Class 3-psychotic disorders Flashcards
1
Q
INDUCED PSYCHOTIC DISORDERS- MEDICATION
A
o Dopamine agonists o Chloroquine o Corticosteroids o Fluoroquinolones o Stimulants * Several other drugs suspected in case reports
2
Q
DOES CANNABIS CAUSE SCHIZOPHRENIA?
A
o Patients who have genetic predisposition may be at greater risk o Other risk factors : - Earlier age of cannabis use - Frequency of use - THC potency
3
Q
NEUROTRANSMITTERS INVOLVED with psychotic disorders
A
- Dopamine
- Serotonin
- Glutamate
- GABA
- Acetylcholine
4
Q
DOPAMINE (DA)- RECEPTORS
A
D1 to D5
5
Q
PHARMACODYNAMICS, which one:
TRANSPORTERS G-PROTEIN-COUPLED RECEPTORS
ENZYMES ION CHANNELS
A
G-PROTEIN-COUPLED RECEPTORS
6
Q
Dopamine binds to what receptor
A
D2 receptors
7
Q
DOPAMINE PATHWAYS
A
A. MESOLIMBIC PATHWAY
B. MESOCORTICAL PATHWAY
C. NIGROSTRIATAL PATHWAY
D. TUBEROINFUNDIBULAR PATHWAY
8
Q
MESOLIMBIC PATHWAY
A
Pleasure, euphoria, interest, energy, dependance
9
Q
MESOCORTICAL PATHWAY
A
Dorsolateral area : intellectual functions
Ventral tegmentum area : integration of emotions
10
Q
NIGROSTRIATAL PATHWAY
A
Relay for motor behavior
11
Q
VOIE TUBÉRO-INFUNDIBULAIRE
A
Regulates prolactin secretion
12
Q
MESOLIMBIC PATHWAY- SCHIZOPHRENIA
A
- «Hyperactivity » or excess dopamine
- Contributes to positive symptoms of schizoprenia
- e.g. hallucinations, delusions
13
Q
MESOCORTICAL PATHWAY- SCHIZOPHRENIA
A
- «Hypoactivity » or lack of dopamine
- Contributes to negative symptoms of schizophrenia
14
Q
1ST GENERATION ANTIPSYCHOTICS
CLASSIFICATION BY POTENCY
A
HIGH POTENCY
• + incisive, better effect on psychotic symptoms
• E.g. haloperidol: very specific only binds to D2
MEDIUM POTENCY
• E.g. loxapine
LOW POTENCY
• + sedative, better effect on agitation
• E.g. chlorpomazine
15
Q
1ST GENERATION ANTIPSYCHOTICS- ????? RECEPTOR ????
A
D2 antagonist
16
Q
NIGROSTRIATAL PATHWAY- D2 RECEPTOR ANTAGONIST
A
Variety of movement disorders named extrapyramidal symptoms (EPS)
17
Q
DYSTONIA
A
Description: Bizarre, involuntary tonic contractions of skeletal muscle; most common dystonias are buccal spasms, oculogyric crisis, facial grimacing er tics
Onset: - Usually within 24 – 96 h of medication initiation or dose change
- Can sometimes come later during treatment or on
discontinuation of treatment (withdrawal dystonia)
Incidence - 0,6 – 8,3 %
Risk factors /antipsychotics involved
- Younger men
- High potency antipsychotic (e.g. haloperidol) and increased dose
18
Q
DYSTONIA
PREVENTION
A
- Start the antipsychotic at a low dose
- Gradually increase the dose
- Plan for the administration of an anticholinergic drug if the patient as an antecedent of dystonic reaction
- e.g. during agitation
19
Q
DYSTONIA
TREATMENT
A
- Reduce dose or change antipsychotic
- Mild to moderate symptomss :
- Benztropine 1 – 2 mg PO
- Diphenhydramine 25 – 50 mg PO
- Moderate to severe symptoms :
- Benztropine 1 – 2 mg IM
- Diphenhydramine 25 – 50 mg IM
20
Q
AKATHISIA
A
Description: Feeling of distress or discomfort, often referred to legs; inner or motor restlessness, inability to sit or stand still.
Onset - Often within the first 2 to 3 weeks after starting treatment
- 90 % dans les 2 premiers mois
Prevalence - 35 %
Risk factors / antipsychotics involved - Aripiprazole and lurasidone often involved in practice
21
Q
AKATHISIA
PREVENTION
A
- Start the antipsychotic at a low dose
- Gradually increase the dose
22
Q
AKATHISIA
TREATMENT
A
- Reduce dose or change antipsychotic
- Beta-blocker (e.g. propranolol 10 mg BID)
- Side effects : ↓HR, hypotension
- Benzodiazepines (e.g. lorazepam, clonazepam)
- Use the smallest effective dose
- Anticholinergics less effective than in other EPS
23
Q
PSEUDOPARKINSONISM
A
Description Generalized slowing of involuntary movements (bradykinesia/akinesia) with masked facies and reduction in arm movement; most noticeable
signs are rigidity (cogwheel) and tremor at rest
* Bradykinesia : motor retardation
** Akinesia : decrease in spontaneous movements
Onset
- Usually develops several days after treatment initiation
Prevalence - Variable : 20- 35 %
Risk factor / antipsychoticsinvolved
- Female gender
- Increased age
- High potency antipsychotics (mostly FGA) and increased dose
24
Q
PSEUDOPARKINSONISM
PREVENTION
A
- Start the antipsychotic at a low dose
- Gradually increase the dose
25
PSEUDOPARKINSONISM
| TREATMENT
- Reduce dose or change antipsychotic
- Anticholinergics
- E.g. benztropine 1 – 6 mg/day
- E.g. diphenhydramine 25 – 300 mg/day
- Beta-blockers (e.g. propranolol)
- If severe tremors or resistance to other treatments
26
TARDIVE DYSKINESIA
Description: Stereotypical involuntary movements including sucking/smacking of lips, lateral jaw movements, and fly-catching darting of tongue ;
may be choreiform or purposeless quick movements
Probably caused by hypersensitivity of D2 receptors due to prolonged blockage
Onset - Appears months to years after initiation of antipsychotic treatment
Prevalence - 13,1 – 32,4 %
Risk factors / antipsychotics involved
- Female, older age
- African American
- Use of an FGA
- Higher dose / longer duration of antipsychotic treatment
27
TARDIVE DYSKINESIA
| PREVENTION
- Use an antipsychotic or anticholinergic only
if indicated
- Try to reduce the dose if patient stable
28
TARDIVE DYSKINESIA
| TREATMENT
- Changing the antipsychotic to quetiapine or
clozapine
if u take them off to quickly, can exacerbate tardive dyskinesia
- Damage is sometimes permanent
- Other possible treatments
- vitamin B6, tetrabenazine, gingko biloba,
clonazepam
29
EPS TREATMENT
ANTICHOLINERGICS
TREATMENT
- Start a low dose when the patient has EPS
| - Parkinsonism: continue for 2 to 3 months and then gradually remove
30
EPS TREATMENT
ANTICHOLINERGICS
PROPHYLAXIS?
- Generally not recommended
- Sometimes with an antipsychotic in an
emergency situation (agitation)
31
ANTICHOLINERGICS
| SIDE EFFECTS
```
o Dry mouth
o Blurred vision
o Mydriasis
o Tachycardia
o Constipation
o Urinary retention
o Delirium
o Confusion
** older patients are more sensitive
```
32
TUBEROINFUNDIBULAR PATHWAY- D2 RECEPTOR ANTAGONIST
• Hyperprolactinemia
33
HYPERPROLACTINEMIA
| SYMPTOMS
- Galactorrhea
- Amenorrhea
- Sexual side effects
- Long-term :
- Osteoporosis
- May interfere with fertility
34
HYPERPROLACTINEMIA
| TREATMENT
- Changing the antipsychotic
- Add a D2 partial agonist
- E.g. aripiprazole or brexpiprazole
- Add a dopamine agonist
- E.g. cabergoline or bromocriptine
35
ATYPICAL ANTIPSYCHOTICS : 2ND GENERATION
MECHANISM OF ACTION
MESOLIMBIC PATHWAH
D2 RECEPTOR ANTAGONIST
36
ATYPICAL ANTIPSYCHOTICS : 3RD GENERATION
MECHANISM OF ACTION
MESOLIMBIC PATHWAH
D2 RECEPTOR PARTIAL AGONIST
• Intrinsic activity lower than DA :
↓hyperactivity of dopamine in the mesolimbic
pathway
37
ATYPICAL EFFECT
| Common mechanism of action of 2nd and 3rd generation antipsychotics
5-HT2A receptor antagonists
• Increased dopamine release
• It's like 'cutting the brake'
38
5-HT2A receptor antagonists
| MESOCORTICAL PATHWAY
Possible improvement of negative symptoms?
39
5-HT2A receptor antagonists
| NIGROSTRIATAL PATHWAY
Less EPS
40
ATYPICAL ANTIPSYCHOTICS : 3RD GENERATION
NIGROSTRIATAL PATHWAY
D2 RECEPTOR PARTIAL AGONIST
Less EPS
41
RISPERIDONE / PALIPERIDONE
| EPS
Side effects similar to FGA :
- EPS
- Especially at high doses
- E.g. risperidone 4 mg/day
42
ARIPIPRAZOLE / LURASIDONE
| EPS
- Akathisia more common in practice
43
ATYPICAL ANTIPSYCHOTICS
MECHANISM OF ACTION
TUBEROINFUNDIBULAR PATHWAY
5-HT2A RECEPTOR ANTAGONIST
Less hyperprolactinemia
44
ATYPICAL ANTIPSYCHOTICS
HYPERPROLACTINEMIA
RISPERIDONE / PALIPERIDONE
Side effects similar to FGA :
- Hyperprolactinemia
- Especially at high doses
- E.g. risperidone 4 mg/day
45
ATYPICAL ANTIPSYCHOTICS
HYPERPROLACTINEMIA
ARIPIPRAZOLE / BREXPIPRAZOLE
- Sometimes used as an adjuvant to an antipsychotic in cases of hyperprolactinemia
46
If atypical antipsychotics ↑ dopamine via the antagonism of the 5-HT2A receptor, is there a ↓ of their antipsychotic effect?
No, because there are no (or few) 5HT2A receptors in the meso-limbic pathway
47
ATYPICAL ANTIPSYCHOTICS
| SUMMARY OF BENEFITS
-Neutral or beneficial effect on negative symptoms
-Lower incidence of extrapyramidal symptoms
-Lower incidence of hyperprolactinemia
BUT, disadvantage on metabolic effects
48
METABOLIC EFFECTS
* Weight gain
* Hypercholesterolemia
* Hyperglycemia / glucose intolerance
* Hypertension
49
Less/ more metabolic effects with 3rd generation
| antipsychotics
less
50
Which Rx have more metabolic effects
Clozapine, olanzapine > quetiapine > risperidone
51
Weight gain
| Mechanism of action :
```
- H1 receptor antagonist
• ↑ sedation, ↓ physical activity
• ↑ appetite
- 5-HT2C receptor antagonist
• Changing the action of serotonin on appetite
```
52
Weight gain
| Other risk factors :
- Young age
- Naive to antipsychotics
- Low BMI before treatment
- Polypharmacy
53
Weight gain
| Treatment
Non-pharmacological measures to prioritize
Pharmacological treatment :
- Topiramate
• Has been shown to be effective in reducing weight, but not recommended
- Metformine
• Limited data despite possible benefits in preventing weight gain
• Liraglutide?
54
METABOLIC EFFECTS
| General considerations :
```
- Changing antipsychotic
• E.g. aripiprazole
• Not always effective in weight loss
- Deal with every problem separately
• E.g. antihypertensive to treat high blood pressure
```
- Non-pharmacological measures!!!
• Intervention on weight loss, modifiable risk factors, nutrition consultation, kinesiology, etc.
55
SIDE EFFECTS
| Dopamine
```
D2
Extrapyramidal symptoms (EPS), hyperprolactinemia
```
56
SIDE EFFECTS
| Serotonin
5-HT2A: Reduction of EPS
| 5-HT2c: Orthostatic hypotension, weight gain, hyperglycemia
57
SIDE EFFECTS
| Noradrenaline
Alpha1: Orthostatic hypotension, dizziness,
| reflex tachycardia, urinary incontinence
58
SIDE EFFECTS
| Acetylcholine
Muscarinic: Anticholinergic effects
59
SIDE EFFECTS
| Histamine
H1: Orthostatic hypotension, weight gain, increased appetite, sedation
60
ANTICHOLINERGIC EFFECTS
| Antipsychotics involved
Clozapine, quetiapine, olanzapine
| 1st generation - sedatives (e.g. chlorpromazine)
61
Treatment of dry mouth :
- Good hydration
- Chewing sugar-free gum
- Suck a piece of ice
- Saliva substitutes (e.g. BioteneTM)
- Aneltholtrithione (SialorTM): salivary gland stimulant
62
Treatment of constipation :
- Good hydration
- Increased physical activity
- Laxatives
• Ex. polyethylene glycol (Lax a dayTM)
63
ORTHOSTATIC HYPOTENSION
Defined as a ↓ 20 mmHg of systolic blood pressure and a ↓ 10 mmHg of diastolic blood pressure
o Risk of falls
o Possible reflex tachycardia
o Often at the beginning of treatment: tolerance develops over time
64
ORTHOSTATIC HYPOTENSION
| PREVENTION
- Start at a low dose and gradually increase
| - Get up slowly and avoid sudden movements
65
ORTHOSTATIC HYPOTENSION
| Antipsychotics involved
Clozapine, quetiapine
66
SEDATION
Often at the beginning of treatment: tolerance develops over time
67
SEDATION MANAGEMENT
- Administer at betdime
| - Start at a low dose and gradually increase
68
SEDATION MANAGEMENT
| Antipsychotics involved
- Clozapine, quetiapine, olanzapine
- 1st generation - sedatives (e.g. chlorpromazine)
- Less sedation with 3rd generation antipsychotics (activators)
69
RISK FACTORS FOR TORSADE DE POINTE
- Bradycardia
- Electrolytic inbalance
- QTc prolongation
70
ANTIPSYCHOTICS AND QTC PROLONGATION
- Most at risk :
- Ziprasidone, rispEridone, olanzapine, halopEridol
- The safest :
- Aripiprazole, lurasidone
71
ECG in prevention?
Relevant if: age > 65, risk factors, physical comorbidities, polypharmacy
72
MALIGNANT NEUROLEPTIC SYNDROME
o Symptoms: fever, rigidity, change in mental status, autonomic instability
o Very rare side effect (0.01 to 2.2%), but can be life-threatening (mortality ad 20% in some cases)
73
MALIGNANT NEUROLEPTIC SYNDROME
| Risk factors :
- Agitation
- High dose
- IM injection
- Young men, naïve to antipsychotics
- Medical conditions (e.g. dehydration)
74
MALIGNANT NEUROLEPTIC SYNDROME
| Treatment
- Stop the medication that acts on dopamine
- Supportive treatment, hydration, complication management
- There are pharmacological treatments (not seen in this course)
75
CLOZAPINE
| PHARMACOLY
D2 receptor antagonist
Powerful antagonistic activity on receptors :
- Muscarinic
- Adrenergic alpha
- Histaminic
- Serotoninergic
Low binding and rapid dissociation of Dw receptors
(partly explains the different side effects profile)
76
CLOZAPINE
| NEUTROPENIA
-↓ absolute neutrophils < 1,5 x 109/L
77
CLOZAPINE
| AGRANULOCYTOSIS
- No granulocytes
- Rare condition (0.8 to 1.2%), but potentially fatal
- More likely in the first few months
- Dose-independent risk
- Also possible with other antipsychotics (but rare)
78
CLOZAPINE
| HEMATOLOGICAL FOLLOW-UP
- CBC anytime in the day
- Circadian change in the number of leukocytes (tendency to increase slightly in PM)
Every week for 26 weeks
Every 2 weeks for 26 weeks
Every 4 weeks thereafter
79
YELLOW CODE
CBC twice a week until the return of GREEN CODE
80
RED CODE
CBC within 24 hours to confirm
81
CLOZAPINE
| SUDDEN CESSATION OF TREATMENT
```
RISK OF CHOLINERGIC REBOUND
o Hallucination
o Irritability
o Insomnia
o Significant agitation
o Altered state of consciousness / cognition
o Nausea/vomiting
o Diaphoresis / rhinitis
o Urinary/fecal incontinence
```
82
Minimizing cholinergic rebound
- Regular benztropine or PRN for a few days
83
CLOZAPINE
| OTHER SIDE EFFECTS + FREQUENT
- Sedation
- Hypotension, dizziness
- Tachycardia
- Anticholinergic effects
- Metabolic effects
- Cardiovascular toxicity
- Liver damage
- Convulsions / myoclonias
- Hypersalivation
84
Hypotension, dizziness
- Start at low doses
- ↑ slowly
- Split doses
- Getting up slowly
- Monitor the BP lying/standing
85
Tachycardia
- ↓ dose HR > 120 bpm or symptomatic
- Add a beta-blocker
- E.g.atenolol 12,5 mg die
- If persists: stop clozapine
86
(tachycardia, chest pain, shortness of
| breath)
Cardiovascular toxicity
87
Convulsions / myoclonias
- Temporarily suspend and then gradually restart
- ↓ dose or split the dose
- Therapeutic monitoring of clozapine
- Administering an anticonvulsant (e.g. divalproex)
88
Hypersalivation
- Non-pharmacological measures: chewing sugar-free gum, putting a towel on the pillow
- Reduce dose if possible
- Atropine eye drops: put under/on the tongue
- Nasal Ipratropium: put under/on the tongue
- Oral glycopyronium solution
89
BEFORE STARTING CLOZAPINE
- Patient consent
- Basic laboratories
- According to your center’s protocol
- Registration for the hematological surveillance network
90
THERAPEUTIC INTERVAL CLOZAPINE
- 1071 – 1835 nmol/L
- Response rate 22 % if < 1071 nmol/L
- > 1835 nmol/L sometimes necessary
No upper limit set
- More side effects if > 2248 nmol/L
91
ACTIVE METABOLITE OF CLOZAPINE
- Norclozapine
- Antipsychotic properties lower than clozapine
- Sedative and metabolic side effects
- Target clozapine : norclozapine ratio = 2 : 1
92
Effect of food on absorption
Most antipsychotics: absorption not affected by food intake
Exceptions :
• Lurasidone (LatudaTM) : must be taken with a 350-calorie meal
• Ziprasidone (ZeldoxTM) : must be taken with a 500-calorie meal
93
ABSORPTION
| Fast-dissolving tablets
- Absorbed by the gastrointestinal tract (just like regular tablets)
- Useful if you want to make sure you are taking the medication properly
94
Absorption by the oral mucosa
Asenapine (SaphrisTM)
• Quick-dissolving tablet to be administered under the tongue
• Do not drink or eat for 10 minutes after taking the medication
• If swallowed and absorbed by the intestinal lining: completely metabolized by the liver during the first liver passage (ineffective)
• Patients report 'numbness' in mouth
95
DISTRIBUTION
Plasma protein binding: Strong binding (90-98%) for the majority of antipsychotics
Passage of the blood-brain barrier: Antipsychotics are fat-soluble = easy passage of BHE
96
METABOLISM
The vast majority of antipsychotics are metabolized by CYP
- Some will be metabolized into active ingredients : risperidone - paliperidone
- Some metabolites do not have antipsychotic activity, but may contribute to the pattern of adverse events: clozapine- norclazapine
97
ELIMINATION
Depending on the half-life time
| Often between 12 and 36 hours
98
Some have shorter half-lifes and require BID administration; examples :
* Quetiapine regular formulation
| * Ziprasidone
99
LAI
| BENEFITS
o Better long-term compliance
o ↓ risk of relapse
o ↓ risk of hospitalization
o ↓ mortality risk
o More stable serum concentration = ↓ side effects?
o More frequent contact with the healthcare team
o Little risk of abuse/overdose
o Reduces tension in loved ones
o Useful if treatment is mandatory
o Less risk of relapse if forgotten/delayed
o Don't think you're sick on every day J
100
LAI
| DISADVANTAGES
```
o Side effects
• Similar to oral
• + pain at the injection site
o Difficult to quickly adjust the dose in case of inefficiency / side effect
•Wait for the next dose
• Importance of stabilizing with oral tablets before
o Organisation
• Patient movement
• Delivery of the dose
oPerception of gravity of the disease
• From patient, family, health care workers
• Patient control
```
101
LAI
| ORAL TEST
The drug should always be given orally before the long-acting injection
MINIMALLY: To ensure tolerability (allergy, side effects)
IDEALLY: To ensure efficiency
102
LAI
| ORAL OVERLAP
* To overcome the delay of action of the injection
| * Not necessary if a loading dose is given
103
LAI
| LOADING DOSE
* Allows you to reach the state of equilibrium faster
| * Subsequently: maintenance doses keep the drug's concentrations at steady state
104
risperdal consta only prescribe if
kidney failure
105
CHOOSING AN ANTIPSYCHOTIC
| INDIVIDUALIZE TREATMENT
```
• Patient preferences
• Routes of administration
• Dosage
• Side effects
• Follow-up constraints (e.g. blood test)
• Administrative constraints (e.g. taken with food)
• Psychiatric and physical comorbidities
(agitation, insomnia, etc.)
• Lifestyles (tobacco, alcohol, drugs)
• Interactions
```
106
CHOOSING AN ANTIPSYCHOTIC
| Generally,
- 2nd or 3rd generation (popular choices: aripiprazole, risperidone)
- Avoid olanzapine (metabolic profile)
- Avoid clozapine (not indicated as a first intention)
107
ONSET OF ACTION
Quickly
o Reducing disorganization and agitation
In the first 14 days
o Decrease in major positive symptoms of schizophrenia
Longer term
o Possible decrease in negative and cognitive symptoms
108
RESISTANCE TO TREATMENT
o Little clinical improvement despite the use of 2 antipsychotics, at an appropriate dose, for at
least 6 weeks
Treatment choice :
o Consider clozapine
o Why not first line treatment?
• Risk of agranulocytosis, blood tests, closer follow-up
109
IN CASE OF FAILURE TO CLOZAPINE ...
o Return to another treatment (e.g. risperidone or olanzapine)
o Amisulpride? Via special access program
o Combination with another treatment
110
COMBINATION OF ANTIPSYCHOTICS
o Little evidence supporting the use of combinations
o Increased risk of side effects
o Guidelines: not recommended or in 4th line of treatment ...
Still used in practice, may be considered for the following cases :
o Use of 3 antipsychotics in monotherapy that led to treatment failure
o Substitution of one antipsychotic to another
o Combination with clozapine
111
NEGATIVE SYMPTOMS- Other options
o Adding an antidepressant?
| o Experimental treatments: memantine, minocycline, etc.
112
A patient is admitted for the first time to the hospital. He has no psychiatric history and has not received any medication in the past. A diagnosis of schizophrenia is made. Which antipsychotic would be a good first-line treatment choice?
Latuda
113
A.B. is a 27-year-old man with paranoid schizophrenia. He smokes about 20 cigarettes a day, drinks two to three alcoholic drinks per week and smokes cannabis occasionally. He was admitted to the hospital because he has been more suspicious for a few weeks and reports that the police have placed microphones in his apartment. Since his admission, he has been agitated because he cannot go outside to smoke. Also, since the hospital has banned smoking, he will not be able to smoke for at least a few days. His usual medication is prescribed in the emergency room:
- Olanzapine 20 mg HS
- Lorazepam 1 mg BID PRN if anxiety
a) How can smoking cessation affect the patient's usual medication?
Smoking increases metabolism of drug, so might have to give higher dose. Be careful if patient stops smoking, his usual dose will be higher in his blood.
114
A.B. is a 27-year-old man with paranoid schizophrenia. He smokes about 20 cigarettes a day, drinks two to three alcoholic drinks per week and smokes cannabis occasionally. He was admitted to the hospital because he has been more suspicious for a few weeks and reports that the police have placed microphones in his apartment. Since his admission, he has been agitated because he cannot go outside to smoke. Also, since the hospital has banned smoking, he will not be able to smoke for at least a few days. His usual medication is prescribed in the emergency room:
- Olanzapine 20 mg HS
- Lorazepam 1 mg BID PRN if anxiety
The doctor prescribes nicotine patches 21 mg/day (step 1) to avoid nicotine withdrawal symptoms. He also tells you that this will prevent a change in the blood levels of olanzapine. What do you think?
nicotine doesn't cause the interaction, it's the smoke
115
A.B. is a 27-year-old man with paranoid schizophrenia. He smokes about 20 cigarettes a day, drinks two to three alcoholic drinks per week and smokes cannabis occasionally. He was admitted to the hospital because he has been more suspicious for a few weeks and reports that the police have placed microphones in his apartment. Since his admission, he has been agitated because he cannot go outside to smoke. Also, since the hospital has banned smoking, he will not be able to smoke for at least a few days. His usual medication is prescribed in the emergency room:
- Olanzapine 20 mg HS
- Lorazepam 1 mg BID PRN if anxiety
c) With which other antipsychotic is this interaction important? (smoking)
clozaril
116
A.B. is a 27-year-old man with paranoid schizophrenia. He smokes about 20 cigarettes a day, drinks two to three alcoholic drinks per week and smokes cannabis occasionally. He was admitted to the hospital because he has been more suspicious for a few weeks and reports that the police have placed microphones in his apartment. Since his admission, he has been agitated because he cannot go outside to smoke. Also, since the hospital has banned smoking, he will not be able to smoke for at least a few days. His usual medication is prescribed in the emergency room:
- Olanzapine 20 mg HS
- Lorazepam 1 mg BID PRN if anxiety
d) A little later in the hospitalization, the patient tells you that he will probably use cannabis and alcohol from time to time. He says that during these periods, he plans to temporarily stop his medication so as not to "take too many substances at the same time". What do you respond?
Has to continue Rx every day
117
```
P.T. is a 25-year-old man admitted to the hospital for hallucinations, delirium and disorganized speech. Physically, it has glucose intolerance and significant obesity. A diagnosis of schizophrenia is made and a treatment zuclopenthixol is introduced.
a) Zuclopenthixol is part of which class of antipsychotic?
```
typical
118
M.P. is a 35-year-old man admitted to the emergency room for toxic psychosis. Since his admission, he has been walking non-stop in the corridor, shouting, provoking and threatening nurses.
a) What non-pharmacological measures can you take to control agitation?
haldol + ativan + benadryl
| loxapac + ativan
119
A patient has been receiving paliperidone palmitate (Invega SustennaMD) for the past few months. She complains of galactorrhea. She also tells you that she has not had her periods since the introduction of this treatment.
A change in her treatment is being considered, what antipsychotic do you recommend?
abilify maintenna
120
A patient is taking clozapine 400 mg HS. He says that every morning, his pillow is wet.
b) What do you recommend?
Atropine S/L
121
You receive a call from a clozapine monitoring network for a patient who is in a «yellow code».
a) What do you do?
CBC twice a week until the return of GREEN CODE
| monitor symptoms
122
In the next CBC, neutrophils are at 0.76 x 109/L. What does that mean?
c) How do you deal with this situation?
d) After the code-red has been confirmed, clozapine is permanently discontinued. What follows up do you need to do?
RED CODE neutropenia
| recheck blood work and then stop
123
M.B. is a 54-year-old man with paranoid schizophrenia. It has been treated with haloperidol for many years and this medication is effective in controlling its symptoms. He also receives benztropine to control parkinsonism secondary to his treatment, which manifests as resting tremors. Lately, his tremors are important, which affects his quality of life. The treating team plans to change the antipsychotic for a second generation.
b) What antipsychotic would be a good choice for that patient?
abilify
124
Symptoms associated with schizophrenia improved after 3 months of treatment, but the patient complains of drowsiness. What tool can be used to optimize the use of clozapine, minimize associated side effects and reduce the risk of relapse?
therapeutic monitoring
| 12h post dose
125
Following receipt of the plasma dosing result, the clozapine dose is slightly reduced to 400 mg HS and sedation subsides. However, it should be noted that the patient is more impulsive and has behavioral problems. The doctor is considering adding a carbamazepine treatment in this indication. What do you think?
no, contraindication, increases risk of agranaulocytosis
126
clopixol accupahse
peak: 24-48h, lasts 72h, typical. don't give any other medication during the 3 days
127
loading dose injection deltoid/ gluteal?
gluteal takes longer to reach steady state
128
more than 2 relapse, continue rx ??
forever
