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ART_MRCPSYCH_B_MENTOR > Clozapine - 2 > Flashcards

Clozapine - 2 Flashcards

1
Q

Pros of lithium augmentation in clozapine therapy?

A

Enable patients to continue on clozapine when they develop neutropenia as lithium can raise the white cell counts

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2
Q

Cons of lithium augmentation in clozapine therapy

A

Reports of toxicity, hence, used with caution.

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3
Q

can Lithium augmentation be used in clozapine-induced agranulocytosis

A

Literature advise against that.

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4
Q

are white cell increased by lithium mature?

A

yes, mature and functional ( no left shit: immature outpouring from marrow)

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5
Q

mechanisms behind lithium effect on while cell counts

A
  • Granulocyte-Macrophage Colony-stimulating factor (GM-CSF)
  • demargination
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6
Q

what is demargination?

A

The process by which neutrophils are released from the endothelium of blood vessels back into circulation

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7
Q

Availabe forms of clozapine

A

CLozaril (more commonly used in clinic)
Zaponex
Denzapine

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8
Q

General monitory for clozapine

A

weekly for first 18 weeks
then fortnightly for 52 weeks
then montly for duration of the treatment

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9
Q

What is CPMS?

A

Clozaril Patient Monitoring Service, anyone wishing to dispense clozaril need to be registred with CPMS

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10
Q

who makes a colour for clozpine blood level?

A

CPMS

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11
Q

what does an amber colour mean?

A

Patient must take another test in one or two days, and twice weekly subsequently until resutl is normalized.

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12
Q

what does an red colour mean?

A

patient should stop clozaril

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13
Q

what service is used for zaponex?

A

Zaponex Treatment Access System (ZTAS)

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14
Q

what service is used for Denzapine?

A

Denzapine Patient Monitoring System (DPMS)

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15
Q

10% of patients on clozapine develop what side effects?

A

Drowsiness & insomnia
Constipation & nausea and vomitting
Salivation
Weight Gain
Dizziness
Dyspepsia

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16
Q

prevalence of sialorrhoea in clozapine therapy?

A

31%

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17
Q

when is hypersalivation worse?

A

Early in treatment
At late

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18
Q

RCT based evidenced Rx for hypersalivation?

A

Hyoscine Hydrobromide

Amisulpride

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19
Q

troubles with hypersalivation?

A

socially embarrassing
potentially life-threatening (asphyxiation)

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20
Q

Antagonist mechanism of clozapine

A

-D1, D2, D3 and D4
-Alpha 1 & 2
-M1, M2, M3, M5
- H1
-5-HT 2C

21
Q

agnonist mechanism of clozapine

A

M4

22
Q

paradox of hypersalivation in clozapine anticholinergic effects

A

parasympathetic stimulation causes high salivary flow
sympathetic stimulation causes high levels of protein

23
Q

What are causes behind the hypersalivation paradox?

A
  • M4 agonist
  • while the M antagonist diminishes saliva, the alpha 2 antagonist increases salivation
  • reduced frequency of swallowing
24
Q

Adverse Event associated with Clozapine

A

Agranulocytosis
Myocarditis, pericarditis and cardiomyopathy
Seizures
Severe orthostatic hypotension w/ or w/out syncome
Colitis
Pancreatitis
Thrombocytopenia (low platelets)
Insuline resistance and diabetes

25
Q

prevalence of diabetes over 10 years in clozapine therapy

A

33%
33%
33%
33%

26
Q

BNF advices caution in what circumstances for clozpaine therapy?

A

BPH
Susceptibility to angle-closure glaucoma
over 60s

27
Q

When is the risk of seizure high in clozpaine therapy?

A

high dose 500 mg/day
or
plasma level >0.5 mg/L

28
Q

what to do when seizure risk is high in clozapine therapy?

A

Consider add prophylactic anticonvulsants

29
Q

candidate prophylactic anticonvulsants in clozpaine therapy?

A

Topiramate
Lamotrigine
Gabapentin
Valproate

30
Q

what if seizure happened in clozpaine therapy?

A

stop clozapine for one day
restart at half the previous dose
add anticonvulsant

31
Q

Prevalence of myocarditis in clozapine therapy?

A

1 in 500 to 1 in 1000 ( generally 1 in 500)

32
Q

onset of myocarditis in clozapine therapy

A

80% in 4 weeks
90% in 8 weeks

33
Q

pathological findings of myocarditis in clozapine therapy?

A

damaged myocytes and eosinophilic infiltration

34
Q

what do eosinophilic infiltration indicate in clozpaine induced myocarditis?

A

type 1 Ig E-mediated acute hypersensitivity reaction

35
Q

Does a mild increase in inflammatory markers and eosinophil at the start of clozapine therapy mean absolute progression to myocarditis?

A

Nope!

36
Q

sign and symptoms of clozapine-induced myocarditis?

A

Fever
Chest pain
Tachycardia
Dyspnoea
Flu-like symptoms
Elevated oesinophils
Elevated cardiac biomarkers.

37
Q

Cardiac biomarkers for clozapine induced myocarditis?

A

Treponin

Creatine kinase

38
Q

which one is superior, troponin or CK?

A

Troponin

39
Q

Mortality in clozapine induced myocarditis

A

50%

40
Q

How treatment resistant schizophrenia (TRS) is defined?

A

Blood level
Adequate duration

41
Q

How duration of clozpine therapy helps in defining TRS?

A

30% respond in 6 weeks
20% by 3 months
20% by 6 months

42
Q

How blood level helps in determining TRS?

A

It has to reach .35-.45 mg/l before saying there is resistant (check enzyme inhibitors too)

43
Q

Best antipsychotics to use for augmentation in clozapine therapy?

A

amisulpride and sulpride

44
Q

why amisulpride and sulpride are thought to be best for clozapine augmentation?

A

their d2 affinity which complement clozapine’s affinity for other receptors and lacks that.

45
Q

best mood stabilizer for clozapine augmentation?

A

lamotrigine

46
Q

what antipsychotics should be avoided in clozapine augmentation?

A

Olanzapine
Sertinole
Pimozide

47
Q

other availabe antipsychotics for augmentation in clozapine therapy/

A

Risperidone
Aripirazole
Ziprasidone
Omega-3-triglycerides
Topiramate and lamotrigi

48
Q

If clozapine failed to work, or patient refused, then what?

A

High dose of olanzapine
High dose of Olanzapine with memantine
High dose of Olanzapine with allopurinol
Max dose amisulpride (1200 mg/day)
Max dose of aripiprazole (aroo30)
D-alanine and D-Serin
ECT

ART_MRCPSYCH_B_MENTOR (38 decks)

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