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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
nigrostriatal tract
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)
26
D2 antagonism effects
- improve pos sx | - EPSE, hyperprolactinemia
27
5HT2a antagonism effects
antidepressant effects? improve neg sx? antipsychotic effects?
28
5HT2c antagonism effects
weight gain
29
H1 antagonism effects
sedation/weight gain
30
a1 antagonism
orthostasis (postural hypoTN), sedation
31
M1 antagonism
memory dysfunction, peripheral anticholinergic effects (dry mouth, constipation - drugs given for hand tremors SE of antipsychotics eg benzhexol/benztropine)
32
IKr antagonism
QTc interval prolongation (pro-arrhythmic) - may result in cardiac death - don't start tx unless clear of indication and diagnosis
33
what drug is used for tx-resistant schizo (failed more than 2 adequate trials of different antipsychotics, at least 1 should be a SGA)?
clozapine | - fbc monthly, w ANC
34
medication selection is
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
pt req compliance to an adequate trial of antipsychotic (excl clozapine) of _____ and ____ before being considered as 'non-responders' to the medication
- at least 2-6 weeks | - at optimal therapeutic doses
36
Examples of LA injectable antipsychotics
- IM resperidone micropsheres - IM paliperidone prolonged release suspension - IM aripriprazole LAI - IM halperidol decanoate - IM fluphenthixol decanoate - IM zuclopenthixol decanoate
37
pharmacological tx of schizo usually mono/multi therapy?
mono
38
precautions to antipsychotic use, esp for clozapine
blood dyscrasis: infection (fever, cough, sore throat) is a risk factor
39
precautions to antipsychotic use
cv disease, PD, PH, angle-closure glaucoma, severe respiratory disease, blood dyscrasias, elderly w dementia
40
which fast-acting IM inj is most commonly used?
haloperidol decanoate, cheapest
41
acute agitation - cooperative pt
lorazepam, risperidone
42
acute agitation - uncooperative
im lorazepam, olanzapine, aripiprazole, haloperidol, promethazine - can halo+lora too
43
catatonia behaviours pharmaco tx`
benzodiazepines: po/im lorazepam
44
which antipsychotics must be adm w food
lurasidone, ziprasidone
45
which antipsychotics cannot be taken OD
chlorpromazine, clozapine, quetiapine
46
SGA wo weight gain SE
ziprasidone, aripiprazole, brexipiprazole, lurasidone | - '-ones' or '-piprazoles': less sedating, less weight gain
47
SGA w most weight gain SE
clozapine, olanzapine | - '-ines': more sedaing, more weight gain
48
how to manage dystonia SE from high potency antipsychotics?
IM anticholinergics eg benztropine, diphenhydramine (relax muscles)
49
how to manage psuedo-parkinsonism SE for elderly female w previous neurological damage?
- decr antipsychotic dose, or switch to SGA (quet,sulp) | - anticholinergic PRN eg benzhexol (aka trihexyphenidyl, some abuse potential) < benztropine (long acting)
50
how to manage akathisia SE from high potency antipsychotics?
- decr antipsychotic dose, or switch to SGA - clonazepam or lorazepam (low dose), prn - propranolol 20mg tds (max 160mg/d) - anticholinergics generally unhelpful
51
how to manage tardive dyskinesia SE from FGA?
- 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
how to manage hyperprolactinaemia SE from FGA?
- decr FGA dose - dopamine agonist (eg. amantadine, bromocriptine) - switch to aripiprazole (partial agonist of d2 receptor, reverse effects a little)
53
how to manage metabolic SE?
- lifestyle modification - diet, exercise - treat diabetes eg w metformin - treat hyperlipidemia - switch to lower risk agents
54
antipsychotics w high risk of metabolic SE
olan, cloz
55
antipsychotics w low risk of metabolic SE
ari, lura, halo, brexi, zipra
56
RVMT2 inhibitor
valbenzine, reversible
57
switch to high potency antipsychotics for which SEs
VTE/PE, seizure
58
NMS sx
muscle rigidity, fever, autonomic dysfunction (incr PR, labile BP, diaphoresis), altered cosnciousness, incr CK by 10,000s, lead-pipe rigidity
59
NMS risk factors
- high potency antipsychotics | - non compliant/abrupt stop of PD drugs, as if taking a sudden high potency of d2 block
60
NMS tx
- IV dantrolene 50mg TDS (smooth muscle relaxant) - oral dopamine agonist eg amantadine, bromocriptone - supportive measures - switch to SGA, w lower potency
61
adj tx
benzo (agitation), antide (dep)
62
daytime sedation SE mgmt
- adm dose in early evening eg 7pm for sedation to wear off | - consolidate once-nightly dosing whenever possible (except cloz and quet)
63
dizziness SE mgmt
rise up slowly from lying/sitting position (orthostatic hypotension)
64
monitoring SE
- 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
pregnancy
ola, cloz: watch for gestational dm
66
breastfeeding
- olz, que: suitable | - pt on cloz should cont on drug and not breastfeed
67
renal impairment
- oral aripi preferred | - avoid sul, amisul
68
hepatic impairment
sul,amisul preferred
69
elderly
- 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
when will we see improvements in decr paranoia, hallucinations, bizarre behaviours + improved organisation in thinking
2-4wks
71
Antipsychotics effect threshold
60% D2 receptor blockade
72
Prolactin threshold
70% D2 receptor blockade
73
EPS threshold
80% D2 receptor blockade

PR3136 CA2 (5 decks)

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