You are consulted for medical management of a 45-year-old male, previously unknown to you, who is hospitalized in the psychiatric unit with paranoid schizophrenia. His fasting blood glucose level is 10 mmol/L.
Which one of the following medications is the most likely cause of the hyperglycemia?
Correct Answer D:
The atypical antipsychotics include clozapine, olanzapine, risperidone, ziprasidone, quetiapine, and aripiprazole. As a class, they have fewer extrapyramidal side effects than the classical antipsychotics haloperidol, thiothixene, chlorpromazine, and others. Some of the atypical agents, notably olanzapine and clozapine, have been associated with hyperglycemia and the development of type 2 diabetes mellitus. Neither benzodiazepines like alprazolam nor the classical antipsychotics have been associated with hyperglycemia.
Which one of the following medications is associated with the highest risk for falls in elderly patients?
Correct Answer C:
Most falls result from interactions between predisposing factors and precipitating factors in a person’s environment. The use of four or more prescription medications increases fall risk, as does the use of certain individual classes of medications, including SSRIs (such as sertraline), tricyclic antidepressants, neuroleptics, benzodiazepines, anticonvulsants, and class IA antiarrhythmic agents.
The other agents listed have not been associated with falls in the elderly. Fludrocortisone causes salt and water retention and may reduce the risk of orthostatic hypotension, a cause of falls in the elderly. Pseudoephedrine stimulates adrenergic receptors and tends to raise blood pressure as well. Statin drugs have no known association with falls.
A 43-year-old female seeks treatment for depression, which has begun to seriously interfere with her ability to function. Her only other medical condition is mild hypertension.
Which one of the following antidepressants would be most likely to exacerbate her hypertension?
Out of all of the antidepressants, only venlafaxine is known to exacerbate hypertension, and would therefore be a poor choice for this patient.
A patient that you are starting on valproic acid has a history of elevated ammonia levels in the past when taking this medication.
There are no other options at this point in her treatment, so you make the following recommendation:
The mechanism that leads to elevated ammonia levels in patients taking valproic acid is based on a depletion of the vitamin carnitine which is required in fatty acid transport. If carnitine is depleted by valproic acid, it can disrupt this process, which results in ammonia formation. Some patients can prevent this from occurring by taking carnitine as a supplement. Unfortunately, it does not reverse the process for everyone. Of note, the degree of ammonia elevation is not an accurate indicator of expected severity of symptoms.
A. The liver function tests are not indicators of this specific problem.
B. This is the not the treatment for high ammonia levels.
C. Lactulose decreases ammonia levels in alcoholics by decreasing transit time in the bowel (accelerated bowel movement), which reduces the amount of ammonia absorption of ammonia from the gut. This is minimally helpful in patients with valproic acid induced elevations in ammonia.
Which of the following is not a common side effect seen with SSRIs?
Extrapyramidal symptoms are rarely seen with SSRIs. Many of the side effects associated with SSRIs are similar to those experienced with the older tricyclic antidepressants but typically not so severe.
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