Epilepsy, depression, psychosis and pain

38 Gulf Prometric Pharmacist (DHA, DOH, MOH, SCFHS, QCHP) practice questions on Epilepsy, depression, psychosis and pain, part of Clinical Pharmacy and Therapeutics. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Easy

   A patient on carbamazepine finds that seizure control worsens after a few weeks, although serum levels at the start were adequate. Which mechanism explains the fall in levels?

   1. AInhibition of its own metabolism
   2. BIncreased plasma protein binding
   3. CReduced gastrointestinal absorption
   4. DAutoinduction of its own metabolism through CYP3A4

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   Answer: D · Autoinduction of its own metabolism through CYP3A4

   Carbamazepine induces CYP3A4 and so speeds its own metabolism over the first 2 to 4 weeks, so the dose often needs to be increased gradually. It also lowers levels of many co-prescribed drugs.

   • A: It induces rather than inhibits CYP3A4.
   • B: Binding changes do not explain falling total levels.
   • C: Absorption is not the usual explanation.

   Remember this

   Carbamazepine induces its own metabolism, so levels fall in the first weeks.

2. Question 2 · Easy

   When should a patient starting an SSRI expect to see the first clinical benefit?

   1. AAfter 6 months
   2. BWithin 2 to 4 weeks
   3. COnly after dose escalation to the maximum
   4. DWithin 24 hours

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   Answer: B · Within 2 to 4 weeks

   Antidepressant benefit builds over about 2 to 4 weeks, though full response may take 6 to 8 weeks, so counselling before starting reduces early discontinuation. Early adverse effects such as nausea often appear before benefit.

   • A: Six months is far longer than the usual onset.
   • C: Benefit often appears at starting or standard doses.
   • D: No antidepressant works within a day.

   Remember this

   SSRI benefit appears after 2 to 4 weeks.

3. Question 3 · Easy

   Which antiepileptic drug carries the highest risk of major congenital malformations and neurodevelopmental disorders when used in pregnancy?

   1. AValproate
   2. BLamotrigine
   3. CLevetiracetam
   4. DCarbamazepine

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   Answer: A · Valproate

   Valproate carries the highest teratogenic risk, with neural tube defects and a marked rise in autism and lowered cognitive outcomes in exposed children. It should be avoided in women of childbearing potential unless no other drug works and a pregnancy prevention programme is in place. Lamotrigine and levetiracetam are the safest options.

   • B: Lamotrigine has a low malformation rate.
   • C: Levetiracetam has a low malformation rate.
   • D: Carbamazepine has a moderate risk, lower than valproate.

   Remember this

   Valproate is the most teratogenic antiepileptic and is avoided in women who may conceive.

4. Question 4 · Medium

   What is the first-line drug for a patient in generalised convulsive status epilepticus with intravenous access?

   1. AOral levetiracetam
   2. BOral carbamazepine
   3. CIntravenous phenytoin
   4. DIntravenous lorazepam

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   Answer: D · Intravenous lorazepam

   Benzodiazepines act rapidly to enhance GABA-A activity and terminate seizures, so intravenous lorazepam 4 mg (0.1 mg/kg) is given first, and repeated once if seizures persist. Phenytoin or levetiracetam are second-line after benzodiazepines. Oral drugs are not suitable in an actively convulsing patient.

   • A: Oral drugs cannot be given in active seizures.
   • B: Carbamazepine has no role in status epilepticus.
   • C: Phenytoin is second-line and slower to act.

   Remember this

   IV lorazepam is the first-line treatment in status epilepticus.

5. Question 5 · Medium

   A 72-year-old woman needs regular naproxen for osteoarthritis. She has no history of ulcers. Which addition is recommended?

   1. AA proton pump inhibitor for gastroprotection
   2. BOral sucralfate alone
   3. CNothing, as risk is negligible
   4. DA second NSAID taken at night to spread the analgesic effect

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   Answer: A · A proton pump inhibitor for gastroprotection

   Age over 65 raises the risk of upper gastrointestinal bleeding with NSAIDs, so a PPI should be co-prescribed for the duration of therapy. A second NSAID increases risk, and sucralfate is less proven.

   • B: Sucralfate is less effective than a PPI for prevention.
   • C: Risk is clinically significant at this age.
   • D: A second NSAID raises GI and renal risk.

   Remember this

   Co-prescribe a PPI with a long-term NSAID in older patients.

6. Question 6 · Medium

   A 28-year-old woman on risperidone reports amenorrhoea and galactorrhoea. Her prolactin is markedly raised. What is the best option?

   1. ASwitch to aripiprazole
   2. BAdd carbimazole
   3. CIncrease risperidone
   4. DAdd metoclopramide

   Answer and explanation in LearnFree account

7. Question 7 · Medium

   A patient started on regular morphine for cancer pain has had no bowel movement for 3 days. Which measure should have been prescribed together with the opioid?

   1. AA bulk-forming laxative alone with low fluids
   2. BA stimulant laxative, with or without a stool softener
   3. CNo prophylaxis, as tolerance to constipation develops within a few days
   4. DLoperamide

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8. Question 8 · Medium

   A patient who missed several doses of paroxetine reports dizziness, electric-shock sensations, nausea and irritability. What is the best explanation and action?

   1. ARelapse of depression; double the dose
   2. BSerotonin syndrome; stop paroxetine and give cyproheptadine at once
   3. CAllergic reaction; stop all medicines
   4. DDiscontinuation syndrome; restart and taper more gradually

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9. Question 9 · Medium

   What is the maximum recommended daily dose of citalopram for a patient older than 60 years, and why?

   1. A60 mg, because of seizure risk
   2. B20 mg, because of dose-related QT prolongation
   3. C10 mg, because of renal failure
   4. D40 mg, because of liver failure

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10. Question 10 · Easy

    What is the primary mechanism of action of SSRIs?

    1. AInhibit monoamine oxidase
    2. BBlock alpha-2 autoreceptors
    3. CBlock presynaptic reuptake of serotonin, increasing synaptic levels
    4. DBlock postsynaptic dopamine D2 receptors in the mesolimbic pathways of the brain

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11. Question 11 · Medium

    A 78-year-old woman becomes confused and unsteady one week after starting citalopram. Her serum sodium is 123 mmol/L. What is the most likely explanation?

    1. ASerotonin syndrome
    2. BDiabetes insipidus
    3. CHypothyroidism caused by citalopram
    4. DSIADH due to the SSRI

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12. Question 12 · Medium

    A patient on lithium presents with vomiting, coarse tremor and ataxia. The serum lithium is 1.9 mmol/L. What is the best immediate action?

    1. AContinue lithium and recheck next week
    2. BReduce the dose by 10% and observe
    3. CGive a loop diuretic to flush the lithium out of the body and then restart it that evening
    4. DWithhold lithium and arrange urgent hospital assessment with fluid resuscitation

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13. Question 13 · Medium

    Which baseline and follow-up monitoring is recommended for a patient started on olanzapine?

    1. ASerum lithium level
    2. BRenal function and urine protein every month
    3. CWeekly absolute neutrophil count for 18 weeks
    4. DWeight, waist circumference, fasting glucose and lipids

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14. Question 14 · Medium

    A patient on phenytoin 300 mg daily has a total level of 8 mg/L and normal albumin. What is the safest dose change?

    1. ADouble the dose to 600 mg to reach the range quickly
    2. BIncrease by a small amount, such as 30 to 50 mg, and recheck the level
    3. CIncrease by 100 mg and recheck the level next week
    4. DStop and switch to another drug

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15. Question 15 · Medium

    A patient on sertraline is given linezolid for an infection and develops agitation, tremor, clonus and a temperature of 39 degrees Celsius. After stopping the serotonergic drugs and giving supportive care, which agent is used if symptoms persist?

    1. ACyproheptadine
    2. BParacetamol as the antidote
    3. CDantrolene routinely
    4. DHaloperidol

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16. Question 16 · Hard

    A 40-year-old man who smokes heavily is stable on clozapine. He is admitted to a smoke-free ward and stops smoking abruptly. What is the likely effect?

    1. AClozapine levels fall
    2. BNo change occurs because clozapine clearance does not depend on smoking at all
    3. CNeutrophils rise
    4. DClozapine levels rise by about 50% because CYP1A2 induction is lost

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17. Question 17 · Medium

    A 72-year-old man on warfarin is started on fluoxetine. What is the main safety concern?

    1. AIncreased bleeding risk from impaired platelet function and warfarin interaction
    2. BHypoglycaemia due to enhanced insulin release
    3. CPhotosensitivity reactions only, with no change to bleeding
    4. DReduced warfarin effect and clot formation

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18. Question 18 · Medium

    A patient stabilised on lithium starts regular ibuprofen for back pain. What is the concern?

    1. ANo interaction exists
    2. BNSAIDs lower lithium levels
    3. CLithium reduces the analgesic effect of ibuprofen only, with no change to lithium levels
    4. DNSAIDs reduce renal lithium clearance and can cause toxicity

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19. Question 19 · Hard

    A 35-year-old man on lithium plans to fast during Ramadan. Which advice is most appropriate?

    1. AReview with the prescriber, check a level early and hydrate well outside fasting hours
    2. BFast as usual without any medical review, taking both usual daily doses together at iftar
    3. CStop lithium for the whole month
    4. DDouble the evening dose to compensate

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20. Question 20 · Medium

    A patient takes 120 mg of oral morphine in 24 hours. Using a breakthrough dose of one sixth of the daily dose, what immediate-release oral morphine dose should be prescribed?

    1. A60 mg
    2. B20 mg
    3. C5 mg
    4. D40 mg

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21. Question 21 · Medium

    Which monitoring schedule is recommended for a patient on long-term lithium?

    1. ANo monitoring once stable
    2. BLipid profile and liver enzymes once every year, with no renal, thyroid or calcium tests
    3. CRenal function, thyroid function and calcium at least every 6 months, plus levels
    4. DLiver enzymes weekly

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22. Question 22 · Medium

    A patient takes low-dose aspirin for cardioprotection and also takes ibuprofen regularly for arthritis. What is the concern?

    1. AAspirin lowers ibuprofen levels to almost zero by competing for plasma protein binding
    2. BIbuprofen can block aspirin's antiplatelet effect by competing for COX-1
    3. CIbuprofen increases the effect of aspirin
    4. DNo interaction exists

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23. Question 23 · Medium

    A woman with epilepsy is planning a pregnancy. Which pharmacist advice is most appropriate?

    1. AStart higher-dose folic acid before conception and review the antiepileptic with the specialist
    2. BStop all antiepileptics immediately
    3. CIncrease the antiepileptic dose before conception to build up a safety margin and stay seizure-free
    4. DStart folic acid only after the first trimester

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24. Question 24 · Hard

    A 45-year-old man stable on fluoxetine 20 mg daily is to switch to phenelzine, an MAOI. How long should fluoxetine be stopped before starting phenelzine?

    1. AAt least 5 weeks
    2. B2 weeks
    3. C1 week
    4. D24 hours

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25. Question 25 · Easy

    What is the usual maintenance serum lithium range for bipolar disorder, measured 12 hours after the last dose?

    1. A0.6 to 1.0 mmol/L
    2. B1.5 to 2.0 mmol/L
    3. C0.1 to 0.3 mmol/L
    4. D2.5 to 3.5 mmol/L

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