep but
had to miss work because of extreme
drowsiness in the morning. She wonders A. Citalopram.
whether there are anyy other medications that
she can take. Her other medical problems B. Hydrochlorothiazide
include hypothyroidism (levothyroxine 125
mcg at bedtime), hypertension (HCTZ 25 mg C. Ibuprofen.
in the morning), chronic back pain (ibuprofen
800 mg 3 times/day), and MDD (citalopram D. Levothyroxine.
20 mg in the morning).
Handout Page 1-405; Answer Page 1-416

© 2012 American College of Clinical Pharmacy 25

 Updates in Therapeutics® 2012:
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Patient Case # 17 Insomnia Classification

Which one of the following medications used for insomnia
is most appropriate to recommend for C.D.? Table 13, Page 1-407
A. Eszopiclone. Type Duration Likely Causes
Transient <1 week Acute situational or environmental
stressors
B. Trazodone.
Short term < 4 weeks Continued personal stress
Chronic .> 4 weeks Psychiatric illness, substance
C. Temazepam. abuse
Behavioral causes (poor sleep
hygiene)
D. Zaleplon. Medical causes, primary sleep
disorder (e.g. sleep apnea, restless
legs syndrome)

Handout Page 1-405; Answer Page 1-416 152

Insomnia Insomnia

„ Sedative hypnotics are differentiated by Drug Usual Dose (mg) Half-life (hrs) Duration
‰ Pharmacokinetic properties Triazolam 0.125-0.25 2-6 Short
Temazepam 15-30 8-20 Intermediate
‰ Efficacy in onset and duration
Estazolam 1-2 8-24 Intermediate
‰ Adverse effects Flurazepam 15 30
15-30 48 120
48-120 Long
‰ Drug interactions Quazepam 7.5-15 48-120 Long
Zolpidem 5-10 1.5-4.0 Short
‰ Abuse potential
Zaleplon 5-10 1 Very Short
‰ Cost Eszopiclone 2-3 6 Short
Ramelteon 8 1-3 Short

153 154

Insomnia Substance Abuse – Alcohol

Guess the Sedative-Hypnotic! Patient Case Page 1-410
„ No abuse potential „ L.M. is a 50-year-old man with a 25-year
„ Second dose can be history of alcohol dependence who was found
taken at night unconscious after his last drinking binge. He
„ Can cause was first admitted to the medical unit for
anterograde amnesia alcohol withdrawal symptoms before being
„ Common OTC transferred to the Substance Dependence
sedative Unit. His last drink was 6 hours ago, and
fluids have been started.

155 156

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 Updates in Therapeutics® 2012:
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Substance Abuse – Alcohol Patient Case # 19

Which one of the following symptoms are you most likely to
Patient Case Page 1-410 observe in the medical unit?
„ He has had three alcohol-withdrawal seizures
in the past and an episode of delirium A. Alcohol craving.
tremens.
„ He also has significant hepatitis
hepatitis, and liver B Delirium tremens.
B. tremens
function tests show aspartate
aminotransferase (AST) of 220 and alanine C. Increased heart rate.
aminotransferase (ALT) of 200.
D. Seizures.

Handout Page 1-410; Answer Page 1-416

Patient Case # 20 Patient Case # 22

Which one of the following agents is best for alcohol Which of the following medications is best to use in L.M.
withdrawal symptoms in L.M. for intramuscular for alcohol dependence?
administration?
A. Chlordiazepoxide. A. Acamprosate.

B Clonazepam.
B. Clonazepam B Diazepam.
B. Diazepam

C. Diazepam. C. Disulfiram.

D. Lorazepam. D. Naltrexone.

Handout Page 1-410; Answer Page 1-416 Handout Page 1-410; Answer Page 1-416

Substance Abuse – Alcohol Substance Abuse – Alcohol

Table 15, Page 1-411 Management
„ Labs: tox screen, renal and liver function,
Stage Onset Symptoms
folate, thiamine, B12 levels, electrolytes
1 0-8 hrs Mild tremors, nervousness, tachycardia, nausea
2 12-24 hrs Marked tremors, hyperactivity, tachycardia, „ Nutrition: thiamine, magnesium, vitamins,
insomnia, nightmares, illusions, alcohol craving
fluid
3 12-48 hrs More severe symptoms than during stage 2,
seizures may occur „ Seizures: benzodiazepines, other
4 3-5 days Delirium tremens, confusion, agitation, tremor,
insomnia, tachycardia, sweating, hyperpyrexia
antiepileptics not as effective
„ Hallucinations: benzodiazepines, haloperidol
(caution with seizures)

161 162

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Substance Abuse – Alcohol

Table 16, Page 1-412
Drug Dose Comments
Questions?
Lorazepam 1-2 mg PO/IV/IM Can use with liver
disease
Diazepam 5-20 mg PO Use lower dose with liver
disease, can use
loading-dose strategy
Chlordiazepoxide 25-100 mg PO/IV Long acting; caution with
liver disease

163

© 2012 American College of Clinical Pharmacy 28