Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Mental Health > Antipsychotic Pharmacotherapy > Flashcards

Antipsychotic Pharmacotherapy Flashcards

1
Q

The 5 major receptor targets of AP’s are…

A

Dopamine (D2)
5HT2a
Muscarinic
Alpha-1
Histaminic-1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Majority of 1st generation AP’s primarily target these receptors:

A

Strong D2 receptor antagonism
“dirty” - mixed receptor affinity at alpha, muscarinic, and histamine receptors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Majority of 2nd generation AP’s primarily target these receptors:

A

D2 receptor antagonism
5HT2A/2C antagonism
“dirty” - mixed receptor affinity at alpha, muscarinic, histamine receptors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Majority of 3rd generation AP’s primarily target these receptors:

A

D2 receptor partial agonism
5HT2A antagonism
5HT1A/2C partial agonism

And additional receptor effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

1st generation AP’s are associated with higher rates of this AE…

A

Movement adverse effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

2nd generation AP’s are associated with higher rates of this AE…

A

Metabolic adverse effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

3rd generation AP’s are associated with higher rates of this AE…

A

Akathisia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Despite grouping of AP’s, they are…

A

Very different from each other; receptor profiles relate to tolerability and differences in metabolic pathways are important for drug interactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Overall efficacy of AP’s is…

EXCEPT FOR??

A

Similar - except for clozapine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

D2 antagonism’s therapeutic effect is…

A

The antipsychotic effect - improvement in positive symptoms

Blocking dopamine in the mesolimbic pathway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

AE’s that may result from D2 antagonism includes…

A

EPS
Elevated prolactin: gynecomastia, amenorrhea, impotence, osteoporosis - sexual dysfunction
Worsening of negative symptoms

Nigrostriatal and tuberoinfundibular dopamine blockade

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

5HT therapeutic effect is…

Some are antagonistic, and some are agonistic…

A

2A/2C antagonism: antipsychotic effect (theoretically improve negative symptoms via increased dopamine release in mesocortical pathway)
1A agonism: anxiolytic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

AE’s that may result from 5HT receptor interaction includes…

A

Sedation
Hypotension
Sexual dysfunction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Alpha1/2 antagonism therapeutic effects include…

A

None

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

AE’s associated with alpha1/2 receptors include…

A

Alpha1 - Sedation, hypotension, dizziness, reflex tachycardia, incontinence, drooling
Alpha2 - sexual dysfunction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Muscarinic antagonism therapeutic effects include…

A

None - perhaps potentiation of drugs that have anticholinergic properties

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

AE’s that result from muscarinic antagonism include…

Anticholinergic !

A

Dry mouth
Blurred vision
Constipation
Urinary retention
Confusion/memory disturbance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Histamine antagonism therapeutic effects include…

A

None - May potentiate effect of other CNS depressant drugs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

AE’s that result from histamine antagonism include…

A

Sedation, drowsiness
Postural hypotension
Weight gain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

High potency 1st generation AP’s have higher risk of ____ but weaker ____

A

Higher risk of movement disorders, but weaker anticholinergic effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Common high potency 1st generation AP’s include…

A

Haloperidol
Flupenthixol
Fluphenazine
Perphenazine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Low potency 1st generation AP’s have lower risk of ____ but stronger ____

A

Lower risk of movement disorders, but stronger anticholinergic effects (highly sedating)

Metabolic effects are stronger due to stronger anticholinergic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Common low potency 1st generation AP’s include…

A

Chlorpromazine
Methotrimeprazine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

2nd generation AP’s have lower risk of ____ but higher risk of ____

A

Lower risk of movement disorders, but higher risk of metabolic AE’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Metabolic AE’s may include…

A

Lipid dysfunction
Development of diabetes or HTN
Obesity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Risperidone has high affinity for the following receptors:

A

Dopamine, serotonin, and alpha-adrenergic receptors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Initial dosing of risperidone is…

A

1-2mg/day, once daily or BID

May start at 0.5mg for elderly or those with co-morbidities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Regular doses of risperidone are…

A

4-6mg/day

No higher; 1st generation features at over 8mg/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Different formulations of risperidone include…

A

Oral solution
Oral tablets
Orally disintegrating tablets
Long acting injectable

Switching to injectable would require overlap with oral risperidone for 3 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

When considering 2nd generation AE’s, we can consider the AE’s related to receptors, such as…

Consider the 5 receptors and AE’s caused when affected

A

Alpha-blockade: Dizziness, sedation, orthostatic hypotension
Dopamine-blockade: Worsening of negative symptoms, EPS, prolactin
Muscarinic-blockade: Anticholinergic + metabolic effects
Histaminic-blockade: Anticholinergic + metabolic effects

Serotonin tries to help improve negative symptoms, but clinically has not seen much benefit - adds to sedation, hypotension, sexual dysfunction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Risperidone is unique in that it has low/no affinity for…

A

Low: alpha2, histamine
No affinity for muscarinic
No anticholinergic, lower rate of sedation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Aside from typical AP AE’s, unique AE’s with risperidone include…

A

Weight gain risk is lower vs. other 2nd gen AP’s
Increased risk of prolactin/sexual dysfunction and EPS vs. other 2nd gen AP’s
Headache, rhinitis, anxiety
QT Prolongation

NO anticholinergic, but may still be sedating from histamine action

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Important drug interactions for risperidone include…

A

Pharmacodynamic interactions with other CNS depressants + QTc prolonging agents
3A4/2D6 interactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Paliperidone is the primary active metabolite of…

A

Risperidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Dosing forms of paliperidone includes…

A

Tablets
Long-acting injectable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Paliperidone AE’s and DI’s are quite similar to risperidone, but some are more pronounced than others, such as…

A

Less risk of orthostatic hypotension, weight gain
More risk of insomnia
Similar risk of prolactin/sexual dysfunction

Minimal risk of DI’s compared to risperidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Olanzapine is often not initially used due to…

A

Metabolic AE’s - A LOT of histamine/muscarinic blockade

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Initial dosing of olanzapine is usually…

A

5-10mg at bedtime

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Usual dosing of olanzapine is…

A

10-20mg once daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Dosing formulations of olanzapine includes…

A

Tablets
Orally disintegrating tablets
Short or long-acting injectable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Aside from typical AP AE’s, unique AE’s with olanzapine includes…

A

Weight gain - increased risk of T2DM and/or dyslipidemia compared to other 2nd gen AP’s
Dose-dependent risk of EPS, especially akathisia
QT Prolongation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Important DI’s with olanzapine includes…

A

Smoking - will lower olanzapine levels
1A2 inhibitors/inducers
Pharmacodynamic interactions with drugs of similar actions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

2nd generation AP’s include the following drugs…

A

Risperidone, paliperidone
Olanzapine
Ziprasidone
Asenapine
Lurasidone
Clozapine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

The 2 quetiapine formulations include…

A

XR (once daily)
IR (BID)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

XR quetiapine for psychosis is dosed as follows…

A

1st day: 300mg HS
2nd day: 600mg HS
After day 2: up to 800mg HS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

IR quetiapine for psychosis is dosed as follows…

A

25mg BID, increasing q4-7 days up to 400mg po BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Lower doses of quetiapine are used for ____, because…

A

Insomnia, bipolar, depression, anxiety… Different doses have different affinities for different receptors

~50mg primarily histamine blockade
~300mg includes serotonin receptors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Aside from typical AP AE’s, unique AE’s with quetiapine at high doses include…

A

Increased risk of T2DM and dyslipidemia vs. other 2nd gen AP’s
May reduce thyroid hormone levels
QT Prolongation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Important DI’s with quetiapine include…

A

Pharmacodynamic interactions; CNS depressants, QTc prolonging agents
3A4 interactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Ziprasidone is not often used due to…

A

The need for high food intake with it

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Ziprasidone needs to be administered with ____, because…

A

WITH FOOD: >500 kcal to maximize absorption and therapeutic effect

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Initial dosing of ziprasidone is…

A

40mg BID; 20mg BID for antipsychotic naive first episode psychosis patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Ziprasidone-induced “activation” syndrome includes symptoms such as…

A

Anxiety, restlessness, insomnia, hypomanic-like symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Ziprasidone-induced activation syndrome usually develops…

A

After treatment initiation and occur at the lower end of the dosage range

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Ziprasidone-induced activation syndrome can be avoided by…

A

Rapidly titrating in the first week, up to 120-160 mg/day especially in bipolar disorder or agitated/irritable patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Aside from typical AP AE’s, unique AE’s with ziprasidone include…

A

Less hyperglycemia/dyslipidema risk vs. other 2nd gen AP’s
Higher risk of QT prolongation
Dyspepsia, nausea, constipation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Important DI’s with ziprasidone include…

A

Pharmacodynamic interactions; CNS depressants, QTc prolongation
3A4 Inducers/inhibitors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Asenapine is EDS for bipolar but is not covered for us in schizophrenia because…

A

Superiority vs. placebo was not clearly demonstrated, therefore is not clinically used for schizophrenia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Dosing of asenapine is…

A

Initial 5mg BID, up to 10mg BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Dosing formulation of asenapine is…

A

Sublingual tablets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Aside from typical AP AE’s, unique AE’s with asenapine includes…

A

Mouth numbness x 1hr post dose
Minimal effect on weight, glucose, lipids
Headache, dizziness
QT prolongation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Important DI’s with asenapine includes…

A

PD with CNS depressants, QTc prolonging agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Luraisdone is not used often for schizophrenia in clinical practice, since…

A

Efficacy has only been established in studies up to 6 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Lurasidone has a better AE profile than most 2nd gen AP’s, since…

A

Little to no metabolic concerns
Still some EPS, prolactin, sedation, QTc, -typical AP AE’s, but likely less concerning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Important DI’s with lurasidone includes…

A

PD interactions with CNS depressants and QTc prolonging agents
3A4 inhibitors + inducers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Dosing of lurasidone is…

A

40mg daily, titrated up to 120-160 mg daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Lurasidone administration is unique like zipraidone in that…

A

Food is needed to increase bioavailability (350 kcal)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

3rd generation AP’s include these three drugs…

A

Aripiprazole
Brexpiprazole
Cariprazine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

3rd generation AP’s are unique in that they are dopamine ____

A

Partial agonists

70
Q

Dopamine partial agonists are unique in that they partially…

AKA Dopamine system stabilizer

A

Activate dopamine receptor output, and cause stabilizing balance between stimulation and blockade of dopamine receptors

High levels of dopamine = antagonist
Low levels of dopamine = agonist

71
Q

3rd generation AP’s have a lower risk of ____, but higher rates of ____

A

Lower risk of metabolic + movement AE’s, but higher rates of akathisia

Aripiprazole&raquo_space; Brexpiprazole

72
Q

Dosing of oral aripiprazole is…

A

10-15mg po once daily; max of 30mg/day

73
Q

Key factor for aripiprazole titration is that the half-life is ____, so we cannot increase dose faster than ______

A

Half-life is 75 hours; cannot increase dose faster than 2 weeks

74
Q

Dosing of long-acting aripiprazole is…

A

Long-acting injectable 400mg IM q4weeks

May reduce down to 300mg IM q4weeks when stable, or adverse effects

75
Q

When choosing to initiate depot aripiprazole, we need to continue oral dosing for..

A

2 weeks

76
Q

Aside from typical AP AE’s, unique AE’s with aripiprazole includes…

A

Akathisia
Some anxiety
Headache, GI complaints, insomnia
Minimal weight gain :)
Suicidal behaviour
QT prolongation

77
Q

DI’s with aripiprazole revolve around…

A

CYP 2D6 and 3A4

78
Q

Brexpiprazole is similar to aripiprazole in AE’s except for…

A

Less risk of akathisia

79
Q

Half-life of brexpiprazole is around…

A

~91 hours

80
Q

Target dosing of brexpiprazole for schizophrenia is…

A

2-4mg/day

If MDD add-on: 0.5-2mg daily

81
Q

Dosing of brexpiprazole for schizophrenia should be initiated at…

A

1mg daily

82
Q

Cariprazine is unique in that it targets…

A

D2 + D3 - partial agonist
5HT1A - partial agonist
5HT2A + 2B - antagonist

83
Q

D3 receptors are associated with…

A

Mood, cognition, addictive behaviours, and reward behaviours

84
Q

Partial agonism of the D3 receptor may help…

A

Improve negative symptoms + cognitive impairment of schizophrenia

85
Q

Important PK parameters with cariprazine involve…

A

Highly protein bound
Extensively metabolized by CYP3A4 - affected by inducers/inhibitors
Has active metabolites that extend half-life

86
Q

The downside with cariprazine is that trials did not…

A

Detect clinically meaningful responses for efficacy in improving negative symptoms compared to placebo
No direct comparative evidence vs. other antipsychotics

87
Q

To summarize evidence of cariprazine so far, it may be effective in schizophrenia for treatment of…

A

Acute exacerbations, and prevention of relapse after acute exacberations
Implications for negative symptoms of schizophrenia

MORE direct comparative evidence and research is needed

88
Q

1st generation AP’s have shown higher discontinuation rates due to…

A

Adverse effects (EPS)
Lack of treatment effect

89
Q

____ are the prefered agents for treatment of patients with early psychosis, due to ______

A

2nd generation AP’s, due to significant increased risk of EPS with 1st generation AP’s

90
Q

When selecting an AP, we should individualize to the patient based on factors such as…

A

Symptomatology
AE’s
DI’s
Cost
Convenience

91
Q

If oral AP’s are effective and tolerated, we could…

A
  1. Continue with oral therapy
  2. Switch to long-acting injectable depot
92
Q

Benefit of LAIA’s is…

A

Improved adherence; given q2-4 weeks

93
Q

LAIA’s can be considered if a patient…

A

Relapses due to non-adherence
Or if they simply prefer the injection

94
Q

Proven benefits of LAIA’s include…

A

Lower risk of relapse
Decreased hospitalization rates
Decreased patient/caregiver burden
Improved adherence

95
Q

Before starting a patient on LAIA, we need to…

A

Ensure tolerability, with oral formulation first
Double check how long to overlap with oral formulation

96
Q

The only 3rd generation AP that can be given depot is…

A

Aripiprazole

97
Q

Does aripiprazole require overlap from oral to depot formulation?

A

Yes, 2 weeks

98
Q

2nd gen AP’s that can be given as depot include…

A

Paliperidone
Risperidone

99
Q

Paliperidone is unique in that it has two depot formulations that differ by…

A

Time of administration. One is every 1 month, and another is every 3 months.

100
Q

Do 2nd gen AP require overlap from oral to depot?

A

Paliperidone does not. Risperidone does, for 3 weeks

101
Q

1st gen AP in depot formulations include ____, however…

A

Flupenthixol, haloperidol, and zuclopenthixol. These should not be used unless all other options are exhausted

102
Q

General monitoring guidelines for all AP’s include…

A

Vitals
Behaviours
AE’s - CNS changes, anticholinergic, EPS, hyperprolactin
CBC, LFT’s, ECG if cardiac risk factors or QT prolonging drugs

Will depend on the agent chosen

103
Q

Cloazpine has most distincitve activity for these receptors…

A

D4
5-HT2A
Alpha-1
Muscarinic

104
Q

Common AE’s with clozapine include…

THINK OF THE RECEPTORS

A

Anticholinergic (Constipation, blurred vision, drowsiness, dizziness)
Metabolic (weight gain, increased cholesterol, BG)
Alpha-1 (tachycardia, orthostatic hypotension, dizziness, drooling)

105
Q

Serious AE’s with clozapine include…

A

Agranulocytosis
Myocarditis/cardiomyopathy
Severe constipation
Seizures
Neuroleptic malignant syndrome

106
Q

Clozapine-induced agranulocytosis is…

A

A dangerously low neutrophil count - highly increases infection risk

107
Q

Clozapine-induced myocarditis is…

A

Inflammation of the heart muscle - allergic reaction

High mortality rate

108
Q

Severe constipation caused by clozapine can lead to…

A

Adynamic ileus

High mortality rate; monitor bowel functioning

Peristalsis stops in the GI tract, can rupture

109
Q

Agranulocyotis with clozapine is most likely to occur in…

Timeframe

A

The first 6 months of treatment

110
Q

Myocarditis with clozapine is most likely to occur in…

Timeframe

A

The first 4-8 weeks of treatment

111
Q

Cardiomyopathy with clozapine is most likely to occur in…

A

Months to years of treatment

112
Q

The difference between myocarditis and cardiomyopathy is…

A

Myocarditis = allergic-like reaction causing inflammation
Cardiomyopathy = Disease of heart muscle, making it harder to pump blood

113
Q

Clinical presentation of myocarditis and cardiomyopathy are similar when beginning, and this may include…

A

Orthostatic blood pressure changes
Fatigue, decreased exercise tolerance
Chest pain, discomfort, palpitations with increased heart rate
SOB
Peripheral edema
Fever

114
Q

Lab markers that can indicate cardiomyopathy or myocarditis include…

A

CRP - non-specific for inflammation
Troponin - protein in heart muscle (that typically should not be in the blood)

115
Q

Monitoring for agranulocytosis with clozapine requires specific blood tests, which is…

A

The absolute neutrophil count - need to order CBC with differential, vs. just a CBC

116
Q

Clozapine can ONLY be used and dispensed if…

A

Patient is actively registered with a clozapine registry, and hematological monitoring can be guaranteed

Remember CBC with diff - neutrophils

117
Q

How often does blood work need to be done for clozapine monitoring?

A

Weekly for first 6 months
Then once every 2 weeks if green light maintained and clinically stable
Then once every 4 weeks if green light for another 6 months

118
Q

If a patient stops clozapine, do they still need to monitor their neutrophil counts?

A

Yes, for 4 weeks after stopping

119
Q

Clozapine dosing needs to be re-titrated if missed for longer than…

A

48 hours

120
Q

If clozapine therapy is disrupted for more than ____, blood testing needs to be done…

How frequently?

A

3+ days; blood testing resumed weekly for an additional 6 weeks

121
Q

“Green” neutrophil count with clozapine monitoring is above…

A

2.0 x 10^9/L

122
Q

“Yellow” neutrophil count with clozapine monitoring is…

How often do we test if yellow?

A

In range of 1.5-2.0 x 10^9/L

Test at least twice weekly until ANC stabilizes or increases

Can continue to dispense in meantime

123
Q

“Red” neutrophil count with clozapine monitoring is…

What do we do next?

A

Below 1.5 x 10^9/L

Immedaitely withhold and discontinue if confirmed. Monitor for signs of infection

124
Q

Clozapine is non-rechallengable in regards to agranulocytosis, whihch means…

A

Patient must stop and cannot ever restart therapy if they were in “red” neutrophil count

Still requires the weekly CBC x 4 weeks when stopped

125
Q

The amount of clozapine dispensed must align with…

A

The frequency of clozapine bloodwork

q2weekly blood work can only have 2 weeks of clozapine dispensed from the pharmacy

126
Q

Initial dosing and titration of clozapine is usually…

A

12.5-25mg/day PO; increase by 12.5-25mg on 2nd day, then 25-50mg daily PO depending on tolerance

Minimize risk of orthostatic hypotension and sedation

127
Q

Usual dosing of clozapine is ____, and can go up to…

A

300-600mg PO/day after 2 weeks - max of 900mg PO/day

OD, BID, or TID

128
Q

An important drug interaction with clozapine is…

A

SMOKING - induces 1A2, reducing levels
Also consider anything that may affect CYP 1A2

129
Q

Clozapine in relation to suicide risk has shown…

A

A reduction in risk of suicide in schizophrenia/schizoaffective patients

NNT = 13

130
Q

Extrapyramidal system differs from pyramidal system mainly by…

A

Pyramidal = Voluntary movement
Extrapyramidal = Involuntary movement

131
Q

Acute extrapyramidal effects usually onset within ____ days, and are mostly due to…

A

Within 30 days; mostly due to dopamine (D2) blockade

132
Q

Treatment of acute EPS is usually with…

A

Antiparkinsonian drugs - centrally acting anticholinergics (cross BBB, block excitatory muscarinic pathways, restore dopamine/ACh balance disrupted by AP’s)

133
Q

Treating acute EPS symptoms is important to prevent…

A

Tardive symptoms

134
Q

Tardive symptoms onset is usually after…

A

Months/years of treatment, especially if drug dose is decreased or discontinued; and tend to persist for years or decades

Can may become permanent even with removal of AP; precise pathophysiology remains unclear

135
Q

FDA-approved drugs for treating tardive dyskinesia includes…

A

Valbenazine
Deutetrabenazine

DOESN’T actually treat TD, just lowers AE’s. Also isn’t available in Canada yet; therefore PREVENTION IS KEY

136
Q

Important factors to consider with TD prevention include…

All related to AP’s, and dose

A

Early recognition + discontinuation of offending AP (not always an option)
Dose reduction/use of lowest effective dose (weigh against risk of relapse)
SLOW tapers with AP to avoid withdrawal emergent symptoms
Switch to atypical AP’s

137
Q

Acute EPS effects may include…

A

Dystonia
Akathisia
Pseudoparkinsonism
Pisa syndrome, rabbit syndrome

138
Q

Physical symptoms of acute dystonia includes…

A

Torsions and spasms of muscle groups - mostly affecting the muscles of the head and neck
Painful and spasmodic

139
Q

Psychological symptoms that can occur with acute dystonias include…

A

Anxiety, fear, panic
Dysphoria
Repetitive meaningless thoughts

140
Q

Time of onset for acute dystonia in relation to AP treatment is usually…

A

Within 24-48 hours of the 1st dose; 90% occur within 1st week of treatment

141
Q

Acute dystonia can be life-threatening because…

A

Dystonia relating to laryngeal/pharyngeal pathways may stop swallowing/breathing reflexes

142
Q

With acute dystonia, oculogyria may be present, which is…

A

Sustained upward and lateral deviation of the eyes

143
Q

Treatment options for acute dystonia includes…

A

1st line: IM benztropine
IM diphenhydramine, sublingual lorazepam

144
Q

Physical symptoms of akathisia include…

A

Motor restlessness (fidgeting, pacing, rocking, inability to be still)
Respiratory - dyspnea or breathing discomfort

145
Q

Psychological symptoms of akathisia include…

A

Restlessness, intense urges to move
Irritability, agitation, violent outbursts
Feeling uncomfrotable, “antsy”
Can contribute to suicide and violence

146
Q

Proposed risk factors for developing acute akathisia include…

A

High potency 1st gen AP’s, and 3rd gen AP’s
Anxiety, mood disorders
Stimulant usage; caffeine

147
Q

Time of onset of acute akathisia in relation to AP treatment is…

A

Hours-days; 90% occur within first 6 weeks of treatment and may continue throughout entire treatment

148
Q

Treatment options for acute akathisia include…

A

Reduce dose (slow taper) or change AP
Trial of benzodiazepines, non-selective beta-blocker, or mirtazapine

149
Q

Physical symptoms of acute pseudoparkinsonism include…

A

Tremor
Cogwheel rigidity
Bradykinesia

150
Q

Presentation of bradykinesia may include…

A

Mask-like facial expression
Diminished/absent arm swing
Shuffling gait; slowness of movement
Stooped posture

151
Q

Psychological symptoms of pseudoparkinsonism include…

A

Slowed thinking
Fatigue
Cognitive impairment, drowsiness

152
Q

Time of onset of pseudoparkinsonism in relation to AP treatment is…

A

Acute - 90% occur within first 6 weeks of treatment and may continue through entire treatment

153
Q

Treatment options for pseudoparkinsonism include…

A

Dose reduction, or changing AP
Antiparkinsonian drugs - anticholinergics (benztropine, diqphenhydramine, procyclidine, trihexyphenidyl)

154
Q

Pisa syndrome is when the patient is…

A

Leaning to one side

155
Q

Onset of pisa syndrome can be…

A

Either acute or tardive; usually ignored by patients

156
Q

Rabbit syndrome is defined by…

A

Fine tremor of the lower lip

157
Q

Onset of rabbit syndrome is usually…

A

After months of therapy; often ignored by patients

158
Q

Treatment of pisa and rabbit syndrome is with…

A

Antiparkinsonian drugs - benztropine, procyclidine, trihexyphenidyl

159
Q

Physical symptoms of tardive dyskinesia may include…

A

Involuntary, abnormal movement of the face, lips, jaw, tongue, eyelids, limbs, trunk, neck, or respiratory system

Can co-exist with parkinsonism and akathesia

160
Q

Psychological symptoms of tardive dyskinesia may include…

A

Cognitive impairment
Distress (talking, eating, swallowing)
Embarassment/anxiety

161
Q

Onset of tardive dyskinesia is usually…

A

After 3 or more months of therapy in adults; earlier in elderly

162
Q

Some proposed risk factors for tardive dyskinesia include…

A

40+, female
History of severe EPS early in treatment
Chronic usage of AP’s (1st gen > others), or high doses of dopamine agonists
Presence of mood component or cognitive impairment
Diabetes
Alcohol/drug abuse

163
Q

Tardive dyskinesia symptoms may be persistent + permanent, but discontinuation of AP early ____

A

Increases chance of remission

Spontaneous remission in 14-24% after 5 years

164
Q

Are there any approved options for treating tardive dyskinesia?

A

No - valbenazine and deutetrabenazine are not available in Canada
May possibly switch to 2nd gen or 3rd gen AP, or try options such as clonzaepam, tetrabenazine, levetiracetam…

165
Q

A good way to measure severity of tardive dyskinesia is using this scale…

A

AIMS - Abnormal Involuntary Movement Scale

166
Q

A good way to measure severity of akathisia is using this scale…

A

BARS - Barnes Akathisia Rating Scale

167
Q

Proposed risk factors for acute dystonia may include…

Contains both modifable risk factors and uncontrollable risk factors

A

Young male, AP naive, high potency FGA
Rapid dose increases
Prior dystonic reaction
Dehydration
Recent cocaine usage
Hypocalcemia, hyperthyroidism

168
Q

Tardive dystonia and akathisia are similar to acute presentations, except…

A

THey are persistent and may be permanent even with removal of the AP

169
Q

Neuroleptic Malignant Syndrome (NMS) is a type of ____ that is…

A

EPS that is acute and life-threatening, which can occur with any AP at any dose

VERY rare, idiosyncratic

170
Q

Physical manifestations of NMS include…

A

Severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC and creatine kinase

171
Q

When can NMS occur with AP usage?

A

Anytime - often early in treatment

172
Q

Treatment for NMS mainly revolves around…

A

Stopping AP immediately, and providing supportive care
Bromocriptine may be used (D2 receptor agonist), dantrolene for malignant hyperthermia

Mental Health (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions