Class 4 Flashcards
Chlorpromazine 2 effects
very strong but very HTO, SEP, constipating
Loxapine 2 effects
weight gain, SEP, sedating
True or false? Abilify, not very sedative
true
Metabolically favorable antipsychotics
Lurasidone, asenapine, abilify, ziprasidone
Paliperidone % will have weight gain
15-20%
Quetiapine, Zyprexa, clozapine: x% will have weight gain
30%
Which antipsychotics have a little bit better efficacy
zyprexa and risperdal
Efficacy all of the antipsychotics
: all about 80%
When do you expect to see some efficacy of antipsychotic
1 week
What’s the best LAI
Abilify maintenna
What % of patients will respond to higher doses of antipsychotics
5-10%
When to do neuropsychological assessment
1st episode and those with poor response to treatment. Can help with academic planning, predictor of function.
Psychosocial interventions patients with schizophrenia
Family interventions for all patients: 10 sessions over 3 months period. Focus on communication skills (how to communicate concerns to mental health professionals), Supported employment programs,
CBT (all pts who haven’t adequately responded to antipsychotics and have persistent symptoms. Minimum 6 sessions. Reduces symptoms severity, hospitalization and relapse).
Cog remediation: pts with persisting problems associated with cognitive difficulties (attention, memory, problem solving)
Social skills training: patients who are having difficulty and or experiencing stress and anxiety related to social interaction.
Life skills training: if difficulties
Patient education: everyone
Prescribe clozaril
Initial: 12.5 mg once or twice daily; increase, as tolerated, in increments of 25 to 50 mg daily to a target dose of 300 to 450 mg daily (administered in divided doses) by the end of 2 weeks; may further titrate in increments not exceeding 100 mg and no more frequently than once or twice weekly. Maximum total daily dose: 900 mg.
Common side effects of clozaril
hypotension, tachycardia, constipation (bowel obstruction), sialorrhea, weight gain, sedation, hyperglycaemia (ketoacidosis)
When to say patient is sedated
sleep more than 10-12h
Serious side effects of clozaril
Agranulocytosis Neutropenia NMS QT prolongation Seizures Hepatotoxicity
severe neutropenia, defined as an absolute neutrophil count (ANC) less than
500/mm3
Prior to initiating clozaril, a baseline ANC must be
≥1,500/mm3for the general population and must be ≥1,000/mm3for patients with documented Benign Ethnic Neutropenia
What to advise patients regarding risk of neutropenia
Advise patients to immediately report symptoms consistent with severe neutropenia or infection (eg, fever, weakness, lethargy, sore throat).Risk is greatest within the first 18 weeks of therapy.
Because of risk of QT prolongation, be cautious giving clozaril to patients with
history of QT prolongation, long QT syndrome, family history of long QT syndrome or sudden cardiac death, significant cardiac arrhythmia, recent myocardial infarction, uncompensated heart failure, treatment with other medications that cause QT prolongation, treatment with medications that inhibit the metabolism of clozapine, hypokalemia, and hypomagnesemia
Because of risk of seizure, be cautious giving clozaril to patients with
history of seizures, head trauma, brain damage, alcoholism, or concurrent therapy with medications which may lower seizure threshold
When you’re at 550 mg of clozaril and the patient still has symptoms, what do you do
Add Luvox 25 mg: raise the blood levels of clozapine, drop levels of norclozapine, less side effects; and titrate clozaril down
Normal QtC
less than 460 ms for women and less than 450 ms for men.
When to discontinue drug because of QTc
Drug discontinuation for Qtc more than 500 ms or if increase of 60 ms or more from baseline
Increased risk of Qtc elongation:
sertindore, amisulpride, ziprasidone, iloperidone, risperidone, olanzapine, quetiapine, haloperidole, clozaril
No risk of Qtc elongation:
lurasidone, abilify, paliperidone, asenapine
Risk factors Qtc elongation:
Dose dependant, + F, risk increases with age
Monitoring clozaril
CBC: If the ANC remains ≥1,500/mm3, the monitoring frequency can be reduced to every 2 weeks for the next 6 months. If the ANC remains ≥1,500/mm3for the second 6 months of continuous therapy, the ANC monitoring frequency can be reduced to once every 4 weeks.
vital signs (as clinically indicated);
ECG (as clinically indicated);
BP (baseline; repeat 3 months after antipsychotic initiation, then yearly);
signs and symptoms of myocarditis and cardiomyopathy;
weight, height, BMI, waist circumference (baseline; repeat at 4, 8, and 12 weeks after initiating or changing therapy, then quarterly; consider switching to a different antipsychotic for a weight gain ≥5% of initial weight);
electrolytes and liver function (annually and as clinically indicated);
personal and family history of obesity, diabetes, dyslipidemia, hypertension, or cardiovascular disease (baseline; repeat annually);
fasting plasma glucose level/HbA1c(baseline; repeat 3 months after starting antipsychotic, then yearly);
lipid panel (baseline; repeat 3 months after initiation of antipsychotic; if low-density lipoprotein level is normal, repeat at 2- to 5-year intervals or more frequently if clinical indicated);
changes in menstruation, libido, development of galactorrhea, and erectile and ejaculatory function (yearly);
abnormal involuntary movements or parkinsonian signs (baseline; repeat weekly until dose stabilized for ≥2 weeks after introduction and for 2 weeks after any significant dose increase);
tardive dyskinesia (every 12 months; high-risk patients every 6 months);
ocular examination (yearly in patients >40 years of age; every 2 years in younger patients, more sensitive for developing cataracts, mostly seroquel)
bowel function (baseline and regularly during treatment)
fall risk (baseline and periodically during treatment in patients with diseases or on medications that may also increase fall risk).
PRL, TSH
Clozapine levels
at the beginning for a baseline, level should not go over 3500. No evidence of upper level of toxicity
Neutropenia incidence and definition
abnormally low number of neutrophils (a type of white blood cell) in the blood. ≤3%
Agranulocytosisincidence and definition
is an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count), most commonly of neutrophils, and thus causing a neutropenia in the circulating blood. 0,3%
Interaction Clozapine and abilify
Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]).CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants
Interaction Clozapine and epival
CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants.
