Chapter 64: Schizophrenia/Psychosis Flashcards
Schizophrenia cause is multifactorial and includes altered brain structure and chemistry, primarily involving _____, ____ and _____
DA, serotonin, and glutamine
Common symptoms of schizophrenia
Hallucinations
Delusions
Disorganized thinking/behavior
Negative Signs and Symptoms of schizophrenia according to the DSM-5 include
- Loss of interest in everyday activities
- Lack of emotion (apathy)
- Inability to plan or carry out activities
- Poor hygiene
- Social withdrawal
- Loss of motivation (avolition)
- Lack of speech (alogia)
Positive Signs and Symptoms of schizophrenia according to the DSM-5 include
- Hallucinations: can be auditory (hearing voices), visual or somatic
- Delusions: beliefs held by the patient that are without a basis in reality
- Disorganized thinking/behavior
- Difficulty paying attention
Antipsychotics primarily bock which receptors
DA and serotonin
What drug class is used first line in schizophrenia & why
Second-generation antipsychotics; they have a lower risk of extrapyramidal symptoms
Medications/illicit drugs that can cause psychotic symptoms
- Anticholinergics (centrally-acting, high doses)
- Dextromethorphan
- DA or DA agonists (e.g., Requip, Mirapex, Sinemet)
- Interferons
- Stimulants
- Systemic steroids
- Illicit drugs include bath salts, cannabis, cocaine, LSD, methylphenidate/ice/crystal, PCP
FGAs have a high incidence of EPS, including ____, ______, ______, and _____
- painful dystonias (muscle contractions)
- dyskinesias (abnormal movements)
- tardive dyskinesias (repetitive, involuntary movements such as grimacing and eye blinking)
- akathisia (restlessness, inability to remain still)
Tardive dyskinesias (TD) can be irreversible; the drug causing the TD should be ____
discontinued
Which two drugs should not be given together (i.e., in an injection) d/t risk of excessive sedation and breathing difficulty
Olanzapine and benzodiazepines
There is an increased risk of mortality when antipsychotics are used for ____ in elderly with dementia-related psychosis
agitation control
Several antipsychotics also carry a warning for an increased risk of ____ in patients with dementia
stroke
First-generation antipsychotic MOA
work mainly by blocking dopamine-2 (D2) receptors, with minimal serotonin receptor blockade
Thioridazine boxed warning
QT prolongation
Which FGAs have a warning for QT prolongation
thioridazine, haloperidol, chlorpromazine
Besides QT prolongation, what are other warnings for FGAs
orthostasis/falls, anticholinergic effects, CNS depression, EPS, hyperprolactinemia, neuroleptic malignant syndrome (NMS)
Side effects of FGAs
Sedation, dizziness, anticholinergic effects, increased prolactin, EPS
What medication class can you give with FGAs to limit/avoid painful dystonic reactions
Anticholinergics (e.g., benztropine, diphenhydramine)
(higher or lower) potency drugs have ↑ sedation and ↓ EPS
Lower
(higher or lower) potency drugs have ↓ sedation and ↑ EPS
Higher
Haloperidol brand name
Haldol, Haldol Decanoate
Haldol Decanoate is given how often and via what route
IM monthly
Fluphenazine decanoate is given how often and via what route
IM every 2 weeks
Second generation antipsychotic MOA
work mainly by blocking dopamine-2 (D2) receptors & serotonin (5-HT2A) receptors
Aripiprazole brand name
Abilify
Abilify Maintena is an IM suspension given every ____
month
Aristada (Abilify) is an IM suspension given every ____
4-6 weeks
Clozapine brand name
Clozaril, Fazaclo ODT, Versacloz suspension
Clozapine is very effective and has ↓ risk of EPS/TD, but used no sooner than ___ line due to severe SE potential (metabolic effects, neutropenia)
3rd
Clozapine boxed warning
- Significant risk of potentially life-threatening neutropenia/agranulocytosis (REMS program)
- Myocarditis and cardiomyopathy: d/c if suspected
- Seizures
Clozapine side effects
Agranulocytosis, seizures, constipation, metabolic syndrome (↑ weight, ↑ BG, ↑ lipids)
Abilify side effects
Akathisia
Which SGA requires REMS program
Clozapine
To start clozapine treatment, baseline ANC must be
> /= 1500/mm3
Clozapine therapy must be stopped if ANC falls below
1000/mm3
Lurasidone brand name
Latuda
Lurasidone side effects
Somnolence, EPS (dystonias), nausea
- Nearly weight, lipid and glucose neutral
Olanzapine brand name
Zyprexa, Zyprexa Zydis ODT, Zyprexa Relprevv injection
Zyprexa Relprevv injection suspension lasts ____
2-4 weeks
Zyprexa Relprevv injection can cause sedation (including coma) and delirium following injection & must be administered in a registered healthcare facility. Patients must be monitored for _____ post-injection (REMS program requirements)
3 hours
Olanzapine side effects
Somnolence, metabolic syndrome (↑ weight, ↑ BG, ↑ lipids)
Paliperidone brand name
Invega, Invega Sustenna, Invega Trinza
How often is Invega Sustenna IM injection given
monthly
How often is Invega Trinza IM injection given and when should it be started
every 3 months; start only after receiving Invega Sustenna x 4 months
Paliperidone side effects
- ↑ prolactin – sexual dysfunction, galactorrhea, irregular/missed periods
- EPS, especially at higher doses
- Metabolic syndrome (↑ weight, ↑ BG, ↑ lipids)
Quetiapine brand name
Seroquel
Quetiapine SE
- Somnolence, metabolic syndrome (↑ weight, ↑ BG, ↑ lipids)
- Low EPS risk- often used for psychosis in PD
When should Seroquel XR be taken and how
At night, without food or with a light meal
Risperidone brand name
Risperdal, Risperdal Consta
How often is Risperdal Consta IM injection given
every 2 weeks
Risperidone SE
- ↑ prolactin – sexual dysfunction, galactorrhea, irregular/missed periods
- EPS, especially at higher doses
- Metabolic syndrome (↑ weight, ↑ BG, ↑ lipids)
Ziprasidone brand name
Geodon
Should ziprasidone be taken with or without food
with food
Ziprasidone CI
QT prolongation: do not use with QT risk
What SGA comes as a sublingual tablet
Asenapine (Saphris)
Counseling for Asenapine (Saphris)
No food/drink for 10 min after dose
Asenapine (Saphris) side effect with SL tab
Tongue numbness
Which antipsychotics can cause increased prolactin, leading to painful gynecomastia
Risperidone, paliperidone
Which SGA can cause painful dystonia and tardive diskinesia
Haloperidol
Which SGAs have cardiac risk/QT prolongation
Ziprasidone, haloperidol, thioridazine, chlorpromazine
Besides FGAs, which SGAs have high risk of EPS
Risperidone, paliperidone (at high doses)
Which SGA should you give someone if they have history of movement disorder (e.g., Parkinson’s Disease)
Quetiapine
Which SGAs worsen metabolic issues
Olanzapine, quetiapine
Which SGAs are preferred in overweight/metabolic risk (e.g., increased TG)
Aripiprazole, Ziprasidone, lurasidone, and asenapine
Which antipsychotics should be given in someone who has acute psychosis and refusing PO meds
Haloperidol IV or IM
Alternatives:
Ziprasidone IM
Olanzapine IM
Which SGAs come as ODT
Aripiprazole, olanzapine, risperidone
Which SGAs come as oral liquids
Aripiprazole, fluphenazine, haloperidol, risperidone
Which SGA comes as a patch
Asenapine
Which SGAs can cause hyperglycemia and weight gain
Olanzapine, quetiapine, risperidone, and paliperidone
Risperidone oral solution cannot be mixed with
Cola or tea
What is the first drug that has been approved for tardive diskinesia
Valbenazine (Ingrezza)
Valbenazine warnings
Somnolence
Deutetrabenzine, another drug approved for tardive diskinesia, has a CI for
Hepatic impairment
Neuroleptic malignant syndrome (NMS) is rare, but highly lethal. It occurs commonly with FGAs and is due to
D2 blockade
Signs of NMS include
- Hyperthermia
- Extreme muscle rigidity (called “lead pipe” rigidity), which can lead to respiratory failure
- Mental status changes
- Other signs can include tachycardia, tachypnea, and BP changes
How do you treat NMS
- Taper off the antipsychotic quickly and consider another choice (quetiapine or clozapine)
- Provide supportive care
- Cool the pt down
- Muscle relaxation with BZDs or dantrolene is sometimes used, as some cases may require a DA agonist such as bromocriptine
