57 - Pharmacotherapy of schizophrenia and psychotic disorders

Question 1

Warnings for all Antipsychotics

• Boxed Warning: increased risk of death in ___ patients treated with antipsychotics for dementia with related behaviors
• ___ adverse effects
• EPS
• risk of somnolence, postural ___ , and motor/sensory instability increases the risk for falls/fractures
• fall risk assessment should be performed for patients taking other medications or having other disease states that also have a fall/fracture/somnolence/hypotension risk
• assess when initiating antipsychotic and repeat routinely if on continuous long term treatment

Answer 1

• elderly
• metabolic
• hypotension

Question 2

fluphenazine and haloperidol decanoate

fluphenazine
- given every 2 weeks
- short onset of action - dont need oral overalp dosing
- oil based - need to Z-track

haloperidol
- given every ___ weeks
- load: ___ x oral dose
- maintenance: ___ x oral dose
- if only use maintenance, may need ___ overlap
- oil-based - Z-track

Answer 2

• 4
• 20x
• 10x
• oral

Question 3

Risperdal Consta (risperidone)

starting dose = 25 mg IM every week

MUST supplement with ___ risperidone (or another oral antipsychotic) for the first few weeks of treatment
- Otts tells providers until ___ injection (week 4)

Answer 3

oral
3rd

Question 4

Perseris (risperidone)

• abdominal ___ injections
• ___ inducers - use ___ mg dose or may need ___ supplementation

Answer 4

• SubQ
• 3A4, 120, oral

Question 5

Rykindo (risperidone)

• every ___ week ___ injection
• oral dose overlap is shorter than Risperdal Consta ( ___ days vs ___ days)

Answer 5

• 2, IM
• 7, 21

Question 6

Uzedy (risperidone)

• abdominal or upper arm ___ injection
• initiate the day after the last oral dose
• can switch to Uzedy only from oral risperidone
• given once ___ or every ___ months

Answer 6

• SubQ
• monthly, 2

Question 7

Invega Sustenna (paliperidone)

• ___ dose, then booster, then every ___ weeks (starting ___ weeks after loading injection)
• initial loading and booster does must be given in ___ to improve absorption consistency
• if loading strategy followed, no need for ___ overlap
• may require dose adjustment in moderate to severe ___ impairment

Answer 7

• loading, 4, 5
• deltoid
• oral
• renal

Question 8

Invega Trinza (paliperidone q3mo)

• may be initiated for a patient who has been on a stable monthly IM injection of ___ (only way that it should be used)
• at least ___ stable ___ doses
• recommended to be given in the ___; ___ administration results in lower Cmax
• not recommened if CrCl < ___ mL/min
• VERY EXPENSIVE

Answer 8

• Invega Sustenna
• 4, invega Sustenna
• deltoid, gluteal
• 50

Question 9

Invega Hafyera (paliperidone q6mo)

• may be initiated after stable Invega Sustenna for ___ months or stable Invega Trinza after one ___ month dose
• ___ injection only
• SUPER EXPENSIVE
• not recommended in renal impairment (CrCl < 90 mL/min)

Answer 9

• 4, 3
• gluteal

Question 10

Zyprexa Relprevv (olanzapine)

SE similar to oral olanzapine

___ - requires registration of patient, facility giving injection, prescriber, adn pharmacy with Eli Lilly

PDSS - ___
- significant sedation
- must be done by clinic staff
- must be monitored 3 hours after dose and have accompanied ride home

Dosing for IM q 2 weeks only compare to up to 20 mg oral dose daily. Most patients take more than 20 mg.
- will have to do oral supplementation in addition to shot

Answer 10

REMS
post dose sedation syndrome

Question 11

Abilify Maintena (aripiprazole)

MUST overlap with ___ aripiprazole (or another oral anntipsychotic) for at least ___ days after first injection
- ___ or ___ injection

Answer 11

oral, 14
- deltoid, gluteal

Question 12

Abilify Maintena (aripiprazole) CYP interaction dose adjustments

Question 13

Abilify Asimtufii (aripiprazole)

Question 15

Abilify Maintena Dose Adjustments for CYP Interactions

if taking ___ or ___ inhibitors or ___ inducers for more than ___ days as concomitant therapy

Answer 15

2D6, 3A4, 3A4, 14

Question 16

Abilify Asimtufii (aripiprazole)

• every 2 ___ dosing
• ___ injection only
• must establish tolerability to aripiprazole with oral dosing up to ___ weeks to assess; after tolerability is established, continue oral aripiprazole for ___ weeks after first injection

Answer 16

• month
• gluteal
• 2, 2

Question 17

Aristada (aripiprazole lauroxil)

• ___ of aripiprazole
• overlap with oral aripiprazole for ___ weeks after first injection

Answer 17

prodrug
3

Question 18

Aristada Initio

• developed to ___ need for 21 day oral overlap of antipsychotic
• avoid in patients who are ___ poor metabolizers or with strong ___ or ___ inhibitors

Answer 18

• avoid
• 2D6, 3A4, 2D6

Question 19

Immediate Release Antipsychotic Injections / Psychiatric Emergencies

• ___ , ___ , and ___ are used
• ___ is the most common
• often given with lorazepam in the same syringe
• ___ immediate release IM - CANNOT be given at the same time as a ___ immediate release injection - boxed warning for respiratory depression
• ___ for inhalation (Adasuve) - not commonly used due to REMS - bronchospasm. Developed to improve patient acceptance

Answer 19

• haloperidol, chlorpromazine, fluphenazine
• haloperidol
• olanzapine, benxodiazepine
• loxapine

Question 20

Clinical Treatment Strategies for EPS

Acute Dystonia - not life threatening, but very frightening
- IM ___ NOW dose ( ___ 2mg, ___ 50 mg)

Answer 20

anticholinergic
- benztropine, diphenhydramine

Question 21

Clinical Treatment Strategies for EPS

Drug-Induced Parkinson’s - longer term side effect, months into antipsychotic treatment
- oral ___ (3)
- amantadine

Answer 21

anticholinergics
- benztropine, trihexyphenidyl, diphenhydramine

Question 22

Clinical Treatment Strategies for EPS

Akathisia - subjective feeling of restlessness; increases risk for suicidal thinking
- BB - ___ preferred first line
- benzodiazepine - usually ___

Answer 22

• propranolol
• lorazepam

Question 23

Clinical Treatment Strategies for EPS

Tardive Dyskinesia - ___ dose of antipsychotic if possible or switch to antipsychotic with less risk
- ___ inhibitors

Answer 23

lower
- VMAT

Question 24

VMAT inhibitors

inhibit the vesicular monoamine trasporter to ___ storage / ___ release of dopamine, serotonin, and norepinephrine

Answer 24

decrease, increase

Question 25

VMAT inhibitors

tetrabenazine (Xenazine)
- not FDA-approved to treat TD, indicated for ___
- boxed warning for suicidality/depression
- CI in actively suicidal pts, undertreated depression, hepatic impairment
- ___ prolongation

Answer 25

• Huntington’s chorea
• QTc

Question 26

VMAT inhibitors

___ (Ingrezza)
- ___ / ___ substrate
- SE: ___ prolongation, somnolence, hypersensitivity reactions, anxiety, insomnia, dose-related __ increase, increased weight and BG

Answer 26

valbenazine
- 2D6, 3A4
- QTc

Question 27

VMAT inhibitors

___ (Austedo)
- FDA approved for both ___ and ___
- ___ substrate
- SE: ___ prolongation, neuroleptic malignant syndrome, Parkinson’s symptoms, sedatioin, somnolence, anxiety, insomnia, fatigue, diarrhea

Answer 27

deutetrabenazine
- TD, Huntington’s chorea
- 2D6
- QTc

Question 28

neuroleptic malignant syndrome

• life threatening - medical ___
• may happen with first dose, dose increase, or earlier course of treatment
• hyper ___ , ___ cardia, labile blood pressure
• muscle ___ - significantly elevated CK, myoglobinuria
• treatment is supportive - d/c antipsychotics, consider ___ agonist

future antipsychotic use is NOT CI
- may use same drug, likely to switch to another agent

Answer 28

• emergency
• hyperpyrexia, tachycardia
• rigidity
• dopamine

Question 29

metabolic adverse effects

• hyper ___ , hyper ___ , hyper __
• weight gain

atypical antipsychotic risk
- clozapine = ___ >
- quetiapine = ___ = paliperidone = asenapine - iloperidone = cariprazine = brepiprazole >
- ziprasidone = lurasidone = ___

Answer 29

• hyperglycemia, hyperlipidemia, hypertension
• olanzapine
• risperidone
• aripiprazole

Question 30

metabolic monitoring

• personal/family Hx
• weight (BMI)
• waist circumference
• BP
• FPG/A1c
• fasting lipids

Answer 30

Question 31

medications for weight loss/diabetes

___ most commonly used
- ___ treatment for weight gain

___ studied for weight loss

GLP-1s can also be considered

Answer 31

metformin
topiramate