NURS 660 Exam 2 LATEST
ANSWER ALL QUESTIONS IN THIS SECTION
QUESTION 1
Clomipramine major drug interactions - ANSWERS--Tramadol increases the risk
of seizures in patients taking TCAs
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not
use with MAOIs or at least for 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing clomipramine
-Use of TCAs with anticholinergic drugs may result in paralytic ileus or
hyperthermia
-Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors
may increase TCA concentrations
-Fluvoxamine, a CYP450 1A2 inhibitor, can decrease the conversion of
clomipramine to desmethyl-clomipramine, and increase clomipramine plasma
concentrations
-Cimetidine may increase plasma concentrations of TCAs and cause
anticholinergic symptoms
-Phenothiazines or haloperidol may raise TCA blood concentrations
-May alter effects of antihypertensive drugs
-Use of TCAs with sympathomimetic agents may increase sympathetic activity
-TCAs may inhibit hypotensive effects of clonidine
END OF
PAGE
1
, NURS 660 Exam 2 LATEST
-Methylphenidate may inhibit metabolism of TCAs
-Activation and agitation, especially following switching or adding
antidepressants, may represent the induction of a bipolar state, especially a mixed
dysphoric bipolar II condition sometimes associated with suicidal ideation, and
require the addition of lithium, a mood stabilizer or an atypical antipsychotic,
and/or discontinuation of clomipramine
QUESTION 2
Clomipramine lab tests - ANSWERS--Baseline ECG is recommended for patients
over age 50
-Monitoring of plasma drug levels is potentially available at specialty laboratories
for the expert
-Since tricyclic and tetracyclic antidepressants are frequently associated with
weight gain, before starting treatment, weigh all patients and determine if the
patient is already overweight (BMI 25.0-29.9) or obese (BMI ≥30)
-Before giving a drug that can cause weight gain to an overweight or obese patient,
consider determining whether the patient already has pre-diabetes (fasting plasma
glucose 100-125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or
dyslipidemia (increased total cholesterol, LDL cholesterol and triglycerides;
decreased HDL cholesterol), and treat or refer such patients for treatment,
including nutrition and weight management, physical activity counseling, smoking
cessation, and medical management
-Weight and BMI during treatment
END OF
PAGE
2
, NURS 660 Exam 2 LATEST
While giving a drug to a patient who has gained >5% of initial weight, consider
evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider
switching to a different antidepressant
-EKGs may be useful for selected patients (e.g., those with personal or family
history of QTc prolongation; cardiac arrhythmia; recent myocardial infarction;
uncompensated heart failure; or taking agents that prolong QTc interval such as
pimozide, thioridazine, selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.)
-Patients at risk for electrolyte disturbances (e.g., patients on diuretic therapy)
should have baseline and periodic serum potassium and magnesium measurements
QUESTION 3
Clomipramine neurotransmitters and moa - ANSWERS--Boosts neurotransmitters
serotonin and norepinephrine/noradrenaline
-Blocks serotonin reuptake pump (serotonin transporter), presumably increasing
serotonergic neurotransmission
-Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably
increasing noradrenergic neurotransmission
-Presumably desensitizes both serotonin 1A receptors and beta adrenergic
receptors
-Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which
largely lacks dopamine transporters, clomipramine can increase dopamine
neurotransmission in this part of the brain
QUESTION 4
END OF
PAGE
3
, NURS 660 Exam 2 LATEST
Clomipramine pregnancy risk - ANSWERS-Controlled studies have not been
conducted in pregnant women
Clomipramine crosses the placenta
Adverse effects have been reported in infants whose mothers took a TCA
(lethargy, withdrawal symptoms, fetal malformations)
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of
depression, worsening of OCD, maternal health, infant bonding) to the mother and
child
For many patients this may mean continuing treatment during pregnancy
Amitriptyline (Elavil) major side effects TCA
Commonly Prescribed for
*Depression
*Endogenous depression
Neuropathic pain/chronic pain
Fibromyalgia
Headache
Low back pain/neck pain
Anxiety
END OF
PAGE
4
ANSWER ALL QUESTIONS IN THIS SECTION
QUESTION 1
Clomipramine major drug interactions - ANSWERS--Tramadol increases the risk
of seizures in patients taking TCAs
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not
use with MAOIs or at least for 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing clomipramine
-Use of TCAs with anticholinergic drugs may result in paralytic ileus or
hyperthermia
-Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors
may increase TCA concentrations
-Fluvoxamine, a CYP450 1A2 inhibitor, can decrease the conversion of
clomipramine to desmethyl-clomipramine, and increase clomipramine plasma
concentrations
-Cimetidine may increase plasma concentrations of TCAs and cause
anticholinergic symptoms
-Phenothiazines or haloperidol may raise TCA blood concentrations
-May alter effects of antihypertensive drugs
-Use of TCAs with sympathomimetic agents may increase sympathetic activity
-TCAs may inhibit hypotensive effects of clonidine
END OF
PAGE
1
, NURS 660 Exam 2 LATEST
-Methylphenidate may inhibit metabolism of TCAs
-Activation and agitation, especially following switching or adding
antidepressants, may represent the induction of a bipolar state, especially a mixed
dysphoric bipolar II condition sometimes associated with suicidal ideation, and
require the addition of lithium, a mood stabilizer or an atypical antipsychotic,
and/or discontinuation of clomipramine
QUESTION 2
Clomipramine lab tests - ANSWERS--Baseline ECG is recommended for patients
over age 50
-Monitoring of plasma drug levels is potentially available at specialty laboratories
for the expert
-Since tricyclic and tetracyclic antidepressants are frequently associated with
weight gain, before starting treatment, weigh all patients and determine if the
patient is already overweight (BMI 25.0-29.9) or obese (BMI ≥30)
-Before giving a drug that can cause weight gain to an overweight or obese patient,
consider determining whether the patient already has pre-diabetes (fasting plasma
glucose 100-125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or
dyslipidemia (increased total cholesterol, LDL cholesterol and triglycerides;
decreased HDL cholesterol), and treat or refer such patients for treatment,
including nutrition and weight management, physical activity counseling, smoking
cessation, and medical management
-Weight and BMI during treatment
END OF
PAGE
2
, NURS 660 Exam 2 LATEST
While giving a drug to a patient who has gained >5% of initial weight, consider
evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider
switching to a different antidepressant
-EKGs may be useful for selected patients (e.g., those with personal or family
history of QTc prolongation; cardiac arrhythmia; recent myocardial infarction;
uncompensated heart failure; or taking agents that prolong QTc interval such as
pimozide, thioridazine, selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.)
-Patients at risk for electrolyte disturbances (e.g., patients on diuretic therapy)
should have baseline and periodic serum potassium and magnesium measurements
QUESTION 3
Clomipramine neurotransmitters and moa - ANSWERS--Boosts neurotransmitters
serotonin and norepinephrine/noradrenaline
-Blocks serotonin reuptake pump (serotonin transporter), presumably increasing
serotonergic neurotransmission
-Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably
increasing noradrenergic neurotransmission
-Presumably desensitizes both serotonin 1A receptors and beta adrenergic
receptors
-Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which
largely lacks dopamine transporters, clomipramine can increase dopamine
neurotransmission in this part of the brain
QUESTION 4
END OF
PAGE
3
, NURS 660 Exam 2 LATEST
Clomipramine pregnancy risk - ANSWERS-Controlled studies have not been
conducted in pregnant women
Clomipramine crosses the placenta
Adverse effects have been reported in infants whose mothers took a TCA
(lethargy, withdrawal symptoms, fetal malformations)
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of
depression, worsening of OCD, maternal health, infant bonding) to the mother and
child
For many patients this may mean continuing treatment during pregnancy
Amitriptyline (Elavil) major side effects TCA
Commonly Prescribed for
*Depression
*Endogenous depression
Neuropathic pain/chronic pain
Fibromyalgia
Headache
Low back pain/neck pain
Anxiety
END OF
PAGE
4
