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445- Pain and Mental Health > Antipsychotics and Schizophrenia > Flashcards

Antipsychotics and Schizophrenia Flashcards

1
Q

what are positive schizophrenia sx

A

delusions, hallucinations

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2
Q

what are negative schizophrenia sx

A

affective flattening, alogia, avolition, anhedonia

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3
Q

which AP are approved for children

A

aripiprazole, lurasidone, paliperidone

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4
Q

what gens are atypical AP

A

2nd and 3rd

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5
Q

1st gen AP MOA

A

dopamine antagonists

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6
Q

_________ acetate is considered
1. short acting
2. intermed acting
3. long acting

A

2

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7
Q

________ decanoate is considered
1. short acting
2. intermed acting
3. long acting

A

3

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8
Q

SEs of FGA

A

EPS, metabolic/ antihistamine/ anticholinergic, NMS

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9
Q

which FGA may be mixed for acute and LT control

A

zuclo acetate + decanoate

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10
Q

SGA MOA

A

serotonin dopamine antagonists

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11
Q

T or F: ODT olanzapine/ risperidone work faster

A

F- not actually absorbed in oral mucosa, must swallow fragments to be absorbed in stomach

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12
Q

name the 3 short acting SGA / TGA

A

olanzapine, ziprasidone, aripiprazole

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13
Q

name the 3 long acting SGA/TGA

A

risperidone, paliperidone, aripiprazole LAOI

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14
Q

SGA/TGA SEs

A

metabolic, lowered risk of NMS (appears as more agitation/ anxiety), lower movement issues

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15
Q

NMS results in

A

rhabdomyolysis, hyperkalemia, renal failure, seizures, death

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16
Q

SGA NMS presents as ______________ which often results in ____________

A

more like agitation/ anxiety = give more of drug = worsen NMS

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17
Q

sx of NMS

A

↑ body temp >38C, confused or altered consciousness, sweating, muscle rigidity, autonomic imbalance

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18
Q

NMS tx

A

stop med immediately, go to hospital, supportive care (cool, hydrate, electrolytes), meds (dantrolene, diazepam- not v effective but no other options)

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19
Q

what is the gold standard AP

A

clozapine

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20
Q

clozapine class

A

prototypical atypical
SGA

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21
Q

clozpine is indicated for

A

treatment refractory schizophrenia (failure of 2 APs)

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22
Q

clozapine SEs

A

metabolic, sedation, hypersalivation, myocarditis, cardiomyopathy, seizures, hematological (1% risk of agranulocytosis)

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23
Q

T or F: clozapine does not lower suicidal ideation

A

F- has antisuicide effect

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24
Q

clozapine monitoring

A

NC qwk blood tests f6mths, q2wk f6mths, then qmth for duration of Rx

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25
Q

all FGA-LAIs are _______ dissolved in _______

A

prodrugs
vegetable oil

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26
Q

FGA-LAI SEs

A

neurological, vehicle leakage, injection site induration

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27
Q

what are the 3 FGA-LAIs

A

haloperidol/ flupenthixol/ zuclopenthixol decanoate

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28
Q

why are SGA/TGA-LAIs more difficult to use

A

must mix/ refrigerate due to different vehicles
all have different PK = different titration/ loading protocol

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29
Q

list 3 circumstances of schizophrenia where the risk of suicide is higher

A

Hospitalization hx: first, recent, frequent, early in hospitalization
Pt characteristics: young, white, single, unemployed, male
Disease state: <5yrs of illness, paranoid schizophrenia, dpressive sx, hx substance abuse, hx suicide attempts (including FamHx)
Functioning: good premorbid function, higher cog fxn, greater insight, hopelessness, dissatisfaction in social relationships
Tends to go for methods with more lethality like jumping from heights

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30
Q

suicidality in schizophrenia tends to
1. be less predictable than mood disorders
2. have a plan
3. be in the worse functioning pts (ex- lower cog abilities, more + sx)
4. be longer in their course of illness (>5yrs)
5. 3, 4

A

1

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31
Q

schizophrenia is
1. more common in lower socioeconomic classes
2. seen earlier in women than in men
3. has higher prevalence in men
4. decreases life expectancy by 10yrs

A

1

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32
Q

RF for schizo with substance use

A

younger age, male, homelessness, incarceration, living in urban center

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33
Q

what is public stigma

A

beliefs people hold about the pt- can become institutionalized

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34
Q

what is internalization/ self stigma

A

person feels that something is wrong with them

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35
Q

what is institutionlized stigma

A

less access to care due to stigma

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36
Q

schizophrenia etiology

A

genetics (strong gene component)
external factors (OB complications, SU, smoking)

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37
Q

what external factors may contribute to schizophrenia

A

Obstetrical complications
Inflammation
Cannabis use (RF for development of psychosis)
Cigarette smoking
immigration

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38
Q

waht is the neurodevelopmental hypothesis of schizophrenia

A

schizophrenia is a neurodevelopmental disorder where there is increased vulnerability to insults (pre/ parinatal + external) + brain morphology and neuropathology sees lower gray matter in multiple brain regions

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39
Q

which NT play a part in schizophrenia pathophysiology

A

dopamine, glutamate, GABA, ACh

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40
Q

increased DA in the misolimbic system results in

A

+ sx

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41
Q

increased DA in the mesocortical system results in

A
  • sx
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42
Q

______ of DA receptors in the _______ results in EPS

A

blocking
nigrostriatal

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43
Q

________ DA in ______ pathway results in increased prolactin

A

block
tuberoinfundibular

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44
Q

which hypothesis forms the basis of current antipsychotics

A

dopamine hypothesis

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45
Q

glutamate is a _____ NT

A

excitatory

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46
Q

what changes are seen in the schizophrenic brain based on the glutamate hypothesis

A

increased levels in certain areas
decreased function of NMDA receptors

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47
Q

________ agonists help with + and - sx (mixed evidence)

A

NMDA

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48
Q

what is psychosis

A

loss of touch with reality + brain creates false reality to make sense of it

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49
Q

visual hallucinations usually look like

A

often unformed- glowing orbs, flashes of colour, less commonly fully formed human figures/ faces

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50
Q

what is the most common type of hallucination

A

auditory

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51
Q

what are delusions

A

Fixed, false beliefs + may have delusional explanations for hallucinations

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52
Q

what is the difference between bizarre and nonbizarre delusions

A

Bizarre: clearly implausible
Nonbizarre: not true but technically possible

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53
Q

what are persecutory delusions

A

most common- belief that one will be harmed by another party

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54
Q

what are referential delusions

A

belief that certain gestures, comments, environmental cues are directed at oneself

55
Q

what are nihilistic delusions

A

thinks that major catastrophe will occur

56
Q

what are somatic delusions

A

preoccupations about health/ organ function (ex- pregnant delusions)

57
Q

describe tangential and circumstantial speech

A

Tangential speech: off topic from question, will not answer Q
Circumstantial speech: round about way to answer Q

58
Q

what are neologisms

A

creating new words that don’t exist

59
Q

what is word salad

A

putting together random words that don’t mean anything

60
Q

4 clinical + sx of psychosis

A

hallucinations
delusions
disorganized thinking
changes in behaviour

61
Q

what is anhedonia

A

decreased pleasure

62
Q

what is alogia

A

decreased communication

63
Q

what s avolition

A

decreased motivation

64
Q

the clinical course of schizophrenia
1. is heterogenious in onset, sx presentation, and outcomes
2. first starts usually in the late teens/ early 20s
3. rarely include a prodromal phase
4. 1+2

A

4

65
Q

what is the 4 step clinical course of schizophrenia

A

Premorbid → prodromal → onset/ deterioration → residual/ stable

66
Q

what is schizophrenia prodrome

A

period of time before psychotic disorder presents, deterioration in personal functioning (memory/ attention, social withdrawal, unusual behavior, communication, affect, bizarre ideas, poor hygiene)

67
Q

first episode psychosis
1. usually happens in late 20s
2. only sees 15-20% fully recover
3. may result in residual sx
4. 2,3
5. all of the above

A

2,3

68
Q

residual sx may be similar to
1. baseline functioning
2. mild depression/ anxiety
3. occasional psychotic breaks
4. prodromal sx

A

4

69
Q

goals for acute psychosis

A

initial management

70
Q

goals in 2-3wks after acute psychosis

A

↑ socialization, improvement in self care and mood, ↓ severity of + sx

71
Q

what are some nonpharm tx for schizophrenia

A

therapy
psychosocial rehab
multidiscp teams
ECT in treatment resistant cases

72
Q

is ECT used in schizophrenia?

A

yes- in tx resistant cases

73
Q

characteristics of 1st gen AP

A

↑ D2 receptor occupancy, varying lvls of potency of D2 antagonism

74
Q

characteristics of atypical AD

A

lower/ transient D2 ant (more time off), 5HT2A receptor antagonism

75
Q

in schizophrenia tx studies
1. olanzapine had the lowest rates of drop out
2. risperidone had longest time to d/c
3. ziprasidone had lowest d/c due to lack of efficacy
4. risperidone had lowest hospitalization rate for exacerbations

A

1

76
Q

olanzapine SEs

A

assoc with ↑ weight gain, hyperlipidemia, hyperglycemia

77
Q

ziprasidone AEs

A

assoc with weight loss + improvements in lipids and BG

78
Q

which AP has the lowest rate of d/c and longest time to d/c

A

olanzapine

79
Q

which AP had the lowest hospitalziation rate for exacerbations? which had the highest?

A

lowest = olanzapine
highest = quetiapine

80
Q

which of the following is false
1. only minority of pts remain on assigned treatment
2. there is no AP that is statistically superior
3. FGA are statistically worse than SGA in preventing relapses
4. FGAs are tolerated just as well as newer gens

A

3

81
Q

AP should be selected based on

A

medical comorbidities
psych comorbs
age
medication considerations

82
Q

which AP should be avoided if pt has metabolic sx

A

olanzapine, quetiapine, risperidone

83
Q

which AP should be avoided if pt has QT prolongation

A

ziprasidone, quetiapine, chlorpromazine

84
Q

which AP should be used if pt has insomnia

A

more sedating ones like olanzapine, quetiapine, risperidone

85
Q

which AP to use if mania

A

risperidone, aripiprazole, paliperidone, quetiapine

86
Q

which AP to use if depression

A

risperidone, aripiprazole, quetiapine are 1st line, quetiapine = 2nd line monotx

87
Q

in anxiety ____. ____. ____ can be used as augmenting agents, ____ can be used as monotx in some cases

A

risperidone, aripiprazole, quetiapine can be used as augmenting agents, quetiapine can be used as monotx in some cases

88
Q

which AP may exacerbate OCD

A

2nd gen AP

89
Q

how should APs be selected in older pts >70yrs old

A

Older adults (>70yrs) more sus to AP SEs (esp anti-ACh) + OH (falls) = select those with lower a-antagonist activity

90
Q

first episode psychosis
1. has no placebo controlled trials on efficacy of AP
2. would wait to trial AP to see if mediated by something else
3. often starts in late 20s
4. TGA prefered, esp LAI

A

1

91
Q

how should first episode psychosis be tx

A

In most cases = start tx with AP ASAP- shorter duration of untx psychosis = better outcomes

92
Q

in the acute management of psychosis, which AP are first line

A

SGA

93
Q

4 common AP if severely agitated/ psychotic

A

olanzapine, loxapine, haloperidol, lorazepam

94
Q

what AP may be given in acute psychosis if there is severe agitation

A

zuclo acetate

95
Q

after initial agitation is managed in acute psychosis, ____ are preferred as first line tx

A

SGA/ TGAs (less EPS)

96
Q

+ sx should respond within ____, with full response in ____

A

4wks
12wks

97
Q

how long is an adequate trial of AP

A

min 4-6wks

98
Q

at 4 wks of AP, what should we do if there is
no response
partial response

A

No response: consider changing meds
Partial response: optimize dose, reassess at 8wks

99
Q

LAIs have a delayed ____ and ___

A

therapeutic effect and SS = later peak plasma levels

100
Q

T or F: in a patient who has been on an LI for 2 mths, but plasma levels are not yet at target (trending up), we should increase the dose

A

F- plasma lvls ↑ over wks-mths without ↑ in dose due to accumulation

101
Q

what is an absolute sx change

A

treatment response defined as having no more than mild dx

102
Q

how is sx change used to evaluated treatment efficacy

A

evaluation of tx response relative to baseline
Better form of measurement
A change of 20% = min that can be routinely detected clinically

103
Q

what is the minimum sx change that can be routinely detected clinically

A

20%

104
Q

what is considered an adequate treatment response to AP

A

Absolute or relative response to treatment
Functional impairment should be no more than mild
Resp sustained for min 12wks

105
Q

what is considered remission in a schizophrenic pt

A

Pt has no/min sx
Sx do not interfere with behaviour
Sustained for min 6mths

106
Q

remission must see no/min sx for ____

A

6mths

107
Q

3 times to switch AP

A

Insuff tx response
AEs (risk psych destabilization if pt stable)- can it be managed?
if pt/ fam wants to switch - Engage pt/ fam with decision

108
Q

in regards to AP polypharmacy
1. it may be used after failure of one AP
2. it has insig increased efficacy
3. it has a much higher risk of AEs
4. usually only used in treatment resistant schizophrenia
5. all
6, 2, 3
7. 1, 2, 3

A

6

109
Q

switching AP is usually done through ________

A

crosstapering/ titration

110
Q

when would we not crosstaper AP to switch

A

if there is severe EPS/ NMS with AP = must do complete washout

111
Q

how should LAIs be cross tapered?

A

don’t need to be- they are self tapering and you just need to admin the new LAI on the day the previous one was due

112
Q

____% pts do not respond adequately to P

A

30%

113
Q

TRS is defined as

A

persistent psychotic sx of at least mod severity + mod functional impairment
min 2 failed AP trials

114
Q

what is considered 2 failed AP trials

A

=>6 wks adequate duration trial at therapeutic dose with adequate adherence (=>80% doses taken)

115
Q

what is considered adequate AP adherence

A

=>80% doses taken

116
Q

what is the tx of choice for TRS

A

clozapine

117
Q

clozapine has _____ D2 binding, which results in lowered risk of ____ and _____

A

lower binding
EPS and hyperprolactinemia

118
Q

clozapine has increased risk of

A

weight gain + metabolic SEs (H1)
Sedation (H1)
OH (a1, a2)
Tachycardia (a1, a2)
Anticholinergic SEs (M1): constipation (+++), blurred vision, dry mouth, etc

119
Q

what are some concerns specific to clozapine that are severe

A

neutropenia, myocarditis, cardiomyopathy, seizure risk

120
Q

how should you monitor for hematological changes with clozapine

A

monitor ANC baseline, qwk f26wks, then q4wks after

121
Q

how would you monitor for cardiomyopathy and myocarditis with clozapine

A

CRP and troponin q4wks
watch for flu like sx, respiratory sx, persistent tachy, chest pain, syncope

122
Q

which of the following is not a MAJOR/ severe clozapine SE
1. constipation
2. seizures
3. orthostatic hypotension
4. increased blood glucose
5. hyperprolactinemia
6. cardiomyopathy

A

5- lowered risk due to decreased D2 binding

123
Q

clozapine is a substrate of CYP ___

A

1A2

124
Q

what induces clozapine metabolism

A

smoking increases CYP 1A2 = higher metabolism

125
Q

what is the issue with transfering to hospital/ out to community with clozapine and smoking

A

Admission to hospital → abrupt d/c smoking → ↑ clozapine conc = ↑ risk toxicity
Discharge from hospital → abrupt resumption = ↓ clozapine conc = ↑ risk psych decompensation

126
Q

what is ultraresistant schizophrenia

A

clozapine resistant schizophrenia
Pts that meet criteria for TRS + inadequate tx response to adequate tx with clozapine

127
Q

___% respond adequately to clozapine

A

30-60%

128
Q

which treatment for URS has the most robust effects?
1. higher dose clozapine
2. mood stabilizers
3. additional AP
4. ECT
5. none of the above

A

5

129
Q

which strategy is the most promising for URS
1. higher dose clozapine
2. mood stabilizers
3. additional AP
4. ECT
5. none of the above

A

4

130
Q

which AP combination has better evidence in URS

A

clozapine + aripiprazole or amisulpride

131
Q

EPS with AP are _____ related, more common with _____

A

dose related
more common with high dose FGA

132
Q

EPS is less common with these 4 AP

A

clozapine, olanzapine, quetiapine, aripiprazole

133
Q

EPS can
1. occur early or later as tardive after AP start
2. may present as akathisias
3. is more common with high dose SGAs than FGAs
4. 1+2

A

4

445- Pain and Mental Health (21 decks)

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