Time for a subforum?

[DrPak]

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How about creating subforums to this one where the actual USMLE Step 1 subject-matter can be discussed. This forum mostly has talk about which books to use, how to study, and then of course endling pissing contests b/w egomaniacs. A subforum dedicated just to pure academic jabber might be useful. Sometimes facts sink in and concepts clear up when you've got a bunch of people discussing it. There are a lot of smart people here, I'm sure the the exercise will have some positive results. Who knows, a thread discussing a certain fact might actually come to mind in the actual exam and add a point or two.

We could have just one subforum where all the subjects are discussed together, or have separate forums for every subject.

Who's with me? 😀

 

[DrPak]

Not interested ay?

Just to maybe start thing off, here's a question I dreamt up:

The huband of a 31 year old woman brings his wife to you for treatment. He says his wife has been behaving very recklessly of late. She would go out on expensive shopping sprees to buy things they didn't need, she would start projects like painting the house only to leave the job undone, she would act irritably, wouldn't sleep much or pay attention to events around her and generally would be on the move all the time. Hhe said such episodes would last about a week until she exhausted herself and would thereafter sleep for 14 hours a day, and feel tired even when she woke up. She would cry impulsively and wouldn't eat. After a week of this sort of behavior, she would go back to her previous pattern of behavior. He said this cycle of behavior has been repeating itself for half a year now. Her husband in the end reveals to you that his wife is 2 months pregnant.

What medication would you give to this patient?

a. Carbamazepine
b. Clonazepam
c. Valproic Acid
d. Fluoxetine
e. Lithium
f. Bupropion
g. Clozapine

 

[Pox in a box]

Not interested ay?

Just to maybe start thing off, here's a question I dreamt up:

The huband of a 31 year old woman brings his wife to you for treatment. He says his wife has been behaving very recklessly of late. She would go out on expensive shopping sprees to buy things they didn't need, she would start projects like painting the house only to leave the job undone, she would act irritably, wouldn't sleep much or pay attention to events around her and generally would be on the move all the time. Hhe said such episodes would last about a week until she exhausted herself and would thereafter sleep for 14 hours a day, and feel tired even when she woke up. She would cry impulsively and wouldn't eat. After a week of this sort of behavior, she would go back to her previous pattern of behavior. He said this cycle of behavior has been repeating itself for half a year now. Her husband in the end reveals to you that his wife is 2 months pregnant.

What medication would you give to this patient?

a. Carbamazepine
b. Clonazepam
c. Valproic Acid
d. Fluoxetine
e. Lithium
f. Bupropion
g. Clozapine

C. Valproic acid seems to be the obvious wrong answer. This is a good question Dr. Pak. However, I feel like valproic acid would be a safe treatment option in a woman who is 2 months pregnant. This is a classic case of bipolar disorder. You need to treat with a mood stabilizer (such as valproic acid, carbamazepine, or lithium) and then add an anti-depressant. The reason you can give valproic acid at this time is that the teratogenic effects of valproic acid occur if there is valproate on board between the 17th and the 30th day after fertilization. This is the time the neural tube is being formed.

Lithium is usually the choice but is highly contraindicated in the entire first trimester (the USMLE pearl: cardiovascular defects or Epstein anomaly). Likewise, carbamazepine is contraindicated in the first trimester.

Great question, however, it seems more appropriate for Step 2. Also, you better be 100% positive by dates and have a good lawyer if you decide to give valproic acid to a pregnant lady so close to the first month of her pregnancy. Don't look dumbfounded if the baby comes out with a huge NTD. 👍

 

[DrPak]

Thanks a lot for bumping up the "pimp" thread!

I posted this question on another forum. Everyone kept saying clozapine. It's not that nor valproic acid. Like you said, the dates could be off. After all, the wife is crazy and it's the husband whose telling you. In anycase, there are drugs for bipolar disorder that can be used in preganancy, so why go for one that might be teratogenic.

I'll cut and paste my response from the other forum:

Yes, clonazepam is the right answer. The woman obviously has bipolar disorder so your choice of drugs is lithium and then the backup drugs, valproic acid, carbamazepine, gabapentin and clonazepam. Of these choices, only clonazepam and gabapentin can be given to pregnant patients, and the answer available is clonazepam.

Clozapine isn't an option at all here, it's an antipsychotic and even for that is mostly a drug of last resort. It was actually taken off the market for 10 years for the agranulocytosis side effects and if used now requires mandatory regular blood monitoring. I think you're confusing the use of clozapine with that of the older antipsychotics in bipolar disorder. Antipsychotics are used for bipolar disorder (Kaplan Pharma page 162), but Anthony Trevor said that it's real use in such conditions is to calm the patient down through the sedative effects that antipsychotics have. Sedation occurs with the older antipsychotics, not the newer ones, like clozapine.

Bottom line:
pregnant bipolar=clonazepam or gabapentin.

 

[DrPak]

If the option were there, I would choose first of all to confirm her pregnancy and see how far along she is. If that choice were there, it would be more of a step 2 question. As it is, it's mostly a pharma question.

 

[Pox in a box]

Thanks a lot for bumping up the "pimp" thread!

I posted this question on another forum. Everyone kept saying clozapine. It's not that nor valproic acid. Like you said, the dates could be off. After all, the wife is crazy and it's the husband whose telling you. In anycase, there are drugs for bipolar disorder that can be used in preganancy, so why go for one that might be teratogenic.

I'll cut and paste my response from the other forum:

Yes, clonazepam is the right answer. The woman obviously has bipolar disorder so your choice of drugs is lithium and then the backup drugs, valproic acid, carbamazepine, gabapentin and clonazepam. Of these choices, only clonazepam and gabapentin can be given to pregnant patients, and the answer available is clonazepam.

Clozapine isn't an option at all here, it's an antipsychotic and even for that is mostly a drug of last resort. It was actually taken off the market for 10 years for the agranulocytosis side effects and if used now requires mandatory regular blood monitoring. I think you're confusing the use of clozapine with that of the older antipsychotics in bipolar disorder. Antipsychotics are used for bipolar disorder (Kaplan Pharma page 162), but Anthony Trevor said that it's real use in such conditions is to calm the patient down through the sedative effects that antipsychotics have. Sedation occurs with the older antipsychotics, not the newer ones, like clozapine.

Bottom line:
pregnant bipolar=clonazepam or gabapentin.

Clonazepam for bipolar?

 

[DrPak]

Clonazepam for bipolar?

Hey Pox, I've looked into this a little further in my spare time.

Kaplan Pharma clearly sez Clonazepam and gabapentin are used for pregnant bipolar patients. Trevor and Katzung's Pharmacology Examination and Board Review (6th Edition) book sez that they are back up drugs (page 264). Clinical Pharmacology by Katzung also mentions the use of benzodiazepines for bipolars although without much emphasis. I looked the matter up in the web and it seems that there is no consensus really about what to do in pregnant bipolars. We certainly can use the drugs I mentioned, but no one in the field was really happy with the options. It seems like I was hasty with my "bottom line" remark. There doesn't really seem to be a very good range of options for pregnant bipolar patients.

I did learn another useful thing though. From my reading it seemed like for many diseases for which the incidence is relatively low, the pharmaceutical companies don't exactly fall over themselves to find new drugs that could work simply because of the cost-benefit ratio. They won't even break even if they spend 10s of millions for a condition that doesn't have that many victims. According to the NIMH, about 3 million Americans that suffer from bipolar disorder, which seems a lot to me, but obviously isn't enough to turn a profit. This also explains to some extent why the 'back up' drugs we use for bipolar disorder are borrowed from other classes of drugs (the sedative hypnotics and anticonvulsants) rather than coming from a drug class exclusively dedicated for the bipolar disorder.

In any case, I think my original question wasn't realistic. 😳 There isn't really a clearcut answer to the delimma of a pregnant bipolar disorder.

Any further comments are welcomed if anyone has something to add.