Kirkpatrick > Antipsychotics Flashcards
what are the 4 appropriate uses for antipsychotics?
psychosis
non-psychotic mania
autism
adjunct to antidepressants
what are 2 common uses for antipsychotics that do not follow guidelines?
behavioral probs in pts w/ dementia (2nd or 3rd line)
delirium (2nd or 3rd line)
do all pts respond to antipsychotics?
nope
responses are variable, some don’t respond at all
what 3 things can transiently increase psychotic symptoms?
NMDA antagonist (ketamine) serotonin agonist (MCPP) cannabis
T/F: because DM drugs work on schizophrenia, schizophrenia must be a disease of DM only
false
think of plague > if aspirin lowers your fever, that doesn’t mean that plague is a disease of aspirin deficiency
what are the 2 dopamine pathways?
mesocorticolimbic
nigrostriatal
what dopamine pathway is useful for antipsychotic drugs?
mesocorticolimbic
what dopamine pathway has extrapyramidal side effects?
nigrostriatal
what 5 functions does the DM pathway control?
reward (motivation) pleasure/euphoria motor fxn compulsion perseveration
what 4 functions does the serotonin pathway control?
mood
memory processing
sleep
cognition
what are the 4 commonly used 1st gen antipsychotics?
fluphenazine/Prolixin
perphenazine/Trilafon
trifluoperazine/Stelazine
haloperidol/Haldol
what 2 1st gen antipsychotics have depot formulations?
fluphenazine/Prolixin
haloperidol/Haldol
what are the 2nd gen antipsychotics (there are 9)?
aripiprazole/Abilify olanzapine/Zyprexa quetiapine/Seroquel risperidone/Risperdal ziprasidone/Geodon iloperidone/Fanapt asenapine/Saphris paliperidone/Invega lurasidone/Latuda (AOQRZIAPL)
T/F: all of the 2nd gen antipsychotics are superior to 1st gen
FALSE
no superiority est for negative sx
which 2nd gen antipsychotics have depot formulations?
aripiprazole/Abilify
olanzapine/Zyprexa
risperidone/Risperdal
paliperidone/Invega
do 2nd gen antipsychotics have a risk of extrapyramidal side effects?
yes
varies by drug
dose related
do antipsychotics undergo a linear dose response?
partly
there’s a linear range containing the ED50
then there’s a near-maximal effective dose range
then a plateau
what are the side effects of 1st gen antipsychotics?
extrapyramidal side FX
orthostatic hypotension
liver probs
neuroleptic malignant syndrome
what is neuroleptic malignant syndrome?
adverse drug rxn muscle rigidity fever autonomic instability cognitive changes like delirium elevated plasma creatine phosphokinase
what is the primary problem w/ 2nd gen antipsychotics?
metabolic side effects
weight gain
diabetes (w/ or w/o weight gain)
which 3 2nd gen antipsychotics have extrapyramidal sx?
risperidone (esp w/ high doses)
geodon
abilify
which 2 2nd gen antipsychotics can cause akathisia?
abilify & geodon
what is akathisia?
the inability to be still
what is Clozapine?
a drug in a class all its own w/ superior efficacy but it's hard to use
what are the side effects of Clozapine?
agranulocytosis sustained tachycardia weight gain orthostatic hypotension hypersalivation sedation
is the agranulocytosis w/ Clozapine permanent?
no it’s reversible
when does agranulocytosis w/ Clozapine occur?
in the 1st year of taking the drug
how many people that take clozapine experience agranulocytosis?
1% (w/i the 1st year)
what are some extrapyramidal side effects?
rigidity tremor bradykinesia hypersalivation neuroleptic malignant syndrome akathisia
what is the treatment for extrapyramidal sx d/t antipsychotics?
decrease dose
change meds
anticholinergic drugs
amantadine
what is the treatment for akathisia as a side effect of antipsychotics?
change meds
beta blockers > propranalol
MAYBES
high dose B6
clonazepam
what are the anticholinergic drugs you can give for extrapyramidal symptoms?
diphenhydramine/Benadryl
trihexiphenidyl/Artane
benztropine/Cogentin
what drugs do not work for akathisia?
anticholinergics
why do pts discontinue their antipsychotics?
intolerable side effects
inadequate sx control
“other”
what is tardive dyskinesia?
syndrome of involuntary choreo-athetoid movements
involuntary repetitive movements w/ belated onset
what can cause tardive dyskinesia (generally)?
1st gen antipsychotics
what can increase the risk of tardive dyskinesia?
other extrapyramidal side FX
T/F: tardive dyskinesia only affects the mouth & lips
FALSE
is tardive dyskinesia dose or time related?
BOTH
who is at greatest risk for developing tardive dyskinesia? (race, gender)
male, african american
what can happen if you stop the meds causing tardive dyskinesia?
it might worsen
or it might resolve
which has the higher risk of developing tardive dyskinesia: haloperidol vs. olanzapine
haloperidol (risk = 7.45%)
olanzapine risk = 0.52%
at 1 yr
which antipsychotic drug has the greatest weight gain?
clozapine (nearly tied w/ olanzapine)
which antipsychotics have the lowest weight gain?
moban (weight loss)
geodon
what can you do to treat weight gain d/t antipsychotics?
change meds decrease dose exercise nutritional counseling metformin
what side effects can D2 receptor drugs cause?
EPS
elevated prolactin
what side effects can muscarine receptor drugs cause?
cognitive deficits dry mouth constipation inc HR urinary retention blurred vision
what side effects can histamine receptor drugs cause?
sedation
weight gain
dizziness
what side effects can alpha 1 receptor drugs cause?
hypotension
what side effects can serotonin (5-HT2C) receptor drugs cause?
satiety blockade
what side effects can serotonin (5-HT2A) receptor drugs cause?
maybe anti-EPS
what is the QT interval?
time btwn start of Q wave & end of T wave in an EKG
what is happening in the heart during the QT interval?
electrical depolarizaiton & repolarization of the ventricles
what is prolonged QT a risk factor for?
ventricular tachyarrhythmias (esp torsades de pointes) sudden death
what does the normal QT interval depend on?
heart rate
what is QTc?
corrected QT interval
what does QTc estimate QT interval at? (what HR)
60 bpm
what is NORMAL QT?
less than or equal to 400ms (some debate)
what is abnormal QT for males?
<450 ms
what is abnormal QT for females?
<470ms
what is borderline QT for males?
431-450 ms
what is borderline QT for females?
451-470 ms
when is a pt at risk for sudden death d/t QT?
at borderline or abnormal QT (diff for males vs females)
what are the 4 most important risk factors for increased QTc?
hypokalemia
hypomagnesemia
hypocalcemia
meds
what is the avg QT prolongation for risperidone?
4 ms
what is the avg QT prolongation for thioridazine?
30 ms
what are the common behavioral probs in dementia?
psychosis
agitation
suspiciousness
irritability
what meds should you treat dementia behavioral probs with?
antipsychotics & benzos short term (dangerous & ineffective long term)
what side effects might benzos have w/ behavioral probs in dementia?
increased confusion
falls (d/t sedation)
what should your first step be in managing behavioral probs w/ dementia?
psychosocial interventions esp managing env cues (social interactions)
what is the black box warning you should be worried about w/ pts w/ dementia?
increased mortality in elderly pts w/ dementia-related psychosis
which drug is NOT approved for tx of pts w/ dementia-related psychosis?
zyprexa
what drugs can you use for pts w/ dementia-related psychosis?
citalopram
risperidone
T/F: citalopram & risperidone work for dementia-related psychosis immediately
false
takes some time to work
T/F: citalopram & risperidone may not work in pts w/ vascular dementia
true
what increases risk of drug-induced long QT & arrhythmia propensity?
pts w/... hypokalemia abn T wave morphology Hep C virus infection HIV infection
