Kirkpatrick > Antipsychotics Flashcards by Rhonda Mittenzwei

what are the 4 appropriate uses for antipsychotics?

psychosis
non-psychotic mania
autism
adjunct to antidepressants

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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)

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do all pts respond to antipsychotics?

nope

responses are variable, some don’t respond at all

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what 3 things can transiently increase psychotic symptoms?

NMDA antagonist (ketamine)
serotonin agonist (MCPP)
cannabis

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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

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what are the 2 dopamine pathways?

mesocorticolimbic

nigrostriatal

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what dopamine pathway is useful for antipsychotic drugs?

mesocorticolimbic

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what dopamine pathway has extrapyramidal side effects?

nigrostriatal

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what 5 functions does the DM pathway control?

reward (motivation)
pleasure/euphoria
motor fxn
compulsion
perseveration

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what 4 functions does the serotonin pathway control?

mood
memory processing
sleep
cognition

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what are the 4 commonly used 1st gen antipsychotics?

fluphenazine/Prolixin
perphenazine/Trilafon
trifluoperazine/Stelazine
haloperidol/Haldol

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what 2 1st gen antipsychotics have depot formulations?

fluphenazine/Prolixin

haloperidol/Haldol

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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)

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T/F: all of the 2nd gen antipsychotics are superior to 1st gen

FALSE

no superiority est for negative sx

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which 2nd gen antipsychotics have depot formulations?

aripiprazole/Abilify
olanzapine/Zyprexa
risperidone/Risperdal
paliperidone/Invega

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do 2nd gen antipsychotics have a risk of extrapyramidal side effects?

yes
varies by drug
dose related

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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

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what are the side effects of 1st gen antipsychotics?

extrapyramidal side FX
orthostatic hypotension
liver probs
neuroleptic malignant syndrome

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what is neuroleptic malignant syndrome?

adverse drug rxn
muscle rigidity
fever
autonomic instability
cognitive changes like delirium
elevated plasma creatine phosphokinase

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what is the primary problem w/ 2nd gen antipsychotics?

metabolic side effects
weight gain
diabetes (w/ or w/o weight gain)

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which 3 2nd gen antipsychotics have extrapyramidal sx?

risperidone (esp w/ high doses)
geodon
abilify

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which 2 2nd gen antipsychotics can cause akathisia?

abilify & geodon

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what is akathisia?

the inability to be still

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what is Clozapine?

a drug in a class all its own w/ superior efficacy 
but it's hard to use

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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 ```