MTM Behavioral Health Pharmacotherapy 5 — Questions and Answers
Question 1: An MTM pharmacist is counseling a patient on valproate for bipolar disorder who is considering pregnancy. What is the most critical concern?
- Valproate decreases folate absorption only
- Valproate is a known teratogen causing neural tube defects and cognitive impairment (Correct answer)
- Valproate is the safest mood stabilizer in pregnancy
- Valproate must be stopped 6 months before conception
Correct answer: Valproate is a known teratogen causing neural tube defects and cognitive impairment
Valproate is a category X teratogen associated with neural tube defects (spina bifida), cognitive impairment, and autism spectrum disorder; alternative mood stabilizers should be considered in reproductive-age women.
Question 2: Which receptor mechanism explains why mirtazapine causes sedation and weight gain as side effects?
- Serotonin reuptake inhibition
- Dopamine D2 receptor blockade
- Histamine H1 receptor antagonism (Correct answer)
- Norepinephrine reuptake inhibition
Correct answer: Histamine H1 receptor antagonism
Mirtazapine's potent histamine H1 antagonism is responsible for its sedating and appetite-stimulating (weight gain) side effects, which can be beneficial in depressed patients with insomnia and weight loss.
Question 3: A patient with schizophrenia refuses oral antipsychotics due to nonadherence history. Which formulation would best address long-term adherence?
- Immediate-release oral tablet
- Extended-release oral capsule
- Long-acting injectable antipsychotic (Correct answer)
- Sublingual tablet
Correct answer: Long-acting injectable antipsychotic
Long-acting injectable (LAI) antipsychotics (e.g., paliperidone palmitate, aripiprazole lauroxil) are given every 4–12 weeks and are the preferred option for patients with known nonadherence to oral medications.
Question 4: Which medication used for alcohol use disorder works by causing an aversive reaction (flushing, nausea, tachycardia) when alcohol is consumed?
- Naltrexone
- Acamprosate
- Disulfiram (Correct answer)
- Gabapentin
Correct answer: Disulfiram
Disulfiram inhibits aldehyde dehydrogenase, causing accumulation of acetaldehyde when alcohol is consumed, producing an unpleasant aversive reaction that deters drinking.
Question 5: A patient on fluoxetine is prescribed tramadol for pain. What pharmacokinetic interaction is most concerning?
- Fluoxetine induces CYP2D6, increasing tramadol's active metabolite
- Fluoxetine inhibits CYP2D6, reducing tramadol's conversion to active analgesic metabolite and increasing serotonin syndrome risk (Correct answer)
- Tramadol increases fluoxetine blood levels via P-glycoprotein inhibition
- No significant interaction exists between these two medications
Correct answer: Fluoxetine inhibits CYP2D6, reducing tramadol's conversion to active analgesic metabolite and increasing serotonin syndrome risk
Fluoxetine inhibits CYP2D6, reducing tramadol conversion to O-desmethyltramadol (active metabolite), decreasing analgesia; additionally, both drugs are serotonergic, increasing serotonin syndrome risk.
Question 6: Which second-generation antipsychotic is associated with the lowest risk of metabolic syndrome (weight gain, dyslipidemia, hyperglycemia)?
- Olanzapine
- Clozapine
- Quetiapine
- Aripiprazole (Correct answer)
Correct answer: Aripiprazole
Aripiprazole (and ziprasidone) have the most favorable metabolic profiles among SGAs, with minimal effects on weight, lipids, and glucose compared to olanzapine and clozapine.
Question 7: A pharmacist performs an MTM session for a patient with obsessive-compulsive disorder not responding to sertraline alone. What is the most evidence-based augmentation strategy?
- Add lithium
- Add clonazepam
- Add an atypical antipsychotic (e.g., risperidone or aripiprazole) (Correct answer)
- Switch to bupropion
Correct answer: Add an atypical antipsychotic (e.g., risperidone or aripiprazole)
Addition of low-dose atypical antipsychotics such as risperidone, aripiprazole, or quetiapine is the most evidence-based augmentation strategy for SSRI-refractory OCD.
MTM Behavioral Health Pharmacotherapy 5
An MTM pharmacist is counseling a patient on valproate for bipolar disorder who is considering pregnancy.
What is the most critical concern?