Exam 4 - Lec 54-57 Schizophrenia Ott Flashcards
key features that define psychotic disorders (5)
delusions
hallucinations
disorganized thinking and speech
disorganized or abnormal motor behavior
negative symptoms
fixed false beliefs that are not amenable to change even with conflicting evidence
a. delusions
b. negative symptoms
c. disorganized or abnormal motor behavior
d. hallucinations
e. disorganized thinking or speech
a. delusions
perception-like experiences that occur without an external stimulus (usually auditory, but can also be visual, tactile, or olfactory)
a. negative symptoms
b. delusions
c. hallucinations
d. disorganized thinking and speech
e. disorganized or abnormal motor behavior
c. hallucinations
switching from one topic to another, unrelated answers to questions
a. disorganized or abnormal motor behavior
b. disorganized thinking and speech
c. delusions
d. hallucinations
e. negative symptoms
b. disorganized thinking and speech
which of the following is FALSE about the disease course of schizophrenia?
a. onset late adolescence to early adulthood
b. men - late teens, early 30s
c. women - late 20s, early 30s
b. men - late teens, early 30s
(should be early 20s not early 30s)
T or F: Smoking is associated with induction of 3A4, not due to nicotine, but because of hydrocarbons produced and inhaled, which decreases the serum concentration of 3A4 substrate antipsychotics (olanzapine, asenapine, clozapine, loxapine)
F (should be 1A2)
T or F: Marijuana, cocaine, and amphetamine use can hasten the onset of schizophrenia, exacerbate symptoms, and reduce time to relapse
T
T or F: mental health and substance use tx should be undertaken at the same time for schizophrenia pts
T
things we must consider for antipsychotic drug therapy (just look at slide 6; there’s a lot of them)
ok you got it
______ antipsychotic drug therapy is generally considered first-line, unless the pt presents with reasons to consider IM depot drug therapy first
oral
typical antipsychotics are older agents, and are primarily ___ receptor antagonists
a. D1
b. D2
c. D3
d. D4
b. D2
T or F: efficacy for positive symptoms for typical antipsychotics is better than atypical antipsychotics
F (similar efficacy)
typical antipsychotics (6 drugs)
haloperidol
fluphenazine
loxapine
chlorpromazine
perphenazine
thioridazine
which of the following is FALSE about typical antipsychotics?
a. haloperidol is most commonly used - routine and PRN
b. more EPS with higher potency typicals
c. effective for treating negative symptoms, but likely to worsen positive and cognitive symptoms
c. effective for treating negative symptoms, but likely to worsen positive and cognitive symptoms
(effective for positive sx, but likely to worsen negative and cognitive sx)
what are positive symptoms? (from internet)
any change in behavior or thoughts, such as hallucinations, delusions, disorganized speech or thought/behavior
what are negative symptoms? give some examples (from internet)
sx are related to motivation and interest
-anhedonia = lack of interest, enjoyment
-avolition = lack of motivation
-emotionless and flat appearance
typical oral antipsychotics are very effective for which symptoms, positive or negative?
positive (makes negative worse)
3 partial agonist drugs
aripiprazole
brexpiprazole
cariprazine
which of the following partial agonists is only a 3A4 substrate?
a. aripiprazole
b. brexpiprazole
c. cariprazine
c. cariprazine
(the other two are 2D6 and 3A4 substrates)
how do partial agonists work?
they “stablilize” dopamine transmission - not too much, not too little
partial agonists are associated with more _________ than other antipsychotics
akathisia
partial agonists are approved for adjunct tx in ________ so all have boxed warnings for _______
depression; suicidal thoughts/behaviors
atypical antipsychotics are antagonists of what two receptors? (not bolded)
D2 and 5HT2A antagonists
which of the following causes the least amount of weight gain?
a. aripiprazole
b. brexpiprazole
c. cariprazine
a. aripiprazole
(aripiprazole -> low weight gain; the other two cause low-moderate weight gain)
what are the 4 “Pine” atypical antipsychotic drugs?
asenapine
clozapine
olanzapine
quetiapine
T or F: the “pines” cause more weight gain than other agents (not bolded)
T
which of the following comes in a sublingual and patch formulation?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
a. asenapine
which of the following is NOT a 1A2 substrate?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
d. quetiapine
(the rest are 1A2 substrates)
which of the following does NOT cause QTc prolongation?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
c. olanzapine
which of the following has a boxed warning for suicidal ideation?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
d. quetiapine
which of the following causes the most significant weight gain and sedation?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
c. olanzapine
which of the following has a high risk of metabolic syndrome and has a DRESS warning?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
c. olanzapine
which of the following has boxed warnings for neutropenia, orthostasis, bradycardia, syncope, seizures, myocarditis, cardiomyopathy?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
b. clozapine
which of the following has side effects of sedation, weight gain, constipation, hypersalivation, dry mouth, GI hypomotility with obstruction risk?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
b. clozapine
which of the following does not cause sedation?
a. asenapine
b. clozapine
c. olanzapine
d. quetiapine
a. asenapine
how often should an asenapine patch be applied?
one patch every 24 hours; make sure to rotate patch site
T or F: the asenapine patch is a UGT and 1A2 substrate, so dose should be reduced if given with strong 1A2 inhibitors such as fluvoxamine
T
what are the monitoring timelines for clozapine REMS?
weekly x 6 months,
biweekly x 6 months,
then every 4 weeks
why is samidorphan added to olanzapine in Lybalvi? (not bolded)
mitigates weight gain and metabolic syndrome potential of olanzapine
samidorphan is an opioid antag with preferential activity at the _____ opioid receptor
mu
the “dones” atypical antipsychotics are antagonists of which two receptors?
D2 and 5HT2A antagonists
what are the 5 “done” atypical antipsychotic drugs?
iloperidone
lurasidone
ziprasidone
risperidone
paliperidone
which of the following has a high risk for orthostasis and syncope?
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
a. iloperidone
which of the following can cause QTc prolongation? SELECT ALL THAT APPLY
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
a, c, e
which of the following are 2D6 substrates? SELECT ALL THAT APPLY
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
a, d
(risperidone is also a minor 3A4 substrate)
which of the following has the highest risk for akathisia?
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
b. lurasidone
which of the following is renally eliminated?
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
e. paliperidone
T or F: risperidone and paliperidone have similiar side effects
T
which of the following has warnings for suicidal thoughts and is adjunct for bipolar depression?
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
b. lurasidone
lurasidone should be taken with about how many calories of food to inc bioavailability?
350 cals
T or F: ziprasidone’s absorption and bioavailability is increased when taken with food
T
ziprasidone CI
QTc prolongation
which of the following has a warning for DRESS?
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
c. ziprasidone
which of the following is a 3A4 substrate (1/3) and aldehyde oxidase (2/3), so it has less worry for P450 interactions?
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
c. ziprasidone
which of the following has side effects of EPS, hyperprolactinemia, weight gain, sedation, and orthostasis? SELECT ALL THAT APPLY
a. iloperidone
b. lurasidone
c. ziprasidone
d. risperidone
e. paliperidone
d. risperidone
e. paliperidone
which of the following is FALSE about lumateperone (Caplyta)?
a. high risk for weight gain or metabolic SE
b. low risk for EPS or akathisia
c. 3A4 substrate
a. high risk for weight gain or metabolic SE
(low risk)
pimavanserin is an antipsychotic that has what FDA-approved indication?
tx of hallucinations or delusions in pt with PD
MOA of pimavanserin
inverse agonist and antag at 5HT2A
pimavanserin is a substrate of which CYP?
3A4
boxed warning for all antipsychotics
inc risk of death in elderly pts treated w/ antipsychotics for dementia with related behaviors
look at warnings for all antipsychotics (slide 21)
for sure
which of the following is FALSE about the haloperidol decanoate injection?
a. given every 4 weeks
b. load: 20 times oral dose
c. maintenance: 10 times oral dose
d. if only using maintenance dose, there is no need for oral overlap
d. if only using maintenance dose, there is no need for oral overlap
(need oral overlap for maintenance)
haloperidol decanoate and fluphenazie are both oil-based IM injections, so what technique is used when administering?
Z-track (putting the needle in and it is pulled out in a Z shape/zig-zag before the needle comes out; helps prevent irritating medications from leaking into subq tissue)
T or F: Risperidone Consta (risperidone) must be supplemented with oral risperidone or another oral antipsychotic for 3-4 weeks i.e. until 3rd injection (week 4)
T
(injection at 0 days, 2 weeks later, then at week 4)
Perseris (risperidone) is what kind of injection?
a. abdominal IM
b. deltoid IM
c. abdominal subQ
d. IV
c. abdominal subQ
(given in abdominal quadrants, rotate sites)
when Perseris (risperidone) is given with _____ inducers, we should use 120 mg dose or may need oral supplementation
3A4
risperidone is a _____ substrate
a. 1A2
b. 2D6
c. 3A4
b. 2D6
how often is the Rykindo (risperidone) injection given? What kind of injection is it?
every 2 weeks IM (gluteal injection)
difference in oral overlap between Rykindo and Risperdal Consta
Rykindo is 7 days, Risperdal Consta is 21 days
Uzedy (risperidone) is what kind of injection? How often is it given?
abdominal or upper arm subq; once monthly or every 2 months
dosing schedule for Invega Sustenna (paliperidone)
loading dose, then booster, then every 4 weeks (starting 5 weeks after loading injection)
where must the initial loading and booster doses be given for Invega Sustenna (paliperidone)?
a. gluteal muscle
b. deltoid muscle
c. abdominal muscle
b. deltoid (improves absorption consistency)
T or F: for Invega Sustenna (paliperidone), you still need an oral overlap antipsychotic if the loading strategy is followed
F (no oral overlap needed)
T or F: Invega Sustenna (paliperidone) does NOT require dose adjustment in moderate to severe renal impairment
F
which of the following is FALSE about Invega Trinza (paliperidone q3mo)?
a. May be initiated for a patient who has been on a stable monthly IM injection of Invega Sustenna, at least THREE stable Invega Sustenna doses
b. recommended for deltoid injection
c. gluteal admininstration results in low Cmax
d. not recommended if CrCl < 50 mL/min
a. May be initiated for a patient who has been on a stable monthly IM injection of Invega Sustenna, at least THREE stable Invega Sustenna doses
(needs to be FOUR stable Invega Sustenna doses)
we can initiate Invega Hafyera (paliperidone q6mo) after stable Invega Sustenna for ____ months or Invega Trinza after ____ three-month dose(s)
4; one
where is Invega Hafyera injected?
gluteal injection only
Zyprexa Relprevv (olanzapine) has a risk for what syndrome?
PDSS (post-dose delirium sedation syndrome)
which of the following is FALSE about Abilify Maintena (aripiprazole)?
a. given every 4 weeks
b. comes in 300 or 400 mg dosage forms
c. must have at least 14 day oral overlap with aripiprazole or another oral antipsychotic
d. gluteal injection only
d. gluteal injection only (can be gluteal or deltoid)
when do we need to make dose adjustments for Abilify Maintena?
if taking 2D6 or 3A4 inhibitors or 3A4 inducers for more than 14 days as concomitant therapy (use chart on slide 34)
which of the following is TRUE about Abilify Asimtufii (aripiprazole)?
a. every 3 month dosing
b. deltoid injection only
c. continue oral aripiprazole for 2 weeks after first injection
c. continue oral aripiprazole for 2 weeks after first injection
(a is every 2 months; b is gluteal injection only)
why does Aristada (aripiprazole lauroxil) have a longer oral overlap (3 weeks vs 2 weeks after first injection) than Abilify Asimtufii (aripiprazole)?
Aristada is a prodrug, so the oral overlap is longer
what drug was developed to avoid need for 21 day oral overlap of antipsychotic?
a. Abilify Maintena
b. Abilify Asimtufii
c. Aristada
d. Aristada Initio
d. Aristada Initio
which pts should we avoid Aristada Inition in?
poor 2D6 metabolizers or with strong 3A4 or 2D6 inhibitors
for IR antipsychotic injections/psychiatric emergencies, which is most commonly used?
a. haloperidol
b. chlorpromazine
c. fluphenazine
a. haloperidol
boxed warning for olanzapine immed release IM
respiratory depression (cannot be given at same time as a BZD IR injection)
what is the name of the inhalation medication used in psychiatric emergencies?
loxapine for inhalation (Adasuve)
tx for EPS: acute dystonia
a. IM anticholinergic NOW dose
b. oral anticholinergic
c. beta blocker or BZD
d. VMAT inhibitor
a. IM anticholinergic NOW dose (benztropine 2 mg, diphenhydramine 50 mg)
tx for EPS: drug-induced PD
a. IM anticholinergic NOW dose
b. oral anticholinergic
c. beta blocker or BZD
d. VMAT inhibitor
b. oral anticholinergic (benztropine, trihexyphenidyl, diphenhydramine)
tx of EPS: akathisia
a. IM anticholinergic NOW dose
b. oral anticholinergic
c. beta blocker or BZD
d. VMAT inhibitor
c. beta blocker or BZD (propranolol first line; lorazepam is preferred BZD)
tx of EPS: tardive dyskinesia
a. IM anticholinergic NOW dose
b. oral anticholinergic
c. beta blocker or BZD
d. VMAT inhibitor
d. VMAT inhibitor
2 VMAT inhibitors to know
valbenazine (Ingrezza)
deutetrabenazine (Austedo)
common side effect of VMAT inhibtors valbenazine and deutetrabenazine (bolded)
QTc prolongation
valbenazine is which cyp substrate?
a. 2D6
b. 3A4
c. 2D6/3A4
c. 2D6/3A4
deutetrabenazine is why cyp substrate?
a. 2D6
b. 3A4
c. 2D6/3A4
a. 2D6
which of the following is FALSE about neuroleptic malignant syndrome?
a. life threatening
b. SE include hyperpyrexia, tachycardia, and labile BP
c. there is muscle rigidity with elevated CK, myoglobinuria
d. tx is supportive
e. future antipsychotic use is CI
e. future antipsychotic use is CI
(it is not CI)
3 metabolic side effects (bolded)
hyperglycemia, hyperlipidemia, HTN
rank the atypical antipsychotics by risk of metabolic adverse effects
clozapine = olanzapine > quetiapine = risperidone = paliperidone = asenapine = iloperidone = cariprazine = brexpiprazole > ziprasidone = lurasidone = aripiprazole
what are the monitoring parameters for schizophrenia? (6 of them)
-personal/family history
-weight (BMI)
-waist circumference
-BP
-FPG/A1C
-fasting lipids
