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Integrated Drug Structure, Action, and Therapeutics > Dr. Aebi's Schizophrenia and Bipolar Disorder > Flashcards

Dr. Aebi's Schizophrenia and Bipolar Disorder Flashcards

1
Q

TAP

A

typical antipsychotic

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2
Q

FGA

A

first generation antipsychotic

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3
Q

What are the treatment goals of schizophrenia treatment?

A
  • Decrease symptoms
  • increase quality of life (minimize adverse effects from treatment)
  • encourage adherence
  • decrease hospitalizations/health care $
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4
Q

Out of the FGAs, what reduces positive symptoms the best?

A

All FGAs reduce positive symptoms at equivalent doses.

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5
Q

How the FGAs handle negative symptoms?

A

Do not reduce negative symptoms well.

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6
Q

What are the general positives and negatives to FGA treatment?

A

EPS is a higher risk, as well as anticholinergic SEs

Lower risk for metabolic syndrome/weight gain

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7
Q

How do SGAs handle positive and negative symptoms of schizophrenia?

A

Handles positive symptoms well (but not as good as FGAs) and has moderate efficacy at reducing negative symptoms.

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8
Q

What are the benefits in using SGAs over FGAs?

A
  • Possible effect on increasing cognition (hits serotonin receptors: 5HT7 Lurasidone)
  • Less EPS because of 5HT2 antagonism in nigrostriatal dopamine pathway
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9
Q

What is the disadvantage in using SGAs over FGAs?

A

Higher risk for weight gain/metabolic syndrome

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10
Q

What are some negative symptoms in schizophrenia?

A

Depression, apathy, anhedonia

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11
Q

How is D2 affinity related to potency in FGAs?

A

The higher the D2 affinity, the more potent the drug is.

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12
Q

What is the range for effectiveness in affinity of the drug for dopamine receptor?

A

60% to see effectiveness. higher than 80% you start seeing AEs

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13
Q

How are FGAs dosed?

A

Dosed based on chlorpromazine equivalents

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14
Q

What is the normal range of CPZ equivalents?

A

300-1000mg CPZ equivalents

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15
Q

In the FGAs, what do the drugs with low mg strength also have?

A

Higher potency, higher D2 affinity, high EPS, low sedation, and low anticholinergic effects.

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16
Q

In FGAs, what do the drugs with the high mg strength also have?

A

lower potency, lower EPS risk, lower D2 affinity, higher sedation, higher anticholinergic SEs.

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17
Q

What drugs have lower mg strength?

A

Haloperidol, Fluphenazine, trifluoroperazone

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18
Q

What drugs have high mg strength?

A

Thioridazine, chlorpromazine

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19
Q

What drug is used for tourette’s?

A

pimozide and delusional parasitosis

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20
Q

Out of the SGAs, which has the lowest risk of EPS?

A

clozapine and quetiapine. Also, olanzasine, ziprasidone, and asenapine have low risk.

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21
Q

Which has the highest sedation of the SGAs?

A

also clozapine and quetiapine

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22
Q

Which has the highest hypotension risks? The lowest hypotension risks?

A

Clozapine has the highest hypotension risk, lurasidone and ziprasidone the least.

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23
Q

Which has the most weight gain SE’s of the SGAs? The least?

A

most: clozapine and olanzapine
least: aripiprazole, asenapine, risperidone, and ziprasidone

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24
Q

Which SGA has the lowest sedation?

A

Aripiprazole, lurasidone, paliperidone, risperidone, ziprasidone

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25
Q

Which SGAs have QT prolongation problems?

A

paliperidone, olanzapine, quetiapine, risperidone, ziprasidone

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26
Q

Which SGA’s do not have many QT problems?

A

asenapine, lurasidone

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27
Q

Which SGAs increase prolactin levels the most?

A

olanzapine, paliperidone, risperidone, lurasidone, and ziprasidone

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28
Q

What is the best way to reduce side effects?

A

Start low, titrate slowly

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29
Q

What are the main long-term side effects to watch out for?

A

Metabolic syndrome
QT prolongation
Prolactin increase
EPS

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30
Q

When do EPS show up in FGAs? SGAs?

A

FGAs: 6-12 months
SGAs: 1.5-2 years

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31
Q

When do you use clozapine?

A

After failing 2 previous antipsychotics

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32
Q

Treatment guidelines: What is recommended with first episode psychosis?

A

SGA: risperidone, quetiapine, aripiprazole

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33
Q

Treatment guidelines: What is recommended with acute severe psychosis? (positive symptoms)

A

Haldol: FGA - good for positive symptoms
Olanzapine: SGA - strong M, H1 receptors for sedation

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34
Q

Treatment guidelines: What meds do you choose for lifelong maintenance if you are younger? Why?

A

SGA (less EPS, less sedation)

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35
Q

Treatment guidelines: What meds do you choose for lifelong maintenance if you are middle-aged?

A

SGA or FGA (more weight gain, diabetes in SGA)

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36
Q

Treatment guidelines: treatment resistant? What drug?

A

FGA or clozapine

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37
Q

Treatment guidelines: Pregnancy?

A

clozapine or lurasidone: category B

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38
Q

What are the special considerations with Lurasidone and ziprasidone?

A

Must be taken with a full meal (350-500 calories)

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39
Q

What are the special considerations with cardiac concerns? What should you avoid?

A

Ziprasidone

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40
Q

What is the most common EPS symptom with SGAs?

A

Akathisia

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41
Q

What happens if you reach risperidone doses of higher than 6mg?

A

Increased EPS risk

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42
Q

What is akathisia?

A

A movement disorder characterized by the need to be in constant motion.

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43
Q

What follow-up do you need if you are taking clozapine?

A

Weekly lab draws
REMs
Baseline WBC/ANC levels must be met prior to administration.

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44
Q

What is neutropenia?

A

An abnormally low number of neutrophils. <1500uL (whites) or <1200 (middle east)

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45
Q

What has a risk of neutropenia?

A

Clozapine has a high risk of this and agranulocytosis, as well as all FGAs and SGAs. Usually seen 4 weeks to 4 months of use.

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46
Q

What is considered leukopenia?

A

WBC < 4000/uL

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47
Q

How long does it take to classify someone as a non-responder?

A

4-6 weeks

12 weeks for clozapine

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48
Q

How long does it take to see the full effects of antipsychotics?

A

12 weeks

up to 6 months for clozapine

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49
Q

When would you switch meds sooner?

A

If there was acute relapse danger

50
Q

How often should you check HbAlc and blood glucose on SGAs?

51
Q

How is clozapine metabolized?

A

Using CYP 1A2, 3A4 ( and 2D6)

52
Q

What non-drug habits can interfere with CYP 1A2?

A

cigarette smoking is a strong 1A2 inducer. So is caffeine

53
Q

What is the main benefit of injectable APs?

A

They can improve adherence to medications

54
Q

What is the main adverse effect of AP injectables?

A

If there is an adverse effect, you cannot retrieve the drug out of the body.

55
Q

What is preferred, oral or injectable?

A

Oral first.

56
Q

What is the preferred route in AP injectables?

A

Gluteal usually over deltoid

57
Q

long-acting medication: what two decanoate medications are there?

A

Fluphenazine and haloperidol

58
Q

What meds are Maintenna and Aristada?

59
Q

What is the longest dosing interval?

A

6 weeks at 882mg for ability Aristada

60
Q

What medication is Consta?

A

Risperidone Consta

61
Q

What medication is Sustenna?

A

Paliperidone

62
Q

What tablets are used to test if paliperidone Sustenna is is tolerated?

A

risperidone

63
Q

What medical conditions may precipitate mania?

A 
Stroke
Traumatic Brain Injury
Epilepsy
HIV/AIDS
Lupus
B12 deficiency
Cushing's
Sleep deprivation
Light exposure
Extreme Stress
Wilson's Disease
64
Q

Drugs which may precipitate mania in a bipolar patient

A 
alcohol
bronchodilators
caffeine
cocaine
stimulants
steroids
TCAs
hallucinogens
Dopamine agonist
Pseudo ephedrine
Interferon
65
Q

What is bipolar I?

A

Manic and depressive episodes, classic bipolar.

66
Q

What is bipolar II?

A

Less severe manic episodes than I, same depressive episodes.

67
Q

What is cyclothymia?

A

chronic but milder form of bipolar disorder, characterized by episodes of hypomania and depression that last for at least two years.

68
Q

What are mixed episodes?

A

Where mania and depression occur simultaneously. may feel hopeless and depressed yet energetic and wanting to participate in risky behaviors.

69
Q

When are destructive times for patients?

A

Either in mania or depressive phase.

70
Q

What is rapid-cycling?

A

Bipolar individuals experience four or more episodes of mania, depression, or both within one year.

71
Q

What is classified as a manic phase?

A

At least 7 days of abnormally or persistently elevated or irritable mood. May alternate back and forth between the two.

72
Q

What symptoms may be part of a manic episode?

A 
Inflated self-esteem
Decreased need for sleep
Intensified speech
Rapid ideas
Distractibility
Increased goal-pursuit
Involvement in pursuits of pleasure with high risks of consequences
73
Q

What is a hypomanic episode?

A

A less intense manic episode.
Only required to be present for 4 days
impacts function
Observable by others

74
Q

What is valproate indicated for?

A

Mania or mixed

75
Q

What is carbamazepine indicated for?

A

Mania and mixed

76
Q

What is lamotrigine indicated for?

A

maintenance and depression

77
Q

What is lithium indicated for?

A

Mania and maintenance

78
Q

What is aripiprazole indicated for?

A

Mania, mixed, and maintenance

79
Q

What is quetiapine indicated for?

A

Mania and depression

80
Q

What is risperidone indicated for?

A

Mania and mixed

81
Q

What is olanzapine indicated for?

A

mania, mixed, maintenance

82
Q

What is olanzapine and fluoxetine indicated for?

A

depression

83
Q

what is ziprasidone indicated for?

A

mania and mixed

84
Q

What is step 1 for bipolar disorder?

A

Li, VPA, or SGA

Li or VPA + SGA

85
Q

What is step 2 for bipolar disorder?

A

Switch to another 1st line agent

Combination of any two: Li, VPA, or SGA

86
Q

What is step 3 for bipolar disorder?

A

Combination of any two: Li, VPA, SGA (not 2 SGAs or Cloak) CBZ, FGA, OXC

87
Q

What is the best treatment for hypomania/mania or psychotic mania?

A

Lithium, vaproate, aripirazole, quetiapine, risperidone or ziprasidone

88
Q

What is the best treatment for dysphoric or mixed episodes?

A

Divaproex, risperidone, aripiprazole or ziprasidone

89
Q

Secondary options for mania?

A
  • carbamazepine (many drug interactions)

- olanzapine (metabolic syndrome risk)

90
Q

What would be the most sedating if one wanted to quickly slow down a manic person threatening to cause harm?

91
Q

Which has the best overall evidence for acute euphoric mania?

A

quetiapine

92
Q

If someone had a past history of cardiac myopathy or QT prolongation, which one(s) would you stay away from?

A

Stay away from quetiapine, risperidone, ziprasidone

93
Q

What has the best evidence for treating Bipolar II or severe bipolar I and depression?

A
  • If on lithium, add lamotrigine or quetiapine, then olanzapine with fluoxetine
  • If not on lithium, then add lamotrigine or QTP + antimanic
  • If not on lithium and has not had a recent or severe manic episode, may try lamotrigine by itself
  • May add on olanzasine or olanzasine + fluoxetine
94
Q

What drug interaction do you want to watch out for?

A

valproic acid plus lamotrigine

95
Q

What is wrong with antidepressants in mono therapy for bipolar disorder?

A

Not recommended in BPD I, and could cause a mania switch. Possibly appropriate in BPD II with mood stabilizer on board (lithium or lamotrigine), but evidence of improved stability is lacking.
- SSRI, SNRI, MAOI (phenelzine) suggested. No TCAs

96
Q

Later stages of bipolar disorder, or resistance treatment:

A
  • oxcarbazepine: watch for hyponatremia (na+)
  • Clozapine (treatment resistant cases only)
  • ECT - highly effective for acute mania
  • inhaled loxapine: indicated to treat acute agitation in bipolar I
97
Q

What is lithium indicated for?

A

Acute mania

Maintenance in BPD I and II

98
Q

What should serum levels be for lithium?

A

0.5-1 mEq/L

99
Q

What are prophylactic benefits of lithium useful for?

A

Episodes of mania rather than depression recurrence

100
Q

How does the suicide rate decrease with lithium use?

A

5-fold decrease in suicide rate compared with placebo

101
Q

What direct illness-modifying effect does lithium have?

A

A neuroprotective effect

102
Q

What are the adverse effects of lithium?

A 
Cognitive dulling
Tremor
Memory impairments
Weight gain
Polyuria
Hypothyroidism (30% longterm patients) - cause of Breakthrough depression
Leukocytosis: increases WBC
Pregnancy category D - cardiac malformations 1st trimester
103
Q

What do NSAIDs and lithium cause?

A

They cause increase lithium levels

104
Q

What other drugs cause increased lithium levels?

A

ACE inhibitors, thiazide diuretics

105
Q

What drug causes encephalopathy with lithium?

A

Haloperidol

106
Q

At what serum level does lithium toxicity occur?

A

At higher than 1.2, but symptoms can occur within normal range

107
Q

What symptoms occur with lithium toxicity?

A

GI upset, N&V, diarrhea, tremor, dystonia, hyperreflexia, ataxia, cardiac dysrhythmias, neurotoxicity, nephrotoxicity, dehydration

108
Q

At what lithium levels is dialysis required?

109
Q

If a person is on lithium and is dehydrated, what is the worry?

A

Lithium toxicity. Either way on the water can cause toxicity.

110
Q

What does taking haldol and lithium together increase the risk of?

A

Neurological disorders, especially encephalopathy

111
Q

What are some symptoms of encephalopathy?

A

weakness, fever, tremor, lethargy, fluctuating cognition, delirium, ataxia, rigor in extremities, akinesia.

112
Q

What test would you do to determine neurological impairment?

113
Q

What would you do if neurologic impairment was an issue?

A

Usually stopping the medications will reverse the symptoms.

114
Q

What is the role of a pharmacist in lithium monitoring?

A
  • have patient go in for labs (low therapeutic index)
  • counseling: well hydrated, but avoid polydipsia, light snack with dose if cause, do not restrict sodium intake. Do not take NSAIDs, COX2 inhibitors, ACEs, or diuretics w/o telling MD. May experience light hand tremor, may go away.
  • Don’t stop taking med or interrupt therapy w/o MD
  • Notify MD if diarrhea, vomiting, unsteady gait, excessive urination, weak muscle onset, significant tremor, confusion, ataxia, slurred speech
  • don’t start antidepressant w/o psychiatrist
115
Q

Valproate: IR form, DR form, ER form

A

IR form: valproic acid TID
DR form: Divalproex BID
ER form: divalproex QD

116
Q

What are the therapeutic ranges of valproate?

A

50-125 mpg/L

117
Q

What are the side effects of valproate in acute and maintenance patients?

A
  • Increased sedation, nausea, vomiting, dizziness in acutely manic patients
  • Weight gain, reduced platelets and WBC, increased ammonia levels and alopecia in maintenance
118
Q

Lamotrigine:

  • usefulness
  • often used with?
  • Should not be used if…
  • Warnings:
A
  • bipolar disorder, limited anti-mania efficacy
  • often used with lithium
  • should not be used if history of severe or recent mania w/o antimanic on board
  • start low, go slow. Go slower with valproate.
  • SJS skin reaction, aseptic meningitis
119
Q

Olanzasine + fluoxetine:

  • Indications?
  • AE’s?
  • Take at what time of day?
A
  • Bipolar I associated depression and treatment resistant depression
  • AE’s: Hypotension, weight gain
  • Dosed at bedtime due to olanzapine sedation
120
Q

How can you treat hyperammonemic encephalopathy?

A

With lactulose, the gut can be cleared of ammonia before it is absorbed.

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