Antipsychotics counselling

Question 1

focussed psychosis hx

Answer 1

auditory/visual hallucinations

delusions: persecutory, thought interference etc

screen for depression & risk

explore previous treatments & establish current understanding

Question 2

method of taking antipsychotics

Answer 2

• tablet, OD PO, evening since can make drowsy
• depot injection, once every 2-4 weeks, into buttocks, Dr’s surgery, home visit in special cases

Question 3

why & how antipsychotics

Answer 3

psychosis, schizophrenia, mania

block dopamine activity

“you’re experience [name symptoms specified by patients] because of a brain molecule that is overactive, called dopamine. antipsychotics block dopamine activity”

Question 4

response time

Answer 4

4-6w

if none –> try alternative FGA/SGA (70% respond)

if none –> try clozapine (15% respond)

Question 5

duration

Answer 5

1st episode –> 1 year

multiple episodes –> 5 years

complex –> lifelong (think of poor prognosis factors)

Question 6

cessation

Answer 6

gradual over 4 weeks to prevent relapse

Question 7

specific SEs for each med

Answer 7

haloperidol (FGA) - EPSEs, ++ QT, – seizure threshold, neutropenic malignant syndrome

olanzepine (antimuscarinic) - sleepiness, weight gain, dry mouth, constipation, glucose dysregulation

risperidone - ++ prolacatin (galactorrhea, amenorrhoea/impotence, gynaecomastia), postural hypotension

aripirazole - best SE profile, esp, prolactin

Question 8

elderly specific risk

Answer 8

stroke // VTE

Question 9

monitoring (not clozapine)

Answer 9

FBC, U&Es, LFTs - baseline –> annually

weight, waist circ., lipids, BMI, prolactin - baseline –> 3m –> annually

blood glucose levels –> baseline –> 6m –> annually

BP & ECG –> baseline –> annually

Question 10

pregnancy

Answer 10

generally avoided

can consider if benefits > risks

Question 11

key points of difference in clozapine

Answer 11

tablet only

blocks numerous neurotransmitters

70% success rate

kicks in >4w; take for many years

started >2 antopsychotics fail (>= 1 atypical for 6-8w)

Question 12

stopping/missed doses clozapine

Answer 12

very gradually

missed one dose –> ignore it, don’t ‘double-up’, continue as normal

missed 2 doses –> re-titrate

Question 13

clozapine dose adjustment

Answer 13

start/stop smoking

Question 14

clozapine common & serious SEs

Answer 14

weight gain, somnolence, constipation, hypersalivation, reduced seizure threshold (3% have seizures), myocarditis

agranulocytosis & neutropenia

Question 15

clozapine safety netting symptoms (think toxicity)

Answer 15

toxicity common in infection

ataxia, confusion, drowsiness, tachycardia

(infection rings alarm bells to agranulocytosis)

Question 16

cheeky written card

list EPSEs & mx for some of them

Answer 16

• Parkinsonism
• acute dystonia
  
  • sustained muscle contraction(e.g.torticollis,oculogyric crisis)
  • tx w/ procyclidine or benztropine
• akathisia (severe restlessness)
  
  • tx w/ propanolol
• tardive dyskinesia(late onsetof choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients,may be irreversible, most common ischewing and pouting of jaw)
  
  • tx w/ Tetrabenazine