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PR3136 CA2 > L12 Schizophrenia > Flashcards

L12 Schizophrenia Flashcards

1
Q

subsidised schizo drugs

A
  • older gen
  • resperidone: v potent and effective
  • olanzapine
  • clozapine
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2
Q

is aripiprazole subsidised?

A

no!

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3
Q

diagnoses with assoc psychotic sx

A

organic disorders (iatrogenic causes, psychosis related to alc and psychoactive substance misuse), affective disorders presenting w psychotic sx, schizophrenia (schizotypal personality disorder or delusional disorder)

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4
Q

quetiapine

A

very weak dopamine antagonist, can be used for psychotic sx a/w PD - will not worsen PD sx so much

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5
Q

etiology of schizophrenia

A
  • predisposing: genetics, neurodevelopmental effects
  • precipitating: drugs
  • perpetuating: lack of support, poor adherance w antipsychotic medications
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6
Q

CBT is recommended for

A
  • preventing psychosis in ‘at risk’ group; refer to psychiatrist if a person has transient/attenuated psychotic sx causing distress/impairment
  • first episode psychosis: assess for ptsd
  • schizophrenia
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7
Q

ECT is recommended for

A
  • reserved for tx-resistent schizophrenia, esp catatonic sx
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8
Q

psychosocial rehabilitation program: vocational shelter

A

employment, rehabilitation

- improve pt’s adaptive functioning

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9
Q

What must you assess prior to schizophrenia diagnosis and tx?

A

MSE: suicidal/homicidal ideations and risks

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10
Q

accurate diagnosis of schizophrenia include exclusion that the disorder is due to

A

medical disorder or substance abuse

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11
Q

DSM-5 criteria:

A

2 or more of the following, each persisting for a significant portion of at least 1 month:

  • delusions
  • hallucinations
  • disorganised speech
  • grossly disorganised or catatonic behavior
  • neg sx
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12
Q

signs of disorders must be

A

continuous, at least 6 months

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13
Q

therapeutic goals

A
  • minimise threat to self and others
  • minimise acute sx
  • prevent relapse
  • medication adherence
  • optimise dose vs adverse effects
  • improve functioning and QOL
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14
Q

in short term, antipsychotic medications are used to

A

calm disturbed patients

- whatever the underlying psychopathology which may be: schizophrenia, mania, toxic delirium, or agitated depression

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15
Q

antipsychotics for schizophrenia

A

relieve sx of psychosis such as thought disorder, delusions, hallucinations + prevent relapse:

  • less effective in apathetic withdrawn pts
  • pt w acute sx of schizophrenia generally respond better than those w chronic sx
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16
Q

antipsychotics for schizophrenia: acute or LT tx?

A

LT tx often necessary after the first ep of psychosis and prevent illness from becoming chronic

  • a pt who is maintaining well on an antipsychotic may relapse if tx is withdrawn inappropriately
  • psychotic sx may persisnt continuously in 5-15% of pt: poor response to FGA
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17
Q

relapse upon discontinuation of antipsychotics

A

often delayed for several weeks after cessation of tx

  • adipose tissue acts as depot reservoir after chronic regular usage of antipsychotics
  • antipsychotics stored in fat cells then diffuses back into bloodstream after tx cessation, until depletion
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18
Q

methods to overcome poor treatment adherance

A
  • IM LA inj
  • community psychiatric nurse: conduct home visits to pill count/adm meds
  • patient and family (caregiver) education: supervision/monitoring
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19
Q

the central dopamine systems is composed of the following 4 tracts

A
  1. mesolimbic
  2. mesocortical
  3. nigrostriatal
  4. tuberoinfundibular
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20
Q

antipsychotics

A

dopamine receptor antagonist

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21
Q

mesolimbic tract

A

blockade of dopamine receptors in this tract is probably the common MOA for all antipsychotics
- overactivity in this region is responsible for pos sx of schizophrenia

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22
Q

blockade of which dopamine tracts causes adverse effects?

A

mesocortical, nigrostriatal, tuberoinfundibular

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23
Q

tuburoinfundibular tract

A

dopamine blockage in this region of the anterior pituitary leads to hyperprolactinemia

  • unopposed secretion of prolactin into bloodstream
  • can cause osteoporesis, sexual dysfunction, gynaecomastia (painful)
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24
Q

mesocortical tract

A

responsible for higher-order thinking and executive functions
- dopamine blockade or hypofunction in this region results in neg sx (can sometimes manifest as depression, hard to differentiate)

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25
Q

nigrostriatal tract

A

modulates body movement

  • antipsychotic-induced dopamine blockade in this region causes EPS
  • rest tremor, cogwheel rigidity, oculogenic crisis (eyebrall rolling up), dyskinesia (involutary mvement of tongue or jaw, grimacing)
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26
Q

D2 antagonism effects

A
  • improve pos sx

- EPSE, hyperprolactinemia

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27
Q

5HT2a antagonism effects

A

antidepressant effects? improve neg sx? antipsychotic effects?

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28
Q

5HT2c antagonism effects

A

weight gain

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29
Q

H1 antagonism effects

A

sedation/weight gain

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30
Q

a1 antagonism

A

orthostasis (postural hypoTN), sedation

31
Q

M1 antagonism

A

memory dysfunction, peripheral anticholinergic effects (dry mouth, constipation - drugs given for hand tremors SE of antipsychotics eg benzhexol/benztropine)

32
Q

IKr antagonism

A

QTc interval prolongation (pro-arrhythmic)

  • may result in cardiac death
  • don’t start tx unless clear of indication and diagnosis
33
Q

what drug is used for tx-resistant schizo (failed more than 2 adequate trials of different antipsychotics, at least 1 should be a SGA)?

A

clozapine

- fbc monthly, w ANC

34
Q

medication selection is

A

individualised for a pt
- based on physician’s assessment of clinical circumstances, past response/failures on antipsychotics, patients needs, efficacy and side effect profiles of the therapy

35
Q

pt req compliance to an adequate trial of antipsychotic (excl clozapine) of _____ and ____ before being considered as ‘non-responders’ to the medication

A
  • at least 2-6 weeks

- at optimal therapeutic doses

36
Q

Examples of LA injectable antipsychotics

A
  • IM resperidone micropsheres
  • IM paliperidone prolonged release suspension
  • IM aripriprazole LAI
  • IM halperidol decanoate
  • IM fluphenthixol decanoate
  • IM zuclopenthixol decanoate
37
Q

pharmacological tx of schizo usually mono/multi therapy?

A

mono

38
Q

precautions to antipsychotic use, esp for clozapine

A

blood dyscrasis: infection (fever, cough, sore throat) is a risk factor

39
Q

precautions to antipsychotic use

A

cv disease, PD, PH, angle-closure glaucoma, severe respiratory disease, blood dyscrasias, elderly w dementia

40
Q

which fast-acting IM inj is most commonly used?

A

haloperidol decanoate, cheapest

41
Q

acute agitation - cooperative pt

A

lorazepam, risperidone

42
Q

acute agitation - uncooperative

A

im lorazepam, olanzapine, aripiprazole, haloperidol, promethazine
- can halo+lora too

43
Q

catatonia behaviours pharmaco tx`

A

benzodiazepines: po/im lorazepam

44
Q

which antipsychotics must be adm w food

A

lurasidone, ziprasidone

45
Q

which antipsychotics cannot be taken OD

A

chlorpromazine, clozapine, quetiapine

46
Q

SGA wo weight gain SE

A

ziprasidone, aripiprazole, brexipiprazole, lurasidone

- ‘-ones’ or ‘-piprazoles’: less sedating, less weight gain

47
Q

SGA w most weight gain SE

A

clozapine, olanzapine

- ‘-ines’: more sedaing, more weight gain

48
Q

how to manage dystonia SE from high potency antipsychotics?

A

IM anticholinergics eg benztropine, diphenhydramine (relax muscles)

49
Q

how to manage psuedo-parkinsonism SE for elderly female w previous neurological damage?

A
  • decr antipsychotic dose, or switch to SGA (quet,sulp)

- anticholinergic PRN eg benzhexol (aka trihexyphenidyl, some abuse potential) < benztropine (long acting)

50
Q

how to manage akathisia SE from high potency antipsychotics?

A
  • decr antipsychotic dose, or switch to SGA
  • clonazepam or lorazepam (low dose), prn
  • propranolol 20mg tds (max 160mg/d)
  • anticholinergics generally unhelpful
51
Q

how to manage tardive dyskinesia SE from FGA?

A
  • discontinue any anticholinergics
  • decr antipsychotic dose, or switch to SGA (clozapine possibly effective)
  • reversible inhibitor of vesicular monoamine transporter 2 (VMAT2): valbenazine 40-80mg/day
  • clonazepam prn
52
Q

how to manage hyperprolactinaemia SE from FGA?

A
  • decr FGA dose
  • dopamine agonist (eg. amantadine, bromocriptine)
  • switch to aripiprazole (partial agonist of d2 receptor, reverse effects a little)
53
Q

how to manage metabolic SE?

A
  • lifestyle modification - diet, exercise
  • treat diabetes eg w metformin
  • treat hyperlipidemia
  • switch to lower risk agents
54
Q

antipsychotics w high risk of metabolic SE

A

olan, cloz

55
Q

antipsychotics w low risk of metabolic SE

A

ari, lura, halo, brexi, zipra

56
Q

RVMT2 inhibitor

A

valbenzine, reversible

57
Q

switch to high potency antipsychotics for which SEs

A

VTE/PE, seizure

58
Q

NMS sx

A

muscle rigidity, fever, autonomic dysfunction (incr PR, labile BP, diaphoresis), altered cosnciousness, incr CK by 10,000s, lead-pipe rigidity

59
Q

NMS risk factors

A
  • high potency antipsychotics

- non compliant/abrupt stop of PD drugs, as if taking a sudden high potency of d2 block

60
Q

NMS tx

A
  • IV dantrolene 50mg TDS (smooth muscle relaxant)
  • oral dopamine agonist eg amantadine, bromocriptone
  • supportive measures
  • switch to SGA, w lower potency
61
Q

adj tx

A

benzo (agitation), antide (dep)

62
Q

daytime sedation SE mgmt

A
  • adm dose in early evening eg 7pm for sedation to wear off

- consolidate once-nightly dosing whenever possible (except cloz and quet)

63
Q

dizziness SE mgmt

A

rise up slowly from lying/sitting position (orthostatic hypotension)

64
Q

monitoring SE

A
  • weight gain: BMI, q3 months
  • DM: FPG, q3mths then annually
  • HLD: lipid pannel
  • hypo/hyperTN: BP, q3 months after initiation, then annually
  • EPSE: EPSE exam for rigidity,tremors,akathisia,tardive dyskinesia
  • leucopenia/agranulocytosis: WBC and ANC (cloz), weekly for first 18 weeks, then monthly
65
Q

pregnancy

A

ola, cloz: watch for gestational dm

66
Q

breastfeeding

A
  • olz, que: suitable

- pt on cloz should cont on drug and not breastfeed

67
Q

renal impairment

A
  • oral aripi preferred

- avoid sul, amisul

68
Q

hepatic impairment

A

sul,amisul preferred

69
Q

elderly

A
  • avoid drugs w high propensity for a1 adrenergic blockade (orthostatic hypoTN)
  • or anticholinergic SE (constipation, urinary retention, delirium)
  • start low, go slow
  • simplify regime
  • avoid adverse interactions
  • avoid long t1/2 drugs
  • precautions: FGAs and SGAs reported to incr mortality and CVAs in dementia pt
70
Q

when will we see improvements in decr paranoia, hallucinations, bizarre behaviours + improved organisation in thinking

A

2-4wks

71
Q

Antipsychotics effect threshold

A

60% D2 receptor blockade

72
Q

Prolactin threshold

A

70% D2 receptor blockade

73
Q

EPS threshold

A

80% D2 receptor blockade

PR3136 CA2 (5 decks)

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