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Pharm II Exam 2 > Antipsychotics > Flashcards

Antipsychotics Flashcards

1
Q

All antipsychotics carry the risk of _____________.

A

QT prolongation

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2
Q

What are the 2 classes of antipsychotics?

A
  1. Typical/conventional (1st generation, FGA)

2. Atypical (2nd generation, SGA)

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3
Q

What is EPS? What can EPS turn into?

A

Extra-pyramidal Symptoms from increase in ACh (Parkinsonian sx) - reversible movement disorders, such as tremor, rigidity, drooling, masked fascies, akinesia.
Can turn into tardive dyskinesia, which is irreversible.

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4
Q

Explain the balance of DA and ACh.

A

When the body has too much DA, this decreases the amount of ACh. Anti-psychotic drugs decrease DA, thereby increasing ACh and inducing EPS.

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5
Q

What is the father of the typical antipsychotics?

A

Chlorpromazine - it was an antihistamine that had antipsy properties

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6
Q

What other binding properties do FGA have (other than D2)?

A
  1. H1 blocking- Antihistamine - weight gain
  2. Alpha-1 blocking - orthostatic hypotension
  3. M1 blocking - Anticholinergic - anti-SLUDGE
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7
Q

FGA are sometimes referred to as _______ or _______.

A

Neuroleptics, sedatives

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8
Q

FGA drugs differ in degree of potency. Potency refer to binding capacity of __________ receptors.

A

Dopaminergic

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9
Q

Most FGA have short/long half lives.

A

Long

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10
Q

What is first dose phenomenon? How do you treat it?

A

Acute dystonic rxn

IV benztropine.

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11
Q

What are the ways that you can treat EPS?

A
  1. Decrease dose
  2. Switch to a SGA
  3. Switch to a low potency agent with high anticholinergic properties
  4. Add an anticholinergic (Trihexyphenidyl, benztropine, diphenhydramine)
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12
Q

Neuromuscular Malignant Syndrome is hallmarked by what 4 symptoms?

A
  1. Hyperpyrexia (103-104)
  2. Rigidity
  3. Hyperactive
  4. Increase in CPK from rhabdo
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13
Q

How do you treat NMS?

A

D/C antipsychotic and consider dantrolene (muscle relaxer) and/or bromocriptine (DA agonist)

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14
Q

What are the cons of the FGA?

A
  1. EPS
  2. Negative symptoms not treated well
  3. Decreased adherence
  4. Greater risk for tardive dyskinesia if on for prolonged period of time
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15
Q

What are the pros of FGA?

A
  1. Cheap

2. Multiple dosage forms

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16
Q

Name a high potency FGA. What are 2 pros and 2 cons?

A

Haloperidol - Vitamin H
1. Highly potent sedative, used for agitation or sedation - calming effect without significant resp depression
2. Can clear quickly, good for elderly. (unlike benzos)
CON:
1. May lower sz threshold
2. QT prolongation

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17
Q

Typical agents block the D2 receptor. Atypical agents are also called SGA. They block ____ and _____, which helps blunt ______ and treats ______ symptoms.

A

DA and 5HT2a
blunts EPS
treats negative

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18
Q

What are the concerns raised over for SGA?

A

Metabolic adverse effects - weight gain, DM, dyslipidemia.

$$$$

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19
Q

SGAs have more or less affinity for different receptors than FGAs.

A

MORE

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20
Q

What are the pros of SGAs?

A

Improved adherance
reduced EPS in general
treats negative symptoms
starting to see different dosage forms

21
Q

Quetiapine (Seroquel) treats what 3 issues at what doses?

“Quiet”

A 
Low dose (50) - sleeping pill (hypnotic or sedation)
Medium dose (300)- depression
High dose (800) - antipsychotic
22
Q

Quetiapine has a very low risk of ______ and _________, thereby making it a go-to SGA for this reason.

A

EPS

hyperprolactinemia (least risk)

23
Q

What SGA can be used for bipolar disease?

A

Quetiapine

Risperidone

24
Q

What are the pros and cons of Olanzapine?

A 
Cons: 
Significant risk for metabolic effects
Pros:
Pretty good with negative symptoms
Low risk of EPS
25
Q

Olanzapine is son of _________.

A

Clozapine, first SGA antipsychotic

26
Q

________ is considered the gold standard for SGA, but it has 5 Black Box Warnings, so it is NOT first line.

A

Clozapine

27
Q

What are the major pros/cons of Clozapine?

A 
Pros:
Low incidence of EPS, TD
Very effective vs negative sx
Cons:
Risk of agranulocytosis 
5 BBW
28
Q

What do you need to monitor with Clozapine?

A

CBC for agranulocytosis- qweek for 1st 6mo, then every other week.
max risk is 4-18 weeks after initiation of therapy

29
Q

Name the 5 BBWs for Clozapine.

A
  1. Agranulocytosis
  2. Orthostatic hypotension
  3. Seizures
  4. Myocarditis/cardiomyopathy
  5. Increased mortality in elderly with dementia related psychosis
30
Q

What is the newer agent that could replace Clozapine because it has no risk of agranulocytosis?

A

Olanzapine (Zyprexa)

31
Q

T or F. Risperidone and Paliperidone have similar characteristics. Why?

A

T

Paliperidone is a metabolite of Risperidone, so it carries the same risk of hyperprolactinemia

32
Q

Does risperidone have a high or low risk for the following:
EPS
Metabolic abnormalities
Hyperprolactinemia (sexual dysfunction, bone density)

A

Higher risk of EPS at higher doses
Low risk of metabolic abnormalities
SIGNIFICANT risk for hyperprolactinemia

33
Q

Describe Lurasidone’s risk for sedating/metabolic effects and EPS. Why is that way?

A

Low metabolic risk and Less sedating (L is for low)
Greater risk for EPS
***Lack of anticholinergic properties = less sedation, more EPS

34
Q

Aripiprazole has a lower/higher incidence of EPS, weight gain, prolactinemia, sedation and dyslipidemia.
What else is it approved to treat?

A
  • LOWER risk

- Augmenting SSRI/SNRIs for resistant major depressive disorder

35
Q

What drug is a mood stabilizer that also has an indication for bipolar?

A

Lithium

36
Q

T or F. Lithium has a high therapeutic index.

A

False - low - meaning it can become toxic easily

37
Q

Lithium is a ______ with rapid absorption. What does this mean in regards to using charcoal in OD?

A

Metallic ion

CANNOT use charcoal

38
Q

Lithium has an inverse relationship with Na. what does this mean?

A

Increased Na wasting will increase Li levels (and vice versa) - diuretics that waste Na will retain lithium level

39
Q

What is the therapeutic level of Lithium? when do you check it?

A

0.4-1 mmol/L

AM trough

40
Q

What are the 6 AEs of lithium? What is the heralding sign of too much lithium?

A
  1. fine tremor***
  2. Polys - uria, dipsia
  3. Hypothyroidism (follow TSH to see if it gets high)
  4. Weight gain
  5. metallic taste
  6. Rash
41
Q

VPA is another mood stabilizer. What do you need to monitor (in general and in patients who develop lethargy, AMS, vomiting, hypothermia)

A

LFTs for hepatotoxicity (#1 AE)

Ammonia levels

42
Q

What can you add in refractory cases of SZP or agitation?

A

VPA

43
Q

What are the 4 Pearls?

A
  1. ** SGAs Elderly >65 = higher risk of death from heart issues**
  2. SGAs - Metabolic syndrome, esp in >65
  3. Avoid in pregnancy, esp 3rd trimester
  4. Aripiprazole is not a PPI.
44
Q

What is the relationship between DA and prolactin?

A

DA hates prolactin. So some antipsychotics can cause hyperprolactinemia (decreased DA = increased prolactin)

45
Q

Which SGAs carry the highest and lowest of hyperprolactinemia?

A

Highest - Risperidone, Paliperidone

Lowest - Quetiapine

46
Q

Which SGAs have the highest and lowest risk of EPS?

A 
Highest - Lurasidone (little anticholinergic properties)
Higher risk at higher doses - R and P
Low Risk - COQA
Clozapine
Olanzapine
Quetiapine
Aripiprazole
47
Q

Which SGAs have the highest and lowest risk of metabolic AEs - weight gain, DM, dyslipidemia?

A

High risk - Clozapine, Olanzapine
Mild risk - Quetiapine, R and P
Low risk - Lurasidone, Aripiprazole

48
Q

What are the other 2 SGA that we did not discuss?

A

Ziprasidone

Asenapine

Pharm II Exam 2 (8 decks)

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