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An 8-Step Cognitively Active Strategy to Process MCQs Nikki Dyer Student Academic Support Services & Inclusion July 2016 A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? A. Amoxapine B. Citalopram C. Fluoxetine D. Sertraline E. Tranylcypromine Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? A. B. C. D. E. Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? A. Amoxapine B. Citalopram C. Fluoxetine Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? A. Amoxapine B. Citalopram C. Fluoxetine D. Sertraline E. Tranylcypromine Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? A. Amoxapine (Acts on dopamine receptors) B. Citalopram C. Fluoxetine D. Sertraline (CNS agent) E. Tranylcypromine Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion A 26-year-old woman has been on antidepressant therapy for several months. Today she complains of missing her period and having what is eventually determined to be galactorrhea. Your careful assessment reveals that she has developed some dyskinesias not unlike those you would typically associate with a phenothiazine or butyrophrenone (e.g. haloperidol) antipsychotic drug. Pregnancy tests are negative. What drug is most likely to have caused these findings? A. Amoxapine (Acts on dopamine receptors) B. Citalopram C. Fluoxetine D. Sertraline (CNS agent) E. Tranylcypromine Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion The mention of menstrual irregularities, galactorrhea, and what appears to be extrapyramidal side effects, should be a tip-off that we are dealing with a drug that interacts with dopamine receptorsspecifically D2, by blocking them. Amoxapine, the correct answer, is a tricyclic antidepressant (secondary amine). It is rather unique among all the tricyclics (other secondary amines, and tertiary amines such as the more familiar amitriptyline and imipramine) in several respects. For one thing it inhibits neuronal dopamine and NE reuptake (the others affect mainly NE and serotonin). That however, does not readily explain the amenorrhea-galactorrhea and extrapyramidal side effects. What provides the explanation or mechanism relates to another rather unique property of amoxapine: one of its metabolites is a strong dopamine receptor antagonist, an action not shared by any of the other tricyclics; by the SSRIs( eg, citalopram, fluoxentine, sertraline; answers b, c, and d); or by the monoamine oxidase inhibitors (eg, tranylcypromine, e; or phenelzine). You should recall that such antipsychotic drugs such as the phenothiazines and haloperidol may also cause amenorrhea-galactorrhea and extrapyramidal side effects, by the same dopaminergic receptor-blocking mechanism. Conversely, drugs that activate dopamine receptors in one way or another (eg bromocriptine) can be used to manage these endocrine dysfunctions. Amoxapine’s dopamine receptor blockade also seems to account for why the drug exerts some antipsychotic properties, theoretically making it useful for patients with both psychosis and depression. Reference: PreTest Pharmacology, 13th ed, M. Shlafer, pp. 142 & 178 July 2016 Nikki Dyer, Student Academic Support Services & Inclusion