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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
Q

Usually occurring after long term treatment with high doses, what is tardive dyskinesia?

A

Rhythmic involuntary movement of tongue, face and jaw

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26
Q

Parkinsonian symptoms will resolve on withdrawal. However, which is the most serious EPSE?

A

Tardive dyskinesia

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27
Q

Why is Tardive dyskinesia the most serious EPSE?

A

Can be irreversible on withdrawal

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28
Q

Why do both first and second generation antipsychotics have hyperprolactinaemia as a side effect?

A

Because dopamine inhibits prolactin release

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29
Q

Because it is a partial dopamine agonist, which antipsychotic reduces prolactin release?

A

Aripiprazole

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30
Q

What are the clinical symptoms of hyperprolactinaemia? (5)

A
  1. Sexual dysfunction
  2. Reduced bone mineral density
  3. Menstrual disturbance
  4. Breast enlargement
  5. Galactorrhoea
31
Q

Which side effect is one of the main causes of poor adherence to antipsychotics?

A

Sexual dysfunction - occurs through many pathways

32
Q

Which 2 antipsychotics commonly cause sexual dysfunction?

A
  1. Haloperidol

2. Risperidone

33
Q

As well as increased QT prolongation, which cardiovascular side effects are antipsychotics commonly associated with? (3)

A
  1. Hypotension
  2. Tachycardia
  3. Arrhythmia
34
Q

Cases of sudden death have occured due to QT prolongation caused by doing what?

A
  1. using IV antipsychotics

2. using doses exceeding the maximum

35
Q

Which 2 antipsychotics commonly cause weight gain?

A
  1. Clozapine

2. Olanzapine

36
Q

Which 4 antipsychotics common cause hyperglycaemia?

A
  1. Clozapine
  2. Olanzapine
  3. Quetiapine
  4. Risperidone
37
Q

Which side effect of antipsychotics can lead to falls in the elderly?

A
  1. Postural hypotension
38
Q

What are the signs of neuroleptic malignant syndrome? A rare but potentially side effect of antipsychotics (4)

A
  1. Hyperthermia
  2. Fluctuating consciousness
  3. Muscle rigidity
  4. Autonomic dysfunction with pallor and tachycardia
39
Q

What is the first line antipsychotic suitable for all patients?

A

There isn’t one

40
Q

Which second generation antipsychotics are least likely to cause EPSEs? (4)

A
  1. Aripiprazole
  2. Clozapine
  3. Olanzapine
  4. Quetiapine
  5. Amisulpride
41
Q

Which antipsychotic has the least effect on QT interval?

A

Aripiprazole

42
Q

Is it first or second generation antipsychotics which are least likely to cause diabetes?

A

First generation

43
Q

How long should patients receive antipsychotics for before they are deemed ineffective?

44
Q

Should more than one antipsychotic be routinely prescribed at the same time? Why?

A

No

Increased risk of QT prolongation, sudden death, EPSEs

45
Q

What are the 2 exceptions to prescribing more than one antipsychotic at the same time?

A
  1. Clozapine augmentation

2. When changing medication

46
Q

What is clozapine licensed for?

A

The treatment of schizophrenia in patients unresponsive to or intolerant to other antipsychotic drugs

47
Q

How long should a patient have tried an antipsychotic for before clozapine is an option

A

2 antipsychotics, at least one a second generation, 6-8weeks each

48
Q

How long should a patient be treated with clozapine for before a second antipsychotic can be added to augment it?

A

8-10 weeks

49
Q

Which monitoring is required at the start of therapy with antipsychotic drugs and annually thereafter? (3)

A
  1. FBC
  2. U&E
  3. LFTs
50
Q

What should be measured at baseline, 3 months then yearly thereafter?

A

Bloods and lipids

51
Q

What should be measured at baseline, 4-6months then yearly thereafter?

A

Fasting blood glucose

52
Q

If there are particular concerns about cardiovascular risk factors, which test can be performed?

53
Q

What should be considered before starting treatment and frequently during titration?

A

Blood pressure

54
Q

After initial titration, how often can the total daily dose be administered for most antipsychotic drugs?

A

once daily

55
Q

If compliance is an issue, what can be considered?

A

Long acting depot injections

56
Q

Compared with oral preparations, which side effects can long acting depot injections be associated with?

57
Q

Haloperidol depot is administered how often?

A

Every 4 weeks

58
Q

Flupentixol depot is administered how often?

A

Every 2 weeks

59
Q

Levels of which hormone should be measured at baseline, 6 months then annually thereafter?

60
Q

How often should patients have physical health monitoring - including cardiovascular disease risk assessment?

61
Q

If antipsychotic medication is stopped after 1-2years, what is there a high risk of?

62
Q

How long after withdrawal of antipsychotics should patients be monitored for?

63
Q

Patients should avoid direct sunlight because what may occur with high doses?

A

Photosensitisation

64
Q

Which key safety point must be considered regarding injections of antipsychotics?

A

IM standard release and IM depot preparations

65
Q

Which blood disorder is associated with clozapine?

A
  1. Agranulocytosis

2. Neutropenia

66
Q

With clozapine, how often should blood counts be done to reduce the risk of agranulocytosis and neutropenia? (3)

A
  1. Weekly for 18 weeks
  2. Every 2 weeks for 1 year
  3. Annually thereafter
67
Q

If leucocyte and neutrophil count fall below the threshold, what actions must be taken? (2)

A
  1. Discontinue treatment

2. Refer to haematologist

68
Q

When taking clozapine, which symptoms should patients report immediately?

A

Flu-like, infection

69
Q

Occuring most commonly in the first 2 months of treatment, which fatal event has been reported with clozapine?

A

Myocarditis and cardiomyopathy

70
Q

As well as the effect on immune cells and heart, what is another potential fatal side effect of clozapine?

A

Intestinal obstruction due to impaired peristalsis

71
Q

What other medication would you expect a patient on clozapine to also be prescribed?

72
Q

What can clozapine induced hypersalivation be treated with?

A

Hyoscine hydrobromide

73
Q

The patient, prescriber and pharmacy involved in clozapine should all be registered with what?

A

An appropriate patient monitoring service

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