Exam 3 Flashcards
Non Pharm Treatment for schizo
Realistic goals and time course
-social rehabilitation
-psych education
-targeted cognitive therapy
-active community treatment
-therapeutic alliance
-comprehensive care ( psych services and psych med)
General Approach for schizo
-Optimized monotherapy, combo for treatment resistant (clozapine)
-lack of evidence supporting APS polypharmacy
-2nd gen A> 1st gen A
-Substantial risk of suicide or attemp- add clozapine
CATIE trial
-equal efficiency between old and newer antipsych
-newer agents have more permanent SEs and more expensive
Dopamine antagonism effects
-Movement disorders
-Relief of psychosis
-akathisia
-increased prolactin (causes abnormal periods and gynecomastia)
-impulsivity
clozapine class, major se, dosing
-only m4 agonist; 2nd gen antipsych
-se inc hyper-salivation (add scopolamine patch), severe constipation, orthostatsis
-if dose interrupted for more than 48hrs, re-titrate fro starting dose
Clozapine DDI
Antiepileptics dec ANCs
-Lithium helps by inc ANC
Clozapine BBW and REMS
Blood dyscrasis
when to start clozapine
must trail 2 other antipsych b/f (treatment resistant)
-if severe risk of suicide can start clozapine earlier
Clozapine DDI
benzos especially lorazepam IM
Treatment considerations for schizo
-lifelong for most; rare possibility of d/c
-relapse is high
-watch out for incomplete switch/titrations
-recommend IM meds for initial rapid relief of sym
-limit time over MDD to 2-4 weeks and re-eval
who is considered treatment resistant in schizo, include time frame
lack of improvement with at least 2 APS from different classes at optimal dose for 8 weeks
What should you do for treatment augmentation in schizophrenia
-add non-APS agent with mood stabilizers
-ECT and/or ziprasidone with clozapine
1st gen antipsych (6)
ChlorprOmaziNe
Fluphenazine
halopeRidOl
perpheNazine
ThioridAzine
ThIOthixeNe
(confrontation)
1st gen antipsych SE (8)
-Extrapyramidal side effects
-OT prolongation
-Prolactin elevation (w/ longer use)
-Dermatologic
-photosensitivity
-blue gray skin
-orthostatic hypotension
-altered thermoregulation
Antipsych BBW
-dementia related psychosis inc mortality
-pt has dementia and schio is okay to use antipsych but if they experience psychosis d/c
2nd gen antipsych LAI approved for BP
Aripiprazole
Risperdone
2nd gen antipsych SE (8)
-Metabolic syndrome (inc trigycleride, glycemia and weight gain)
-QT prolongatio
-Blood dyscrasia/Neutopenias
-Seizure threshold
-Anticholingeric
-Sedation
-prolactin inc
-Ophthalmic effects
Only approved medication for agitation in alzheimers
Brexpiprazole
2nd gen approved for MMD (4)
All brokies owe five quarters
Aripiprazole
Brexpiprazole
Olanzapine w/ Fluoxetine
Quetiapine
- no LAI
Olanzapine
-Class, se, monitoring
2nd gen antipsych
-se for metabolic risk in younger men
-REMS for post inj delirium with LAI
-dress
-3 hr monitoring (rems)
which drug is in niosh and why
Ziprasidone
-2nd gen
-se : DRESS
-short acting inj requiring reconstitution, tablet
LAI pearls
-good for non-adherent patients
-should stabilize on mono therapy before initiating
-oral challenge with the same drug
-oral overlap needed b/c LAI take a while to show effect
which 2 first gen antipsychs are high potency and consequence
fluphenazine & haloperidol
*inc risk of EPS b/c target D2
which 2 first gen antipsychs are low potency and consequence
Chlorpromazine & thioridazine
*high anticholingeric risk
New combination therapy for schizo & BD and its moa
Lybalvi (olanzapine & samidorphan)
- treat acute and maintenance
-mono or adj
-samidorphan is a opioid system modulator acts on mu receptor to reduce metabolic effects of olanzapine
-CI use of opioids
*less weight gain
special populations
-elderly: start low go slow, avoid anticholingerics risk of fall; use SSRI first for depression
-Preg: better to be on therapy; use SSRI
What 1st gen drugs are LAI (2)
Fluphenzaine & Haloperidol
What 2nd gen drugs are LAI (4) and indication
Aripiprazole
Olanzapine
Risperidone
Paliperidone
*water based and better tolerated
- for schizo
Paliperidone LAI
invega hafyera has a dosing interval of 6 months
which 2nd gens cause weight gain (3)
Clozapine
Olanzipine
Quetiapine
2nd gen antipsych that cause EPS
Risperidone & Paliperidone
2nd gen antipsych that cause inc prolactin
Risperidone & Paliperidone
Acute Dystonias symptom, risk and treatment
-Symptom: painful prolong muscle contraction
-Risk: high potency or high dose FGA, younger men
-Treatment: Anticholingersics (benzotropic or diphenhydramine), IM> PO Benzo, dec dose or d/c offending agent
Psuedo-parkinsonism symptom, risk and treatment
-Symptom: Tremor, rigidity, etc.
-Risk: high potency or high dose FGA, older age, female
-Treatment: Anticholingerics, dec dose or d/c offending agent
Akathisia symptom, risk and treatment
-Symptom: restlessness, distress, etc
-Risk: high potency FGA, aripiprazole, risperidone
-Treatment: Beta blockers dec dose or d/c offending agent
Tardive dyskinesia symptom, risk and treatment
-Symptom: tongue thrusting, lip smacking, etc
-Risk: high potency or high dose FGA, female, older age, AA
-Treatment: DC offending agent, dont use anticholingeric, VMAT2i (Valbenazine & Deutetrabenazine)
NMS symptom, at risk, treatment
-Symptom: rapidly over 24-72 hrs, inc muscle rigidity, inc wbc/lfts/bp, normal pupils, dec or norm bowel sounds
-Rare potentially lethal, seen with high potency drugs and ALL antipsychs
-at risk: dehydrated, organic mental disorder
-Treatment: d/c antipsychs & da agonist like bromo
-re-challenge in 2 weeks
Serotonin syndrome
- Onset: less than 12 hours
- inc muscle tone
- Hypereflexia
- Dilated pupils
- Inc bowel sounds
Which drugs have CYP1A2 activity
Clozapine and Olanzapine
Medication class that can cause depression (7)
-CV: Beta blockers, Calcium Channel Blockers
-Hormonal: oral contraceptives and steroids
-Antiepileptics: Levetiracetam & Topiramate
-Opioids
-Stimulants
SSRI approved in MDD (5)
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline
SNRI approved in MAD
Desvenlafaxine
Duloxetine
Levomilnacipran
Venlafaxine
SSRI approved in GAD (2)
Escitalopram
Paroxetine
SNRI approved in GAD (2)
Duloxetine
Venlafaxine