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Neurologic & Psych > EXAM 5 Schizophrenia Thomason > Flashcards

EXAM 5 Schizophrenia Thomason Flashcards

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1
Q

What is the diagnosis criteria for Schizophrenia?

A

2 or more symptoms of the following for at least 1 month:

-Delusions
-Hallucinations
-Disorganized Speech
-Grossly disorganized/catatonic behavior (unresponsive, staring)
-negative symptoms: blunted, alogia (not talking), abolition (lack of motivation), anhedonia, amotivation

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2
Q

Positive and negative symptoms

A

Positive:
-Hallucinations
-Delusions
-Disorganized speech
-Grossly disorganized or catatonic behavior

Negative:
-Antipsychotic induced
-Depression
-Extrapyramidal symptoms (EPS, parkinson-like)
-Positive symptoms causing withdrawal

-cognitive symptoms (slow thinking)
-mood symptoms

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3
Q

Which drugs are more effective than others for treating negative symptoms of Schizophrenia?

A

-Olanzapine (Zyprexa)
-Clozapine

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4
Q

What are Delusions?

!!!
there will be a case to distinguish from hallucinations

A

False, fixed beliefs
-Delusion of reference (somebody talks about them)
-Religious
-Persecutory
-Gradnios
-Somatic (they believe they have an illness)
-Erotomania

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5
Q

What are Hallucinations?

!!!

A

Sensory experiences that are not actually present, mostly auditory (speech or sounds)

less common:
visual, olfactory (often brain lesion, check MRI), tactile (feeling bugs or crawling), gustatory

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6
Q

Differentiate other conditions from Schizophrenia

A

-Schizophreniform: don’t meet the full criteria for Schizophrenia

-Schizoaffective: both, mood disorder and schizophrenia

-major depressive disorder or bipolar disorder with psychotic features -> looks like Schizophrenia

-psychosis due to condition: dementia or high dose of steroids

-substance-induced: marihuana, cocaine, PCP, K2, amphetamine)

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7
Q

Risk factors for developing Schizophrenia

A

-Perinatal insults (during delivery): hypoxia, fetal distress, influenza, famine (hunger)

-infection or autoimmune causes
-the use of cannabis and amphetamines
-Genetics (10%, 35% if both mom and dad had schizophrenia)

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8
Q

Where does the tuberoinfedibular pathway end?
!!!

A

Pituitary gland

-when antagonized: prolactin release
RISPERIDONE !!! (also iloperidone)
men get gynecomastia
women (even children) secrete milk

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9
Q

Where does the Nigrostriatal pathway end?
!!!

A

Basal ganglia

EPS symptoms when antagonized

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10
Q

First gen Antipsychotics block which receptors?

A

D2 receptors

but also antagonize:
-alpha-1 receptors
-histamine-1 receptors
-msucarainic receptors

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11
Q

What are the side effects of First-gen Antipsychotics?

A

-QTc prolongation (STOP if greater than 500 ms)
need baseline EKG, then once a year

-Anticholinergic

-Antagonize alpha-2: Orthostatis

-Antagonize Dopamine-2
EPS -> tardive dyskinesia (face, hands)
-dystonia
-akathisia (aunts in the pants)
-parkinsonism

-Hyperprolactinemia, gynecomastia
-sexual dysfunction
-amenorrhea
-osteoporosis
-galactorrhea

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12
Q

Signs of Neuroleptic Malignant Syndrome

A

can happen with antipsychotics (more often with first-gens)

-muscle rigidity
-hyperthermia
-altered mental status
-autonomic dysfunction

treat with fluids, get the temperature down (cooling blankets, icing)
-dantrolene, benzos (decrease rigidity), amantadine

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13
Q

Which side effect is often seen with fluphenazine or Haloperidol (high-potency antipsychotics)?

A

Acute dystonic reaction

-tonic contractions of the back, mouth, arms and legs
-young black males most frequently
-early when starting

-give Benadryl or Benztropine (Cogentin)
-prevent by titrating slow

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14
Q

Which drugs can be used for Pseudoparkinsonism?

A

-Benztropin (Anticholinergic) !!

-Benadryl
-Amantadine

-Pseudoparkinsoism: slowing of voluntary movements after several days or weeks
-often females

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15
Q

What is the best treatment for Akathisia?

A

Propranolol

-Akathisia - Aunts in their pants, they can’t sit still
-35% incidence -> need to counsel
-seen after 2.5 months

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16
Q

Drug used for tardive dyskinesia
!!!
match the side effect with the treatment

A

-VMAT-2 inhibitor -> monitor using AIMS
D/C the drug that causes it

-involuntary movements of the face, can be irreversible
-seen after years
-patients may have early EPS signs, genetics involved (their parents had schizophrenia and dyskinesia)

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17
Q

To which receptors do SGAs bind for the most part?

A

Antagonize
-Dopamine-2 receptors
-5-HT2A receptors

also alpha-2, muscarinic receptors

-all have unique binding profiles -> unique side effects

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18
Q

What are the side effects of SGAs?

A

-QTc prolongation (especially Ziprasidone and Seroquel) -> use one that has less risk for QTc (like Aripraprazole if it is a concern)

-Tardive dyskinesia - long-term

-Orthostasis for those blocking alpha-2

-Anticholinergic effects:
Urinary retention, constipation, sedation

-Metabolic syndrome
weight gain, diabetes, hyperlipidemia

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19
Q

Which antipsychotic mostly causes weight gain?

A

Olanzapine (Zyprexa)
Cloazapine
Quetiapine

Olanzapine is used for anorexia bc it stimulates appetite -> weight gain

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20
Q

Antipsychotics with less weight gain

A

Aripiprazole
Cariprazine
Lumateperone
Ziprasidone

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21
Q

How often should be signs of metabolic syndrome monitored?

A

at baseline
after 3-4 months
annually

LDL and blood glucose, A1c

weight more often

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22
Q

Which drug is tolerated the most (sedation, less weight gain, orthostatic, QTc)?

A

Aripiprazole

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23
Q

Which antipsychotics are sedating?

A

Quetiapine

Olanzapine
Clozapine

24
Q

Which antipsychotics cause QTc prolongation?

A

Iloperidone
Ziprasidone

25
Q

What are the indications of Olanzapine (Zyprexa)?

A

-Schizophrenia
-Bipolar I
-Depression (combi product with fluoxetine)

-Long-acting injectable (Zyprexa Relprevv)

26
Q

Indications of Quetipaine

A

-Schizophrenia
-Bipolar
-Depression

sedation!!, weight gain

27
Q

How is Quetipaine administered?

A

-the ER formulation on an empty stomach or light meal (<300 calories) !!

-the IR can be taken with food (IR not seen that often)

28
Q

Which antipsychotic has a sublingual formulation?

A

Asenapine

-place under the tongue and allow to dissolve
-don’t eat or drink for at leat 10 minutes after taking it

29
Q

Side effects of Risperidone

A

-hyperprolactinemia
-orthostasis (titrate slowly) BID or daily dosing
-EPS (has more D2 antagonism) with higher dosing
-sexual dysfunction

-dose adjust for renal impairment

30
Q

Which drug is the active metabolite of Risperidone?

A

Paliperidone (Invega)

-renal dose adjustment
-LAI formulation (Sustenna (1x month)

-counsel on capsule in the stool (OROS formulation) -> since they are paranoid already

AE: increased prolactin levels, EPS

31
Q

Which antipsychotic has an indication for Schizoaffective disorder?

A

Paliperidone (Invega)

Schizoaffective disorder: mood disorder + schizophrenia

32
Q

Which antipsychotic has to be taken with food to ensure absorption?
!!!

A

Ziprasidone

BID dosing with >500 calories for absorption !!!

-QTc prolongation (10 msec)

Lurasidone -> > 350 calories !!!

33
Q

Side effects of Iloperidone

A

-orthostasis (titrate slowly)
-dizziness, dry mouth, fatigue
-hyperprolactinemia!!!

-can have QTc prolongation
->substrate to CYP2D6 and 3A4 (inhibitors increase levels -> QTc)

34
Q

Indication of Lurasidone

A

-Bipolar depression !!!
-MDD with mixed features
-Schizophrenia (doesn’t work great for schizophrenia, more often seen for Bipolar depression)

has to be administered with food (>350 calories)

D2 activity: Akathisia, parkinsonism, nausea

35
Q

Side effects of Aripiprazole

A

-insomnia (it is activating, some say it is sedative)
-HA
-anxiety
-akathisia -> may be treated with a beta-blocker (propranolol), if D/C the akathisia doesn’t stop for a week due to a long half-life of 75 hr

it is ~weight neutral

CYP2D6 and 3A4 substrate

36
Q

Which drugs are often associated with the side effects of Akathisia?

A

-Aripiprazole
-Brexpiprazole

37
Q

Side effects of Cariprazine

A

Akathisia

also EPS and Parkinson-like

it is activating: take it in the morning

38
Q

Disadvantages of LAI

A

-expensive, often need prior authorization
-less flexible to dose adjustments, patients need to try oral first to see if they tolerate it
-needs time to reach steady state, they need to take oral until it works
-they have to go to the clinic, sometimes pharmacies can administer
-painful injection, injection site rejection

39
Q

Advantages of LAI

A

-don’t need to take daily orals
-reduce risk of overdose
-lower risk for rebound symptoms (psychotic - non–psychotic)
-stable steady state
-they see the provider every time they need an injection (can monitor and assess efficacy)

40
Q

Which antipsychotics have LAI formulations?

A

First-gens:
-Fluphenazine
-Haloperidol

SGA:
-Risperidone
-Paliperidone (1x monthly Sustenna, 2 injections)
-Aripiprazole (need oral supplementation before it reaches a steady state)
-Olanzapine (post-dose hypotension - monitor for 3h)

41
Q

Which antipsychotic LAI needs oral supplementation?
!!!

A

Aripiprazole (Abilify)

Abilify Maintena: 14 days oral

Abilify Asimtufii: 14 days oral

Aristada: 21 days oral or load with 675 mg injection and 30 mg oral

42
Q

Which LAI has a risk for post-dose hypotension?

A

Olanzapine
need 3h monitoring

43
Q

What was the conclusion of CATIE Phase I of the Landmark trial?

A

they compared Olanzapine with quetiapine, risperidone, ziprasidone, and PERPHENAZINE (1st gen)

-pt stayed longer on Olanzapine - but had more weight gain

-Perphenazine (1st gen) worked as well as the 2nd gens -> since it is 1st gen it is much cheaper BUT it has more EPS side effects

44
Q

CATIE Phase III

A

more symptomatic patients (treatment-resistant) chose their antipsychotic drug -> more patients picked clozapine VS combo

45
Q

Conclusion of the InterSePT trial

A

Clozapine decreased suicide in schizophrenia
-> it has an FDA-approval for it

FYI: Lithium decreases suicide in bipolar disorder

46
Q

First-line options for Schizophrenia based on Guidelines

A

1st: FGA or SGA
2nd: change to another SGA or FGA
3rd: Clozapine for treatment-resistant, need to fail at least 2 antipsychotics

if possible avoid combis of antipsychotics

47
Q

Indication (role) of Clozapine

A

-treatment-resistant schizophrenia (failed 2 or more antipsychotics)
-suicidality in patients with schizophrenia or schizoaffective disorder

48
Q

BBW for Clozapine

A

-agranulocytosis (high risk in the first 6 months) -MONITORING CBC weekly at the beginning, watch for fever

-Myocarditis (first 8 weeks) - SOB, cardiac symptoms, arrhythmias

-seizures (dose-dependent)
-orthostasis

-need bowel regimen: stool softener, laxatives (don’t use bulking agents - we don’t want bowel infarction)

49
Q

What tests should be done before starting Clozapine?

A

-check vital signs: HR and BP
-CBC: WBC and neutrophils count (ANC)
-comprehensive metabolic panel (CMP): Blood glucose
-AIMS: assess tardive dyskinesia

-check EKG, troponin enzymes, C-reactive protein

during therapy check the Clozapine level if they take 100 mg/d (may change the dose based on levels and symptoms)

50
Q

DDI for Clozapine
!!!

A

with CYP1A2 inhibitors: decrease the clozapine dose to one-third

with moderate to weak CYP1A2 inh: monitor for side effects
(oral contraceptives, caffeine (competing with Clozapine)

with CYP1A2 inducer: need a higher dose
(cigarettes and cannabis and other inducers like carbamazepine, phenytoin)

51
Q

Which receptors are targeted by the drug Cobenfy (Xanomeline and trospium chloride)?

NEW DRUG

A

M1 and M4 receptors, highly expressed in regions associated with schizophrenia

-less EPS and prolactin release since M1 and M4 is less expressed in regions for motor control and hormonal regulation

-avoid in urinary retention, gastric retention, glaucoma, hepatic impairment

52
Q

Managing using multiple Antipsychotics

A

-Cross titration: go down with one and up titrate the new antipsychotic

-same in Clozapine augmentation: go down in Clozapine and titrate up the new drug (ex Abilify)

53
Q

Pregnant women with Schizophrenia

A

they should continue their meds

-don’t use LAI because we cant dose adjust, use ORAL

-babies may experience EPS, agitation, abnormal muscle tone, difficulty feeding when they are born (since they were exposed)

54
Q

Which drugs are approved for children?

A

-Aripiprazole !!!
-lurasidone
-quetiapine
-risperidone (for autistic patients)
-paliperidone

EPS and weight gain are greater than in adults (use weight-neutral meds if possible)

-clozapine may be used for treatment-resistant

55
Q

Elderly

A

more delusions and hallucinations

-pick meds with fewer effects on BP
-ALL antipsychotics carry the BBW for increased mortality in elderly with dementia-related symptoms

Neurologic & Psych (37 decks)

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