Exam 4 - Ott Schizophrenia Flashcards
Key features of Schizophrenia (5)
positiveSx:
-delusions
-hallucinations
-disorganized thoughts and speech
-disorganized or abnormal motor behavior
negative Sx
Typical disease course in schizophrenia (3)
onset in late adolescence to early adulthood
men-late teens, early 20s
women-late 20s, early 30s
Marijuana, cocaine, and amphetamine use can _____ the onset of schizophrenia, exacerbate symptoms, and ______ time to relapse
hasten, reduce
considerations with antipsychotic drug therapy (6)
-no step therapy
doses per day
SE
previous drug therapy
cost
concomitant disease drug therapy
need for monitoring: labs? weight? ECG?
most common antipsychotic agent used
haloperidol (ruotine and prn use)
-typical antipsychotic
Which agents, atypical or typical, cause more EPS?
more EPS seen in higher potency typicals
which is more effective for treating positive Sx, typical or atypical?
typical, however, they are more likely to worsen negative and cognitive Sx
partial agonists (aripiprazole, brexpiprazole, cariprazine) have ______ for akathisia (increased/decreased)
increased
partial agonists (aripiprazole, brexpiprazole, cariprazine) are approved for adjunct tx in _____ and come with a boxed warning for ________
depression, suicidal thinking
aripiprazole considerations (3)
2D6 and 3A4 substrate
moderate akathisia
low weight gain
brexpiprazole considerations (3)
2D6 and 3A4 substrate
moderate akathisia
low-moderate weight gain
cariprazine considerations (3)
3A4 substrate
moderate akathisia
low-moderate weight gain
the “pine’s” considerations (asenapine, clozapine, olanzapine, quetiapine) (4)
more 5HT2A antagonism, less D2 antagonism
less EPS
more weight gains
smoking is not a CI but still warn pts to be cautious
asenapine considerations (3)
patch (q24h, rotate sites) and SL tab
1A2 substrate
QTc prolongation
clozapine substrate
1A2 substrate
clozapine boxed warnings
bradycardia, syncope, seizures, myocarditis, cardiomyopathy
clozapine SE
sedation, weight gain (most of all of pines), constipation, hypersalivation, dry mouth, QTc prolongation
olanzapine
1A2 substrate
significant weight gain and sedation
high risk metabolic syndrome
DRESS warning
quetiapine
3A4 substrate
QTc prolongation
weight gain and sedation
boxed warning for suicidal ideation
clozapine monitoring timelines for ANC (absolute neutrophil count) due to risk of infection
monitoring timelines weekly x 6 months, biweekly x 6 months, then every 4 weeks
normal ANC level on clozapine
1500 per microliter
Samidorphan (olanzapine/samidorphan combo product) acts on ______ receptors and can cause _______
opioid, opioid withdrawal
the “done’s” (iloperidone, lurasidone, ziprasidone, risperidone, paliperidone)
D2 and 5HT2A antagonists
variable EPS and metabolic effects
iloperidone considerations
high risk for orthostasis and syncope
QTc prolongation
2D6 substrate
lurasidone considerations
3A4 substrate
higher risk for akathisia
warning for suicidal thoughts - adjunct for bipolar depression
take with FOOD (to increase bioavailability)
ziprasidone considerations
QTc prolongation (CI)
DRESS warning
take with FOOD (to increase absorption and bioavailability)
3A4 substrate (less worry for interactions)
risperidone considerations
2D6 substrate
SE: EPS, hyperprolactinemia, weight gain, sedation, orthostasis
paliperidone considerations (3)
renally eliminated - dose adjustments in renal impairment
SE: EPS, hyperprolactinemia, weight gain, sedation, orthostasis
QTc prolongation
lumateperone considerations (3)
low risk for weight gain or metabolic SE
low risk for EPS or akathisia
3A4 substrate
Pimavanserin considerations (3)
FDA approved for tx of hallucinations or delusions in a pt with PD
MOA: inverse agonist and antagonist at the 5HT2A receptor
3A4 substrate
warnings for all antipsychotics (5)
boxed warning: increased risk of death in elderly patients treated with antipsychotics for dementia
metabolic AE
EPS
increased risk of falls
Risperdal Consta (risperidone) considerations (1)
MUST supplment with oral risperidone for first few weeks of treatment (until 3rd injection)
Perseris (risperidone) considerations (2)
abdominal injection every 4 weeks
with 3A4 inducers use 120mg or oral supplmentation
Rykindo (risperidone) considerations (2)
every 2 weeks IM injection
oral overlap is 1 week (compared to 3 with Risperdal Consta)
Uzedy (risperidone) considerations (2)
ab or upper arm SQ injection
once a month or once every 2 months
Invega Sustenna (paliperidone) considerations (4)
loading dose, then booster, then every 4 weeks
initial loading and booster doses must be given in deltoid to improve absorption
no oral overlap
caution in renal impairment
Invega Trinza (paliperidone) considerations (3)
may only be initiated for a pt who has been on stable monthly IM injection of Invega Sustenna for 4 injections (this one given q3months)
deltoid administration recommended
DO NOT USE in CrCl <50
Invega Hafyera (paliperidone) considerations (2)
glute injection only
may be initiated after stable Invega Sustenna for 4 months or Invega Trinza for 1 month
Zyprexa Relprevv (olanzapine) considerations (1)
PDSS - post dose delirium sedation syndrome
Abilify Maintena (aripiprazole) considerations (2)
MUST overlap with oral for 14 days
deltoid or glute injection
Abilify Asimtufii (aripiprazole) considerations (3)
q2months dosing
glute injection
oral aripiprazole overlap for 2 weeks
Aristada (aripiprazole leuroxil) considertions (1)
overlap with oral for 3 weeks
Aristada Initio considerations (2)
developed to avoid need for 21 day oral overlap
avoid in pts who are 2D6 poor metabolizers or strong 3A4 or 2D6 inhibitors
IR antipsychotic injections for emergencies (3 drugs)
haloperidol - most common
chlorpromazine
fluphenazine
olanzapine IM immediate release cannot be given with ________ due to boxed warning for respiratory depression
benzodiazapine immediate release injections
EPS seen in schizophrenia (4)
acute dystonia
Drug-induced PD
akathisia
tardive dyskinesia
acute dystonia tx strategy
IM anticholinergic NOW (benztropine 2mg, diphenhydramine 50mg)
drug induced PD tx strategy
oral anticholinergic (benztropine, trihexyphenidyl, diphenhydramine)
akathisia tx strategy
propranolol is 1st line
lorazepam 2nd line
tardive dyskinesia tx strategy
VMAT inhibitors
VMAT inhibitors
tetrabenazine (Xenazine)
valbenazine (Ingrezza)
deutetrabenazine (Austedo)
valbenazine (Ingrezza)
2D6/3A4 substrate
QTc prolongation
deutetrabenazine (Austedo)
2D6 substrate
QTc prolongation
Neuroleptic Malignant Syndrome
life threatening medical emergency caused by dopamine blockade from antipsychotics
hyperpyrexia, tachycardia, labile BP
muscle rigidity
may use antipsychotics again in the future (not CI)
Metabolic AE
hyperglycemia, hyperlipidemia, hypertension
weight gain
rank the atypical antipsychotics from most metabolic AE to least
clozapine = olanzapine >
quetiapine = risperidone = paliperidone = asenapine = iloperidone = cariprazine = brexpiprazole >
ziprazidone = lurasidone = aripiprazole
Metabolic Monitoring - personal or fam Hx
assess at baseline, then yearly
Metabolic Monitoring - weight (BMI)
at baseline, 4 weeks, 8 weeks, 12 weeks, every 3 months
Metabolic Monitoring - waist circumference
at baseline, then yearly
Metabolic Monitoring - BP
at baseline, 12 weeks, then yearly
Metabolic Monitoring - FPG/A1c
at baseline, 12 weeks, then yearly
Metabolic Monitoring - fasting lipids
at baseline, 12 weeks, then every 5 years
