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PR3153 > IC 11 - Schizophrenia > Flashcards

IC 11 - Schizophrenia Flashcards

1
Q

What is the pathophysiology of schizophrenia?

A

Dysregulation of dopaminergic (DA), serotonergic (5HT) and glutamatergic functions

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2
Q

Name 1 precipitating factor involved in Schizophrenia.

A

Drugs-/substance

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3
Q

What is one perpetuating factor that prolong the course of disorder?

A

Poor adherence to antipsychotic medications

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4
Q

What are symptoms of schizophrenia?

A

≥ 2 of the following for least a 1 month:
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized or catatonic behavior
5. negative symptoms

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5
Q

How is schizophrenia diagnosed?

A
  1. Symptoms
  2. Social/occupational dysfunction
  3. Continuous signs of disorder for min. 6 months (inclusive of prodromal or residual symptoms)
  4. Exclusion of Schizoaffective or mood disorder
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6
Q

What is one of the assessment that should be done for accurate diagnosis of schizophrenia?

A

Mental state exam (assess for suicidal/ homicidal ideations and risks)

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7
Q

List 4 non-pharmacological management for schizophrenia.

A
  1. Individual: Vocational sheltered (sheltered: employment, rehabilitation)
  2. Individual Cognitive Behavioral Therapy (CBT)
  3. Neurostimulation - Electroconvulsive Therapy (ECT)
  4. Psychosocial rehabilitation programs
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8
Q

Electroconvulsive Therapy (ECT) reserved for ____________ Schizophrenia

A

treatment resistant

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9
Q

What is the purpose of antipsychotics for Schizophrenia?

A

Relieve symptoms of psychosis such as thought disorder, hallucinations and delusions, and prevent relapse

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10
Q

Antipsychotics are more useful for _____ schizophrenia.

A

acute

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11
Q

Why is relapse often delayed for several weeks after cessation of treatment of schizophrenia?

A

The antipsychotic are stored in fat cells. This allow them to diffuses back into blood stream after treatment cessation.

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12
Q

List three methods to overcome poor treatment adherence.

A
  1. IM long acting injections
  2. Community Psychiatric Nurse home visit and administer long acting injections regularly
  3. Patient and Family (Caregiver) Education
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13
Q

What is the primary use of antipsychotics in schizophrenia? Relate to MOA.

A

Blockade of the dopamine receptors in mesolimbic tract

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14
Q

What are the three undesirable effects that may occur when dopamine receptors in other tracts (except mesolimbic tract) of the central dopamine systems are blocked?

A
  1. Negative symptoms
  2. Extrapyramidal side effects
  3. Hyperprolactinemia
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15
Q

How can schizophrenia treatment be given?

A
  1. Single antipsychotic (first or second gen)
  2. If no response, use another single antipsychotic
  3. Clozapine if no response from 2
  4. Clozapine + FGA/SGA/Electroconvulsive therapy if no reponse from 3
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16
Q

What is the duration for adequate trial of antipsychotic (excluding clozapine)?

A

2 to 6 weeks at optimal therapeutic doses

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17
Q

What is the duration for adequate trial of clozapine?

A

up to 3 months

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18
Q

What is the drug that can be used for treatment resistant schizophrenia?

A

Clozapine

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19
Q

What is considered treatment resistant schizophrenia?

A

failed ≥ 2 adequate trials of different antipsychotics (at least 1 should be a SGA).

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20
Q

What is a mandatory routine monitoring that should be done for patients on clozapine?

A

Hematological monitoring (periodic FBC due to risks for agranulocytosis)

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21
Q

Who should use antipsychotic with caution?

A
  1. Cardiovascular diseases
  2. Parkinson’s disease
  3. Prostatic hypertrophy
  4. Angle-closure glaucoma
  5. Severe respiratory disease
  6. Blood dyscrasias (esp Clozapine)
  7. Elderly with dementia
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22
Q

In the event of acute agitation (emergency) and patient is cooperative, what are the two medications that can be used?

A
  1. Oral Lorazepam 1 2mg
  2. Risperidone (tab, oro-dispersible, solution) 1 2mg
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23
Q

In the event of acute agitation (emergency) and patient is uncooperative, what are the fast acting medications that can be used?

A
  1. IM Lorazepam 1-2mg
  2. IM Olanzapine
  3. IM Haloperidol 2.5-10mg, with pre treatment ECG
  4. IM Promethazine 25-50mg
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24
Q

What medication in the event of catatonia?

A

Benzodiazepines (i.e. PO/IM Lorazepam)

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25
Q

What is the Tmax of oral antipsychotics in general?

A

1 to 3 hours (except Brexpiprazole,
Olanzapine, Aripiprazole)

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26
Q

What are the oral antipsychotics that do not have long T1/2?

A

Chlorpromazine, Sulpiride; Amisulpride, Clozapine, Quetiapine, Ziprasidone

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27
Q

What are the two risks that should be considered if giving multiple dose of oral antipsychotics?

A

Hypotension and seizures

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28
Q

What are the four extrapyramidal side effects of antipsychotics?

A
  1. Dystonia
  2. Pseudo-parkinsonism
  3. Akathisia
  4. Tardive dyskinesia
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29
Q

What can cause dystonia in treatment of schizophrenia?

A

High potency antipsychotics

30
Q

How to manage dystonia in treatment of schizophrenia?

A

IM anticholinergics e.g. benztropine, diphenhydramine

31
Q

How to manage Pseudo parkinsonism in treatment of schizophrenia?

A
  1. Anticholinergics PRN (e.g. benzhexol, benztropine)
  2. Decrease antipsychotic dose, or switch to SGA
32
Q

How to manage Akathisia in treatment of schizophrenia?

A
  1. Clonazepam (low dose) PRN and/or propranolol
  2. decrease antipsychotic dose, or switch to SGA
33
Q

What are the risks for Tardive dyskinesia in treatment of schizophrenia?

A
  1. FGA > SGA
  2. Anticholinergic drugs (worsen)
34
Q

How to manage Tardive dyskinesia in treatment of schizophrenia?

A
  1. Discontinue any anticholinergics
  2. Valbenazine 40 80mg/day
  3. Decrease antipsychotic dose, or switch to SGA
    (Clozapine)
  4. Clonazepam PRN
35
Q

Tardive dyskinesia is 50% _______.

A

irreversible

36
Q

How can hyperprolactinemia be managed?

A

Switch to Aripiprazole

37
Q

List four drugs that may cause metabolic side effects such as weight gain, diabetes and hyperlipidemia.

A
  1. High risk - Olanzapine, Clozapine
  2. Low risk - Aripiprazole, Lurasidone
38
Q

How to manage metabolic symptoms in schizophrenia patients?

A
  1. Switch to lower risk agents (Aripiprazole, Brexpiprazole, Cariprazine, Lurasidone)
  2. Treat diabetes (e.g. with metformin),
    hyperlipidemia
  3. Lifestyle modification: diet, exercise
39
Q

What are the adjunctive treatments that can be given for agitation and depression in schizophrenia patients?

A
  1. Benzodiazepines (agitation)
  2. Antidepressants (for depression).
40
Q

What is one cardiovascular side effect of antipsychotics?

A

Orthostatic hypotension

41
Q

What is the main CNS side effect of antipsychotics?

A

Neuroleptic malignant syndrome (NMS): Muscle rigidity, fever, autonomic dysfunction (Increase PR, labile BP, diaphoresis), CK, altered consciousness.

42
Q

How can Neuroleptic malignant syndrome (NMS) be managed in schizophrenia patients?

A
  1. IV Dantrolene 50mg TDS
  2. Oral dopamine agonist (e.g. amantadine, bromocriptine)
  3. Switch to SGA
43
Q

How can hematological side effects caused by antipsychotics be managed?

A

Discontinue antipsychotic if severe : WBC<3x10^9 /L or ANC<1.5x10^9 /L

44
Q

List the parameters that is required for monitoring of side effects.

A
  1. BMI (q3 months)
  2. Fasting blood sugar (3 months after SGA then annually)
  3. Lipid panel (3 months after SGA then annually)
  4. BP
  5. EPSE Exam
45
Q

What parameters should be monitored for Clozapine?

A

WBC and ANC (Weekly for first 18 weeks , then monthly)

46
Q

List 5 special population that require caution use of antipsychotics.

A
  1. Pregnancy
  2. Breast feeding
  3. Renal impairment
  4. Hepatic impairment
  5. Elderly
47
Q

Which of the two antipsychotics can be used in pregnant women?

A

Olanzapine, Clozapine

48
Q

What should be monitored for in pregnant women with schizophrenia?

A

Gestational diabetes

49
Q

Which antipsychotics can breastfeeding mothers used?

A

Olanzapine or Quetiapine

50
Q

Patients on _____ should not breastfeed.

51
Q

Which antipsychotic can be used in renal impaired patients?

A

Oral Aripiprazole

52
Q

Which antipsychotic is prefered in hepatic impaired patients when treating schizophrenia?

A

Sulpiride, Amisulpride

53
Q

In the management of elderly with schizophrenia, what can be done?

A
  1. Simplify regime
  2. Avoid drugs with high propensity for α1 adrenergic blockade (orthostatic hypotension) or anticholinergic side effects
54
Q

Which of the antipsychiatry drugs is an inhibitor of CYP1A2 and 2C19?

A

Fluvoxamine

55
Q

Which antipsychiatry drugs are inhibitor of CYP2D6?

A

Bupropion, fluoxetine, paroxetine

56
Q

Which food is an inhibitor of CYP3A4?

A

Grapefruit juice

57
Q

Name one anti-psychiatric drug that has few CYP interactions.

A

Mirtazapine

58
Q

Which of the ASM can cause increased agranulocytosis risk with Clozapine?

A

Carbamazepine

59
Q

Name 3 drugs that can affect metabolism of clozapine.

A

CYP1A2 inhibitors: Fluvoxamine, Quinolones, Macrolides

60
Q

What lifestyle condition can induce CYP1A2?

61
Q

What class of drugs can increase hypotensive risk when taken together with antipsychotic drugs?

A

Antihypertensive

62
Q

Which agents may lead to mutual antagonism with antipsychotics?

A

Dopamine augmenting agents

63
Q

Which of the drug can lead to additive adverse effects in antipsychotics?

A
  1. Antimuscarinic
  2. Antihistaminic,
  3. α-1 adrenergic blockade
  4. Dopamine blockade
64
Q

Drugs with ____ _____ effects can increase CNS side effects.

A

CNS depressant

65
Q

Effectiveness of therapy can be monitored via ______ side effects.

66
Q

How can one monitor for adverse effects of anti-psychotics?

A

Metabolic parameters and EPSE

67
Q

Response of anti-psychotics drugs can be seen in _____ weeks for those that responded early.

68
Q

After 2 to 4 weeks, patients should have decreased ____ and _____.

A

paranoia, hallucinations

69
Q

Late improvements in patients is usually seen in ______ weeks.

70
Q

Which generation of the antipsychotics have more muscular related side effect?

A

First Generation

71
Q

Which generation of the antipsychotics have more metabolic side effects?

A

Second generation (especially -apines)

  • Exception: Aripiprazole, Brexpiprazole
    Cariprazine, Lurasidone
72
Q

For stabilization and maintenance phase, IM _____ antipsychotics such as IM Haloperidol Decanoate is preferred.

A

long acting

PR3153 (16 decks)

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