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depression > IC11: Schizophrenia Treatment > Flashcards

IC11: Schizophrenia Treatment Flashcards

1
Q

List pharmacological therapeutic goals of schizophrenia

A

1. Acute stabilisation
Minimise threat to self & others
Minimise acute sx
- Improve role functioning
- Identify appropriate psychosocial interventions
- Collaboration with family & caregivers; support for carers

2.Stabilization
**Minimise/prevent relapse **
Promote medication adherence
**Optimise dose and manage adverse effects **

3. Stable/maintenance phase
**Improve functioning & QoL **
- Maintain baseline functioning
- Optimise dose vs adverse effects

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2
Q

List at least 3 First Generation Antipsychotics

A
  1. Haloperidol
  2. Chlopromazine
  3. Sulpiride
  4. Trifluoperazine
  5. Sulpiride
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3
Q

List at least 5 Second generation Antipsychotics

A
  1. Aripiprazole
  2. Brexipiprazole
  3. Clozapine
  4. Olanzapine
  5. Quetiapine
  6. Risperidone
  7. Other: Amisulpiride, Cariprazine, lurasidone, paliperidone ER
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4
Q

State the indications of antipsyhoctics

A
  1. Schizophrenia & related psychoses
  2. Short-term adjunctive management of severe anxiety or psychomotor agitation, violent behaviour
  3. Acute mania (eg. bipolar I disorder)
  4. Adjunct with Antidepressant for Major Depression (Quetiapine, Aripriprazole, Brexpiprazole)
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5
Q

List the 4 dopamine tracts blocked by antipsychotics

A
  1. Mesolimbic
  2. Mesocortical
  3. Nigrostriatal
  4. Tuberoinfundibular
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6
Q

State the effect(s) of inhibiting the mesolimbic tract

A
  1. Mesolimbic: Treat positive symptoms (eg. hallucinations & delusion)

The other 3 tracts (MC, NS, TI) cause adverse effects

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7
Q

State the effect(s) of inhibiting the mesocortical tract

A

Mesocortical: Negative symptoms

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8
Q

State the effect(s) of inhibiting the nigrostrital tract

A

Nigrostriatal: EPSE (parkinsonism eg. resting tremor, cogwheel rigidity)

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9
Q

State the effect(s) of inhibitng the Tuberuinfundibular tract

A

Dopamine blockade in the anterior pituitary leads to hyperprolactinemia (a/w osteoporosis, gynecomastia, sexual dysfunction)

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10
Q

State the receptor types inhibited by antipsychotics

A
  1. D2 receptor (improve positive sx)
  2. 5HT1A
  3. 5HT2A
  4. 5HT2C
  5. H1
  6. A1 receptors
  7. Muscarinic 1 receptors
  8. IKr
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11
Q

State the effects of antgonising the following receptors

  • D2
  • 5HT2A
  • 5HT2C
  • H1
  • A1
  • M1
  • IKr
A

D2: Improve +ve sx, EPSE, hyperprolactinemia
5HT1A: Agonism leads to anxiolytic effect
HT2A: Improve -ve sx
5HT2C: Weight gain
H1: Sedation, weight gain
A1: Orthostatic hypotension, sedation
M1: constipation, dry mouth (anticholinergic)
IKr: QTc prolongation

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12
Q

State the factors that determine the choice of antipsychotics selected

A
  1. Physician’s assessment of clinical circumstances
  2. Past responses/failure on antipsychotics
  3. Efficacy
  4. Side effect profile
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13
Q

State the duration for an adequate trial of antipsychotics

A

2-6weeks (except clozapine)

and at optimal therapeutic dose

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14
Q

State the duration for an adequate trial of Clozapine

A
  • At least 3 months
  • Augmentation: 8-10 weeks
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15
Q

When should Clozapine be used for Schizophrenia treatment?

A

Treatment resistant schizophrenia eg. Failed ≥ 2 adequate trials (2-6wks at optimal dose) of different antipsychotics (at least one is SGA)

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16
Q

State at least 7 precautions for antipsychotics use

A
  1. Cardiovascular: QTc prolongation CI, need ECG
  2. Parkinson’s disease (EPSE woresend by antipsychotics)
  3. Prostatic hypertrophy
  4. Angle closure glaucoma
  5. Severe respiratory disease
  6. Blood dyscrasias esp for Clozapine
  7. Elderly with dementia - incr risk for mortality & stroke
  8. Epilepsy & conditions predispoing to seizures
  9. Depression
  10. Myasthenia gravis
  11. Hx of jaundice
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17
Q

State the pharmacologic adjunctive treatment(s) for acute agitation in a cooperative patient

A

1. PO lorazepam 1-2mg OR
2. PO antipsychotics:

  • Haloperidol 2-5mg withpre-tx ECG
  • Risperidone 1-2mg or
  • Quatiapine 50-100mg
  • Olanzapine 5-10mg
18
Q

State the pharmacologic adjunctive treatment(s) for acute agitation in an uncooperative patient

A
  1. IM lorazepam 1-2mg, or
  2. IM antipsychotics (HOPA)
    - Haloperidol (w pre tx ECG)
    - Olanzapine
    - Promethazine
    - Aripiprazole

Concept: give fast acting IM injection

19
Q

State the pharmacologic adjunctive treatment(s) for catatonic patients

A

PO/IM lorazepam

20
Q

State the pharmacologic adjunctive treatment(s) for Depressive sx or negative sx of chronic schizophrenia

A

Antidepressants, SSRIs

21
Q

True or False?

Most PO antipsychotics have rapid onset of action

A

True. Most have Tmax 1-3H (except: Brexipiprazole, Aripiprazole, Olanzapine- BAO)

22
Q

True or False?

Most PO antipsychotics have long half lives and can be dosed once daily

A

True

23
Q

List 2 antipsychotics that have short t1/2 & require divided dosing

A
  1. Clozapine
  2. Quetiapine
  3. Chlorpromazine
  4. Sulpiride
  5. Amisulpiride
24
Q

Which adverse effects are seen more in FGAs vs SGAs

A
  1. EPSE (FGAs stronger D2 antagonism)
  2. Hyperprolactinemia
25
Q

State the adverse effects of antipsychotics

A
  1. EPSE (dystonia, pseudoparksonism, akasthesia, tardive dyskineisa)
  2. Hyperprolactinemia
  3. Metabolic (DM, hyperlipidemia)
  4. Cardiovascular (Orthostatic hypotenxn, QTc prolongation,VTE/PE)
  5. CNS: Sedation, seizure
  6. Neuroleptic malignant syndrome
  7. Hematological (Cloazapine): Agranulocytosis/ neutropenia
  8. Hepatic- raised LFTs
  9. Opthalmologic: cornea/lens change
  10. Dermatological: maculopapular rash, photosensitivity
26
Q

State the S/S of Neuroleptic Malignant Syndrome (NMS)

A
  1. Muscle rigidity
  2. Fever
  3. Autonomic dysfunction - increase pulse rate, labile BP, diaphoresis
  4. Altered consciousness
  5. Raised creatine kinase (CK)
27
Q

List the monitoring parameters of antipsychotics

A
  1. BMI (weight gain)
  2. Waist circumference (obesity)
  3. FBG (DM)
  4. Lipid panel (hyperlipidemia)
  5. Plasma prolactin (hyperprolactinemia)
  6. Blood pressure (incr/decr BP)
  7. EPSE exam: rigidity, tremor, akastheisa, tardvice dyskinesia
  8. Clozapine: WBC & ANC
  9. ECG (Ziprasidone), QTc prolongation
27
Q

Pregnant patients on olanzapine & clozapine should be monitored for which SE?

A

Gestational diabetes

28
Q

List 2 antipsychotics suitable for breastfeeding

A
  1. Olanzapine
  2. Quetiapine
    On clozapine: continue and do not breastfeed
29
Q

State the preferred antipsychotic(s) for renal impairment

A

PO aripiprazole (avoid sulpiride & amisulpiride)

30
Q

State the preferred antipsychotic(s) for hepatic impairment

A
  1. Sulpiride
  2. Amisulpride
31
Q

State the antipsychotic considerations for elderly patients

A

Avoid drugs with
1. high a1-adrenergic blockade (orthostatic hypotension)
2. high anticholinergic SE (constipation, urinary retention, delirium)
3. Others: start low go slow, simplify regime, avoid adverse interactions, avoid long t1/2 drugs
4. Dementia pts: FGAs & SGAss incr mortality & CVA

32
Q

How to monitor the effectiveness of schizophrenia therapy?

A
  1. Mental State Exam (not specific)
  2. Psychiatric rating scale eg. Positive & Negative Syndrome scale
33
Q

State the duration & symptoms improved during early improvement phase

A

1st week: decr agitation, aggression, hostility
2-4 weeks:
- decr paranoia, hallucinations, bizzare behaviours
- improved organisation in thinking

34
Q

State the duration & symptoms improved during late improvement phase

A

6-12 weeks : decr delusions, negative sx may imrpove
3-6mths: cognitive sx may improve with SGAs

35
Q

Between FGAs and SGAs, which causes more EPSE?

A

FGAs > SGAs (due to FGAs having stronger D2 antagonism)

36
Q

SGAs ending with ‘ines’ usually are associated with which adverse effects?

A
  1. Sedation
  2. Weight gain

eg. Clozapine, Quetiapine, Olanzapine

37
Q
A
38
Q

List a treatment option that can be provided if patients have poor adherence/refuse to take meds/prefer IM?

A

IM haloperidol decanoate

39
Q
A

depression (5 decks)

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