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BNF > CHAPTER 4: CNS: Pyschoses and schizophrenia > Flashcards

CHAPTER 4: CNS: Pyschoses and schizophrenia Flashcards

1
Q

When using higher (unlicensed doses) of antipsychotics, which test should be carried out routinely to exclude abnormalities such as increased QT interval?

A

ECG

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2
Q

Can antipsychotics given by mouth be given intramuscular at the same dose?

A

No, reduce the dose due to lack of first pass metabolism

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3
Q

When prescribing antipsychotics what must be specified?

A

The route for each medicine

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4
Q

In schizophrenia, antipsychotics relieve positive symptoms. Give 3 examples of these

A
  1. Hallucinations
  2. Delusions
  3. Thought disorder
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5
Q

In schizophrenia, antipsychotics are less effective for alleviating negative symptoms. Second generation may be better. Give 2 examples of negative symptoms

A
  1. Apathy

2. Social withdrawal

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6
Q

Why is long-term treatment of schizophrenia usually required after the first episode?

A

To prevent relapse

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7
Q

How do the first generation antipsychotics predominantly act?

A

By blocking D2 receptors in the brain

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8
Q

Why do first generation antipsychotics cause a range of side effects?

A

Not selective for any of the four dopamine pathways in the brain

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9
Q

What are the 4 symptoms of first generation antipsychotics?

A
  1. Extrapyramidal symptoms
  2. Elevated prolactin
  3. Sedative effects
  4. Antimuscarinic effects
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10
Q

Give 2 examples of phenothiazine antipsychotics

A
  1. Chlorpromazine

2. Prochlorperazine

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11
Q

Give 5 examples of first generation antipsychotics

A
  1. Chlopromazine
  2. Prochlorperazine
  3. Haloperidol
  4. Flupentixol
  5. Sulpiride
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12
Q

What is the main difference between first and second generation antipsychotics?

A

Less extrapyramidal side effects with second generation

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13
Q

Do second generation antipsychotics also mainly act on D2 receptors like first generation?

A

Yes but they also act on a range of other receptors in the brain

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14
Q

In elderly patients with dementia, what are antipsychotics associated with a risk of?

A

Stroke and TIA

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15
Q

As well as stroke and TIA in elderly patient with dementia, what are 2 other risks with giving elderly people antipsychotics?

A
  1. Hyper/hypothermia

2. Postural hypotension

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16
Q

As well as regular review and only being used in severe psychotic symptoms, what is another measure when prescribing antipsychotics for elderly patients?

A

Give half the adult dose

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17
Q

As well as in elderly patients, which other group of people require special consideration, review and dose reduction of antipsychotic medication?

A

Those with learning disability

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18
Q

What are the 8 main side effects of antipsychotics?

A
  1. Extrapyramidal symptoms
  2. Hyperprolactinaemia
  3. Sexual dysfunction
  4. Hyperglycaemia and weight gain
  5. Hypotension and interference with temperature regulation
  6. Neuroleptic malignant syndrome
  7. Blood dyscrasias
  8. Cardiovascular effects
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19
Q

EPSEs occur most frequently with which antipsychotics? (3)

A
  1. Phenothiazines
  2. Haloperidol and benperidol
  3. First-generation depot preparations
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20
Q

What are the 4 features of EPSEs?

A
  1. Parkinsonian Symptoms
  2. Dystonia and dyskinesia
  3. Akathisia
  4. Tardive dyskinesia
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21
Q

What is dystonia and dyskinesia?

A

Abnormal face and body movements

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22
Q

In which group of patients are Parkinsonian symptoms such as tremor more common?

A

Elderly

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23
Q

In which group of patients are dystonia and dyskinesia more common?

A

Children and young adults

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24
Q

Occurring after large initial doses, what is akathisia?

A

Restlessness

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25
Usually occurring after long term treatment with high doses, what is tardive dyskinesia?
Rhythmic involuntary movement of tongue, face and jaw
26
Parkinsonian symptoms will resolve on withdrawal. However, which is the most serious EPSE?
Tardive dyskinesia
27
Why is Tardive dyskinesia the most serious EPSE?
Can be irreversible on withdrawal
28
Why do both first and second generation antipsychotics have hyperprolactinaemia as a side effect?
Because dopamine inhibits prolactin release
29
Because it is a partial dopamine agonist, which antipsychotic reduces prolactin release?
Aripiprazole
30
What are the clinical symptoms of hyperprolactinaemia? (5)
1. Sexual dysfunction 2. Reduced bone mineral density 3. Menstrual disturbance 4. Breast enlargement 5. Galactorrhoea
31
Which side effect is one of the main causes of poor adherence to antipsychotics?
Sexual dysfunction - occurs through many pathways
32
Which 2 antipsychotics commonly cause sexual dysfunction?
1. Haloperidol | 2. Risperidone
33
As well as increased QT prolongation, which cardiovascular side effects are antipsychotics commonly associated with? (3)
1. Hypotension 2. Tachycardia 3. Arrhythmia
34
Cases of sudden death have occured due to QT prolongation caused by doing what?
1. using IV antipsychotics | 2. using doses exceeding the maximum
35
Which 2 antipsychotics commonly cause weight gain?
1. Clozapine | 2. Olanzapine
36
Which 4 antipsychotics common cause hyperglycaemia?
1. Clozapine 2. Olanzapine 3. Quetiapine 4. Risperidone
37
Which side effect of antipsychotics can lead to falls in the elderly?
1. Postural hypotension
38
What are the signs of neuroleptic malignant syndrome? A rare but potentially side effect of antipsychotics (4)
1. Hyperthermia 2. Fluctuating consciousness 3. Muscle rigidity 4. Autonomic dysfunction with pallor and tachycardia
39
What is the first line antipsychotic suitable for all patients?
There isn't one
40
Which second generation antipsychotics are least likely to cause EPSEs? (4)
1. Aripiprazole 2. Clozapine 3. Olanzapine 4. Quetiapine 5. Amisulpride
41
Which antipsychotic has the least effect on QT interval?
Aripiprazole
42
Is it first or second generation antipsychotics which are least likely to cause diabetes?
First generation
43
How long should patients receive antipsychotics for before they are deemed ineffective?
4-6weeks
44
Should more than one antipsychotic be routinely prescribed at the same time? Why?
No | Increased risk of QT prolongation, sudden death, EPSEs
45
What are the 2 exceptions to prescribing more than one antipsychotic at the same time?
1. Clozapine augmentation | 2. When changing medication
46
What is clozapine licensed for?
The treatment of schizophrenia in patients unresponsive to or intolerant to other antipsychotic drugs
47
How long should a patient have tried an antipsychotic for before clozapine is an option
2 antipsychotics, at least one a second generation, 6-8weeks each
48
How long should a patient be treated with clozapine for before a second antipsychotic can be added to augment it?
8-10 weeks
49
Which monitoring is required at the start of therapy with antipsychotic drugs and annually thereafter? (3)
1. FBC 2. U&E 3. LFTs
50
What should be measured at baseline, 3 months then yearly thereafter?
Bloods and lipids
51
What should be measured at baseline, 4-6months then yearly thereafter?
Fasting blood glucose
52
If there are particular concerns about cardiovascular risk factors, which test can be performed?
ECG
53
What should be considered before starting treatment and frequently during titration?
Blood pressure
54
After initial titration, how often can the total daily dose be administered for most antipsychotic drugs?
once daily
55
If compliance is an issue, what can be considered?
Long acting depot injections
56
Compared with oral preparations, which side effects can long acting depot injections be associated with?
EPSEs
57
Haloperidol depot is administered how often?
Every 4 weeks
58
Flupentixol depot is administered how often?
Every 2 weeks
59
Levels of which hormone should be measured at baseline, 6 months then annually thereafter?
Prolactin
60
How often should patients have physical health monitoring - including cardiovascular disease risk assessment?
Yearly
61
If antipsychotic medication is stopped after 1-2years, what is there a high risk of?
Relapse
62
How long after withdrawal of antipsychotics should patients be monitored for?
2 years
63
Patients should avoid direct sunlight because what may occur with high doses?
Photosensitisation
64
Which key safety point must be considered regarding injections of antipsychotics?
IM standard release and IM depot preparations
65
Which blood disorder is associated with clozapine?
1. Agranulocytosis | 2. Neutropenia
66
With clozapine, how often should blood counts be done to reduce the risk of agranulocytosis and neutropenia? (3)
1. Weekly for 18 weeks 2. Every 2 weeks for 1 year 3. Annually thereafter
67
If leucocyte and neutrophil count fall below the threshold, what actions must be taken? (2)
1. Discontinue treatment | 2. Refer to haematologist
68
When taking clozapine, which symptoms should patients report immediately?
Flu-like, infection
69
Occuring most commonly in the first 2 months of treatment, which fatal event has been reported with clozapine?
Myocarditis and cardiomyopathy
70
As well as the effect on immune cells and heart, what is another potential fatal side effect of clozapine?
Intestinal obstruction due to impaired peristalsis
71
What other medication would you expect a patient on clozapine to also be prescribed?
Laxative
72
What can clozapine induced hypersalivation be treated with?
Hyoscine hydrobromide
73
The patient, prescriber and pharmacy involved in clozapine should all be registered with what?
An appropriate patient monitoring service

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