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PR3153 finals > ic11 schizophrenia > Flashcards

ic11 schizophrenia Flashcards

1
Q

what are the diagnoses associated with psychotic symptoms?

A

organic disorders:
- CNS: infections, epilepsy, dementia, parkinsons.
- Head: trauma, tumours/malignancy.
- Endocrine: hypo/hyperthyroidism
- Drug or substance abuse related
- Iatrogenic causes
- metabolic disorders/physiological disturbances affected nervous system.

affective disorders:
- mania, psychotic depression, postpartum depression

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2
Q

drugs associated with drug-induced psychosis (examples)

A

alcohol
barbiturates (eg phenobarbital)
benzodiazepines
beta blockers (eg propanolol)
corticosteroids
cns stimulants (amphetamines)
dopamine agonists (levodopa, for PD)

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3
Q

what is the dsm5 criteria for diagnosis of schizophrenia?

A

at least 2 of the following for at least 1 month
- disorganised speech
- catatonic behaviour (two extremes)
- hallucinations
- negative symptoms (affective flattening, avoilition)
- delusions

symptoms for more than 6 months

social or occupational dysfunctional

rule out medical disorders or substance abuse.

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4
Q

what are the labs and monitoring prior to diagnosis and treatment

A

almost all labs to rule out any general medical conditions or substance induced psychosis.

FBC
TFT
LFT
kidney function U/E/Cr
FBG
Lipids
ECG
urine toxicology

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5
Q

non phx interventions for schizophrenia

A

Psychosocial rehab: to help with adaptive behaviour/function

Support, counselling (incl vocational sheltered)

CBT: individual and group (eg family members)

ECT: electroconvulsive therapy
rTMS: repetitive transcranial magnetic stimulation

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6
Q

when is ECT used in schizophrenia?

A

for treatment resistant schizophrenia

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7
Q

when is rTMS used in schizophrenia?

A

may be used to help with auditory hallucinations.

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8
Q

mechanism of dopamine antagonism and the additional adverse effects of antipsychotics?

A

1) mesolimbic tract
- positive symptoms

ADR
2) mesocortical tract
- cause negative symptoms (region of higher order thinking and executive functions)
3) nigrostriatal tract
- EPSE
4) tuberofundibular tract
- hyperprolactinemia (anterior pituitary blockade)

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9
Q

receptor affinities and associated clinical implications (therapeutic and side effects)

A

D2
- antagonism: improve positive symptoms
- side effects: EPSE, hyperprolactinemia

5HT2A
- antagonism: possibly antidepressant effects, improve negative symptoms(?)

5HT2C
- antagonism side effects: weight gain

H1
- antagonism side effects: sedation, weight gain

alpha 1
- antagonism side effects: orthostatic hypotension

M1
- antagonism side effects: memory dysfunction, peripheral anticholinergic effect (constipation, dry mouth…)

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10
Q

what is the treatment algorithm for schizophrenia

A

1) FGA or SGA except clozapine
if inadequate or intolerable SE
2) FGA or SGA except clozapine
if inadequate or intolerable SE
3) Clozapine

4) Combination therapy:
- clozapine + FGA/SGA/ECT
- FGA + FGA
- FGA + SGA
- FGA/SGA + ECT

should have adequate response, no intolerable side effects, and compliant

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11
Q

how long should treatment be initiated for schizophrenia before swapping to another agent?

A

atleast 2-6 weeks at OPTIMAL therapeutic doses

(except clozapine up to 3 months for mono therapy; 8-10 wks for combination)

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12
Q

treatment considerations if patient is non-compliant?

A

consider long acting injectable antipsychotics

  • iM risperidone microspheres, paliperidone, aripiprazole, haloperidol decanoate, flupenthixol decanoate, zuclopenthixol decanoate.
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13
Q

what tx can be considered for acute agitation (where patient is cooperative)?

A

consider
1) oral lorazepam 1-2mg

2) oral antipsychotic
- halo 2-5mg tab/sol with pre tx ecg
- risp orodispersible tab/sol 1-2mg
- quetiapine IR tab 50-100mg
- olanzapine orodispersible tab 5-10mg

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14
Q

what tx can be considered for acute agitation (where patient is uncooperative)?

A

1) fast acting
IM lorazepam 1-2mg

2) antipsychotic
- IM olanzapine, aripiprazole, haloperidol, promethazine

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15
Q

what tx can be considered for catatonia (abnormal movement/behaviour, withdrawal)

A

po/im lorazepam

or ECT

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16
Q

what tx can be considered for depressive sx or negative sx

A

depression: antidepressant

negative symptoms: mild/moderate efficacy antidepressant

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17
Q

which oral antipsychotics have poor Tmax >3h (less rapidly absorbed and or slower onset)

A

aripiprazole
brexpiprzole

olanzapine

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18
Q

which oral antipsychotics have shorter t1/2 (will require divided dosing)

A

chlorpromazine
sulpiride
amisulpride
clozapine
quetiapine
ziprasidone

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19
Q

which antipsychotics can be given with food to increase BA

A

lurasidone
ziprasidone

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20
Q

what are the EPSE side effects and their characteristics?

A

fast onset (hours to weeks)
1) dystonia: muscle spasms (mins to hours)
2) akathisia: restlessness
3) pseudo-parkinsonism: dyskinesia, tremors, rigidity, salivation..

late onset
4) tardive dyskinesia: orofacial movements, tongue protrusions (IRREVERSIBLE)

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21
Q

what are the risks and management of dystonia caused by antipsychotics?

A

associated with high potency antipsychotics

lower dose or switch to SGA
manage with IM anticholinergics: benzatropine, diphenhydramine

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22
Q

what are the risks and management of pseudo-parkinsonism caused by antipsychotics?

A

higher likelihood in elderly females and previous neurological damage (stroke, head injury)

lower dose or switch to SGA
manage with benztropine or trihexyphenidyl (benzhexol)

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23
Q

what are the risks and management of akathasia caused by antipsychotics?

A

associated with high potency antipsychotics
FGA> risp > olan >quetiapine, clozapine

Lower dose or switch to SGA
anticholinergics are not effective
consider
clonazepam PRN or
propanol 20mg TDS (max 160mg/day)

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24
Q

what are the risks and management of tardive dyskinesia caused by antipsychotics?

A

FGA > SGA

WORSENS WITH ANTICHOLINERGICS
DISCONTINUE any anticholinergics
lower dose or switch to SGA

consider:
- reversible vesicular monoamine transporter 2 (VMAT2): valbenazine 40-80mg/day
- clonazepam PRN

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25
Q

what are the risks and management of HYPERPROLACTINAEMIA caused by antipsychotics?

A

FGA > pali > risp > SGA

decrease dose of drug
consider switching to aripiprazole OR

use dopamine agonist (amantadine, bromocriptine)

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26
Q

manifestations of hyperprolactinaemia?

A

males
decrease libido
galactorrhea or amenorrhea

male:
gynaecomastia

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27
Q

what are the risks and management of metabolic disorders caused by antipsychotics?

A

risk:
high: olanzapine, clozapine
mid: risp, quet, cpz
low: brex, ari, lura, cariprazine, zipra, haloperidol

management:
- change to lower risk agents
- lifestyle modification: diet and exercise
- treat diabetes with eg metformin AND hyperlipidaemia

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28
Q

what are the manifestations of metabolic disorders?

A

increase FBG, diabetes
increased lipids
weight gain

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29
Q

what are the risks and management of orthostatic hypotension caused by antipsychotics?

A

risk:
- CPZ, Clozapine > Risp, pali, quetiapine > olan, lura, ari, sulpiride (choose these)

get up slowly from a sitting or lying position
switch to lower risk agents.

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30
Q

what are the risks and management of QTC prolongation caused by antipsychotics?

A

risk:
high doses, IV haloperidol, decreased serum k+, IHD, female gender

thioridazine > CPZ > ziprasidone > halo > ilo > quet > risp > olan

if qtc >440ms (male), >470ms (female) = switch to lower risk agent
if qtc >500ms, refer to cardiologist

31
Q

what are the risks and management of VTE/PE caused by antipsychotics?

A

low potency FGA (CPZ)
prevent monitor and treat

32
Q

what are the risks and management of sedation caused by antipsychotics?

A

CPZ, clozapine > quetiapine > olanzapine
consider amisulpride, aripiprazole, brexpiprazole, ziprasidone, paliperidone (switch to lower risk agents)

33
Q

what are the risks and management of seizures caused by antipsychotics?

A

CPZ, clozapine > other antipsychotics (consider -dones, piprazoles)
also high doses, rapid titration, or history of epilepsy.

consider switching to high potency agents

34
Q

what are the risks and management of NMS caused by antipsychotics?

A

high potency antipsychotics

management:
- IV dantrolene 50mg TDS
- oral dopamine agonist: amantadine, bromocriptine
- switch to SGA

35
Q

what is the presentation of NMS

A

autonomic dysfunction: increase PR, labile BP, diaphoresis (sweating)
altered consciousness
increased CK
muscle rigidity
fever

36
Q

what is the risk associated with anticholinergics + antipsychotics

A

psychogenic polydipsia (thirst)
temperature dysregulation

37
Q

what are the risks and management of hepatic side effects caused by antipsychotics?

A

CPZ, quetiapine, olanzapine > other SGAs

if jaundice occurs, discontinue and switch

38
Q

what are the hepatic side effects:

A

increased LFTs

cholestatic jaundice

39
Q

what are the risks and management of opthamologic side effects caused by antipsychotics?

A

phenothiazines (CPZ, thioridazine), quetiapine

if on QUET: EYE exam q6months

40
Q

what are the ophthalmologic side effects:

A

cornea, lens changes
pigmentary retinopathy

41
Q

what are the dermatological side effects

A

maculopapular rash
photosensitivity
pigmentation

42
Q

what are the risks and management of DERM SE caused by antipsychotics?

A

phenothiazines

protective clothing or switch to another agent

43
Q

what are the risk associated with clozapine?

A

may decrease WBC and ANC and cause agranulocytosis

discontinue if severe: WBC<3x10^9 or ANC <1.5x10^9

44
Q

what are the parameters to monitor for antipsychotics

A

x7
Metabolic:
- BMI, Waist circumference, FBG, Lipid

Plasma prolactin

BP

EPSE exam

45
Q

how often to monitor for BMI?

A

WEEKLY x 6 wks
OR
EVERY VISIT (at least monthly) x3-6 months (3mth for SGA)

Q3months when dose stabilised

46
Q

how often to monitor for waist circumference

A

EVERY VISIT x 6 months

then

ANNUAL

47
Q

how often to monitor for FBG

A

low risk: annual

high risk: 4 months from initiation (3 months if SGA), then annually

48
Q

how often to monitor for LIPIDS

A

low risk: q2-5 years
high risk: 3 months after initiation (SGA), THEN Q6 MONTHS

49
Q

how often to monitor for PLASMA PROLACTIN

A

at baseline

50
Q

how often to monitor for BP

A

3 months after initiation

THEN
ANNUALLY

51
Q

how often to monitor for EPSE

A

q weekly x 2 weeks OR until dose stabilised

low risk: q6mth (FGA), q12mth (SGA)
high risk: q3 mth (FGA), 12mth (SGA)

52
Q

how often and wat to monitor for side effects in clozapine

A

WBC and ANC for leucopenia and/or agranulocytosis

weekly x 18 weeks
then monthly

53
Q

what to monitor specifically for ziprasidone

A

QTC prolongation
do ECG
repeat if risk of symptoms like syncope.

54
Q

what antipsychotics to choose for pregnancy

A

clozapine
olanzapine

55
Q

what antipsychotics to choose for breastfeeding

A

olanzapine
quetiapine

continue clozapine and stop breastfeeding

56
Q

what antipsychotics to choose for hepatic impairment

A

amisulpride and sulpiride
RENALLY CLEARED

57
Q

what antipsychotics to choose for renal impairment

A

aripiprazole PO

DO NOT USE AMISULPRIDE OR SULPIRIDE

58
Q

WHAT to caution and treatment planning for elderly on antipsychotics

A

consider drugs with high alpha adrenergic and anticholinergic side effects

start low go slow, simplify, and avoid long t1/2 drugs

risk of increased mortality and CVAs in dementia patients on FGA / SGA.

59
Q

what is one pertinent drug disease to caution

A

drug disease: antipsychotics will worsen PD

60
Q

what are substrates of cyp1a2

A

1a2 substrate

phenothiazines
halo
olan

zipra
clozapine

61
Q

1a2 inhibitors and inducers

A

ia2 inducers: rifampicin, phenobarbital, phenytoin, cigarette smoke

1a2 inhibitors: fluvoxamine, macrolides, quinolones, isoniazid, ketoconazole

62
Q

cyp 2d6 substrates?

A

phenothiazines
halo
olan

risp
aripiprazole
brexpiprazole

63
Q

2d6 inhibitors and inducers

A

2d6 inhibitors: fluoxetine, paroxetine, bupropion, duloxetine

2d6 inducer: rifampicin, phenobarbital, phenytoin, cbz

64
Q

3a4 substrates for antipsychotics

A

lumateperone (CONTRA)
lura (CONTRA)
quet
cariprazine

risp
ari
brex

65
Q

3a4 inhibitors?

A

3a4 inhibitors: macrolides, azoles, grapefruit juice, fluvoxamine, norfluoxetine, TCA, imidazole, isoniazid

3a4 inducers: CBZ, phenytoin, barbiturates

66
Q

what drugs will have additive cns effects

A

cns depressants
- alcohol, opioids, psychotropics like benzodiazepine

67
Q

what drugs will have additive adverse effects

A

antimuscarinics, antihistaminic, alpha1 adrenergic blockade, dopamine blockade

68
Q

what drugs will antagonise antipsychotics

A

dopamine agonists
levodopa
bromocriptine

69
Q

What drugs will increase hypotensive effects

A

antihypertensives,
trazodone (SARI)

70
Q

what happens with adrenaline + antipsychotic combination

A

pressor effects reversed by CPZ or other low potency antipsychotics

71
Q

what will increase the toxicity and alter response of antipsychotics

A

TCAs

72
Q

what may cause neurotoxicity

A

lithium

73
Q

what drug with special interaction with clozapine?

A

carbamazepine maybe increase risk of agranulocytosis

74
Q

what is the time course of treatment response?

A

early:
1st week: decreased agitation, aggression, hostility

2nd-4th week: decrease hallucinations, paranoia, bizarre behaviors
improved organisation in thinking

late:
6-12 weeks: decreased delusions, possibly negative symptoms may improve

PR3153 finals (17 decks)

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