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.
Interaction Abilify and epival
CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants.
How many % have an anxiety disorder
50
How many % have an depressive disorder
30
What to give patients who are overweight
Metformin, topiramate, but they don’t really work
Treatment response
> / 20% change in + and – syndrome scale
An adequate antipsychotic trial is defined as:
-PO
6 weeks of treatment at midpoint or greater of the licensed therapeutic dose
An adequate antipsychotic trial is defined as: LAI
6 weeks of treatment following reaching steady state
An adequate antipsychotic trial is defined as: clozaril
: 8-12 weeks at more than or equal to 400 mg die, trough levels od equal to or more tha 350 ng/mL
When to change antipsychotics first episode
if no response after 4 weeks, after 8 weeks if partial response
First episode, After resolution of positive symptoms, maintenance treatment
18 months
treatment resistant schizophrenia
2 adequate but failed antipsychotic trials
Duration of treatment after resolution of positive symptoms
2-5 years
LAI benefit
better symptoms control, decrease in relapse rate, decrease risk of hospitalization
Treatment resistant schizophrenia (25-30% of patients): x% respond well to clozapine.
20-30%
Clozapine resistant schizophrenia
persistence of 2 or more positive symptoms with at least a moderate level of severity/ a single positive symptoms with increased severity following two or more antipsychotic trials
Invega sustenna, Typical side effects
Local injection site complications, such as pain or redness.
Tachycardia, drowsiness, extrapyramidal reaction, , headache, increased serum prolactin (amenorrhea, increase risk of breast cancer 15%; abilify doesn’t cause that, osteoporosis), increased LDL cholesterol, weight gain, increased serum triglycerides ,increased serum cholesterol, hyperglycemia, vomiting , hyperkinesia, tremor, hto, sedation, weight gain, retrograde ejaculation, decreased orgasmic appreciation
Invega sustenna, Serious side effects
prolong the QTc interval
Leukopenia, neutropenia, and agranulocytosis
Antiemetic effects: May mask toxicity of other drugs or conditions
May cause CNS depression
Neuroleptic malignant syndrome
Seizure
Priapism
Clozaril and Li
Lithium may enhance the neurotoxic effect of Antipsychotic Agents. Lithium may decrease the serum concentration of Antipsychotic Agents.Watch for SEP
Clozaril and invega sustenna
CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants.
Invega and clozaril
Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical])
Invega and Li
Lithium may enhance the neurotoxic effect of Antipsychotic Agents. Lithium may decrease the serum concentration of Antipsychotic Agents.
What to give to patients with tremors
Propanolol 10 mg- 20 mg bid
Risk factors:
EPS (in general)
- Prior history of EPS
- Higher doses
- Younger age (in general, children and adolescents are usually at higher risk for EPS compared to adults)
- Specific antipsychotic: Risperidone is usually associated with a moderate to high propensity to cause EPS.
Risk factors: Acute dystonia:
• Males
• Young age
Cocaine use
Rx: antidepressants, antiemetics, neuroleptics potent D2 blockers
Risk factors: Drug-induced parkinsonism:
- Females
* Older patients
Risk factors: Akathisia:
- Higher antipsychotic dosages
- Polypharmacy
- Mood disorders
- Females
- Older patients
Risk factors:Tardive dyskinesia:
- Increasing age
- Females
- Comorbidities, such as diabetes mellitus, intellectual disability, brain damage, smoking, alcohol and/or substance use disorders, mood disorders
- High antidopaminergic drug dose or plasma level
- Race (White or African descent)
- Longer illness duration
- Higher cumulative doses
- Higher ratings of negative symptoms and thought disorder
Acute dystonia:
Rapid; in the majority of cases, dystonia usually occurs within the first 5 days after initiating antipsychotic therapy (and even with the first dose, particularly in patients receiving parenteral antipsychotics) or a dosage increase
Drug-induced parkinsonism
Varied; onset may be delayed from days to weeks, with 50% to 75% of cases occurring within 1 month and 90% within 3 months of antipsychotic initiation, a dosage increase, or a change in the medication regimen (such as adding another antipsychotic agent or discontinuing an anticholinergic medication).
Akathisia
Varied; may begin within several days after antipsychotic initiation but usually increases with treatment duration, occurring within 1 month in up to 50% of cases and within 3 months in 90% of cases.
Tardive dyskinesia:
Delayed; symptoms usually appear after 1 to 2 years of continuous exposure to a dopamine 2 receptor antagonist and almost never before 3 months with an insidious onset, evolving into a full syndrome over days and weeks, followed by symptom stabilization and then a chronic waxing and waning of symptoms.
What exams to do pt presenting to ER with psychosis
TSH, urine toxicology, glucose, cbc, electrolytes, hdl, lft, efgr, creat, ca phosphore, mg, vih, syphilis, vitamines
Neurological exam
CT: eliminate tumor/ hemorrhage, unusual clinical picture, aren’t responding to treatment as we would expect
Delusional disorder diff dx
Delusional disorder:
Medical: Alzheimer, hutingtons, MS, brain tumor, epilepsy, head trauma, fat embolism, anoxic brain injury, atherosclerotic vascular disease, hypertensive encephalopathy, subarachnoid hemorrhage, temporal artritis, HIV, syphilis, malaria, encephalitis, increased Ca, decreased Na/ glucose, uremia, porphyria, heaptic encephalopathy, Addisons, Cushings, hyper/pothyroidism, B12 deficiency, folate deficiency, thiamine deficiency niacin deficiency
Rx: adrenocorticotropic hormones, setroids, corticosteroids, antibiotics, cimetidine, disulfiram, anticholinergics
Substance: amphetamines, cocaine, ROH, THC, hallucinogens
Toxins: mercury, arsenic, manganese, thallium
Prescribe risperidone
Oral:Initial: 1 to 2 mg/day in 1 to 2 divided doses; may increase by 1 to 2 mg/day at intervals ≥24 hours to usual dosage range of 2 to 6 mg/day. In general, assess full effect for ≥1 week before further advancing, if needed, to 6 to 8 mg/day (usual maximum).Note:Doses up to 16 mg/day have been evaluated in clinical trials and are approved according to manufacturer’s labeling but are associated with increased adverse effects and generally arenotrecommended. 4 mg is average
Risperidone consta prescribe
12,5-50 (can go up to 100 mg) mg q 2 weeks
Scales
PANSS: Positive and negative syndrome scale, clinician
Clinical global impression scale: 2 scales: severity and improvement, clinician
Abnormal involuntary movements scale: clinician
Brief psychotic rating scale: clinician
Calgary depression scale for schizophrenia: clinician
Colombia suicide severity rating scale: clinician
When to use ESRS or AIMS
Use at initiation, change of dose. Every 6 months to one year after stable dose. More often: bipolar disorder/ schizoaffective bipolar type who are taking antipsychotics: because antipsychotics will be high in manic phase but will need to be decreased after
blinking frequently, mouth opening with lateral movements frequently
tardive dyskinesia (move outside the axis of movement)
most problematic EPS
Akathisia + parkinsonism
What to give if akathisia
can give benzos, propranolol, remeron
What to give if Tardive dyskinesia
switching to clozaril if very severe, tetrabenazine, vitamin E 400 UI die or BID, vitamin B6
Wellbutrin and Seroquel
BuPROPion may enhance the neuroexcitatory and/or seizure-potentiating effect of Agents With Seizure Threshold Lowering Potential
Dystonias
Acute dystonias are involuntary contractions of major muscle groups, and are characterized by symptoms such as torticollis, retrocollis, oculogyric crisis, and opisthotonos. These are usually rapid in onset and highly disturbing to patients. An extremely rare dystonia, laryngospasm, can be life threatening.
Treat dystonia
Dystonias that are very disturbing can be treated with 1 to 2 mg of benztropine or 50 mg ofBenadryl daily, administered intravenously or intramuscularly. Milder dystonias can be treated with oral benztropine 1 to 2 mg once or twice daily.
Blepharospasm
involuntary blinking/ twitching of eyelid, more sustained thant dyskinesia
Opisthotonic crisis
severehyperextensionandspasticityin which an individual’s head, neck and spinal column enter into a complete “bridging” or “arching” position
Clozaril can increase symptoms of
OCD
ECT and schizophrenia
only for ultra resistant cases, 50% chance of having a good result, appreciation of the symptoms is different, feel more calm
Cause most dyslipidemia
chlorpromazine, olanzapine, quetiapine, clozaril
Cause most elevated PRL
haldol, paliperidone, risperidone
Cause most anticholinergic effects
clozaril, chlorpromazine
Cause most hto
chlorpromazine, clozapine
Cause most Qtc prolongation
chlorpromazine, ziprasidone
