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therapeutics 3 - exam 4 > lecture 54.57 > Flashcards

lecture 54.57 Flashcards

ott - pharmacotherapy of schizophrenia and psychotic disorders

1
Q

what are the key features to define psychotic disorders?

A

delusions
hallucinations
disorganized thinking and speech
disorganized or abnormal motor behavior
negative symptoms

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2
Q

what is the difference between delusions and hallucinations?

A

delusion - fixed false beliefs that are not amenable to change event with conflicting evidence
hallucinations - perception like experience that occur without an external stimulus

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3
Q

when does SZ normally appear?

A

in general –> onset late adolescence to early adulthood
men –> late teens, early 20s
women –> late 20s, early 30s

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4
Q

how is smoking linked to SZ?

A

associated with induction of 1A2 (not due to nicotine)
hydrocarbons that are produced and inhaled decrease the serum concentration of 1A2 substrate antipsychotics (olanzapine, asenapine, clozapine, and loxapine)

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5
Q

what substances can effect SZ?

A

marijuana, cocaine, and amphetamine
hasten the onset, exacerbate symptoms, and reduce time to relapse

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6
Q

for pts with SUD and SZ, what should be done?

A

pt should have mental health treatment at the same time as SZ treatment

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7
Q

what needs to be considered when choosing an antipsychotics?

A

doses per day
SE
previous drug therapy (success/failure, family hx)
cost of drug therapy (consider PO or IM)
concomitant drug therapy
need for monitoring (labs, weight, ECG)

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8
Q

what dosage form should be considered for antipsychotics?

A

PO is first-line unless pt presents with reasons to consider IM depot drug therapy first

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9
Q

what are the characteristics of typical antipsychotics?

A

older agents
primarily D2 receptor antagonists
efficacy for positive symptoms similar to atypical (likely to worsen negative/cognitive symptoms)
more EPS with higher potency typical

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10
Q

what drug is the most commonly used typical antipsychotics?

A

haloperidol
both PRN and routine

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11
Q

what are the characteristics of partial agonist?

A

stabilize dopamine transmission
associated with more akathisia than other antipsychotics
approved for adj treatment in depression (BW of suicidal thoughts/behaviors)

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12
Q

what drugs are partial agonists?

A

aripiprazole (abilify)
brexpiprazole (rexulti)
cariprazine (vraylar)

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13
Q

what are the CP of partial agonists?

A

substrate 3A4 (all), 2D6 (Abilify/Rexulti only)
moderate akathisia
low (abilify), low-moderate (rexulti/vraylar) weight gain

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14
Q

what are the CP of asenapine (saphris)?

A

sublingual and patch formulations
1A2 substrate
Qtc prolongation

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15
Q

what are the CP of clozapine (clozaril)?

A

1A2 substrate
QTc prolongation
SE – sedation, weight gain, Constipation, hypersalivation, dry mouth, GI hypomotility with obstruction risk

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16
Q

what are the BW of clozapine (Clozaril)?

A

neutropenia
orthostasis
bradycardia
syncope
seizures
myocarditis
cardiomyopathy

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17
Q

what are the CP of olanzapine (zyprexa)?

A

1A2 substrate
significant weight gain and sedation
high risk metabolic syndrome
DRESS warning

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18
Q

what are the CP of quetiapine (seroquel)?

A

3A4 substrate
Qtc prolongation
weight gain and sedation
BW – suicidal ideation

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19
Q

what are the specific CP of the transdermal patch formulation of asenapine?

A

1q24h, rotate patch to minimize application site rxn
warnings for Qtc prolongation
UGT and 1a2 substrate (reduce dose of patch if given with strong 1A2 inhibitors like fluvoxamine)

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20
Q

when should clozapine REMS be monitored?

A

weekly for 6 months, then biweekly for 6 months, then every 4 weeks

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21
Q

what is the purpose of samidorphan in the combination product lybalvi with olanzapine?

A

added to mitigate weight gain and metabolic syndrome potential of olanzapine
opioid antagonist with preferential activity at the mu opioid receptor

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22
Q

what are the CP of iloperidone (fanapt)?

A

high risk for orthostasis and syncope
QTc prolongation
2D6 substrate

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23
Q

what are the CP of lurasidone (latuda)?

A

3A4 substrate
higher risk for akathisia
warning for suicidal thoughts (adj for bipolar depression)
take with food (350 calories) to icnrease bioavailability

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24
Q

what are the CP of ziprasidone (geodon)?

A

QTc prolongation (contraindication)
DRESS warning
take WF to increase absorption and bioavailability
3A4 substrate (1/3) and aldehyde oxidase (2/3) – less worry for P450 interactions

25
what are the CP of risperidone (risperdal)?
2D6 substrate (minor 3A4 substrate) EPS, hyperprolactinemia, weight gain, sedation, orthostasis
26
what are the CP of paliperidone (invega)?
renally eliminated - dose adjustment in renal impairment similar SE of risperidone QTc prolongation
27
what are the CP of lumateperone (caplyta)?
low risk for weight gain or metabolic SE low risk for EPS or akathisia 3A4 substrate
28
what are the CP of pimavanserin (nuplazid)?
approved for tx of hallucinations or delusions in parkinson's disease MOA - inverse agonist and antagonist at the 5HT2a receptor 3A4 substrate
29
what are the CP of xanomeline/trospium (cobenfy)?
moa -- M1/M4 agonist 2D6 substrate baseline and continued monitoring of LFTs, heart rate
30
what is the boxed warning for all antipsychotics?
increased risk of death in elderly pts treat with antipsychotics for dementia with related behaviors
31
what are the warnings of all antipsychotics?
metabolic AE EPS risk of somnolence, postural hypotension, and motor/sensory instability increase risk of fall/fractures
32
how is haloperidol decanoate dosed?
given every 4 weeks load: 20x oral dose maintenance: 10x oral dose (may need to oral overlap if only use maintenance) oil-based Z track
33
how is risperdal consta (risperidone) dosed?
must supplement with oral risperidone (or another oral antipsychotic) for the first few weeks of treatment (usually until 3rd injection/week 4)
34
how is perseris (risperidone) dosed?
abdominal SQ injection when used with 3a4 inducer, use 120 mg dose or may need oral supplementation
35
how is rykindo (risperidone) dosed?
every 2 week IM injection oral overlap needed (7 days) but less than risperdal consta (which is 21)
36
how is uzedy (risperidone) dosed?
abdominal or upper arm SQ injection given once monthly or every 2 months
37
how is invega sustenna (paliperidone) dosed?
loading dose then booster, then every 4 weeks (Starting 5 weeks after loading injection) loading and booster given in deltoid to improve absorption consistency if loading strategy followed, no need for oral overlap may require dose adjustments in moderate to severe renal impairment
38
how is invega trinza dosed (paliperidone q3mo)?
may be initiated for a pt who has been on a stable monthly (every 4 weeks) IM injection of invega sustenna (only way that is should be used) at least 4 stable invega sustenna doses recommended to be given delotoid (gluteal administrations results in a lower Cmax) not recommended if CrCl under 50 mL/min
39
what is the dosing of invega hafyera (paliperidone q6mo)?
may be initiated afte rstable invega sustenna for 4 months or stable invega trinza after 1 3 month dose gluteal injection only
40
what is the SE of zyprexa relprevv (olanzapine)?
REMS (Risk Evaluation Mitigation Strategy) PDSS (Post-dose delirium sedation syndrome)
41
how is abilify maintena (aripiprazole) dosed?
must overlap with oral aripiprazole (or another oral antipsychotic) for at least 14 dayas after first injection deltoid or gluteal injection
42
how should abilify maintena be adjusted when taking another p450 medication?
if taking strong CYP 2D6 or 3A4 --> 300mg / 200 mg if taking CYP 2D6 and 3A4 --> 200 mg / 160 mg
43
how should abilify asimtufii be dosed?
every 2 month gluteal injection only continue oral aripiprazole for 2 weeks after first injection
44
how should aristada (aripiprazole lauroxil) be dosed?
overlap with oral aripiprazole for 3 weeks after first injection unless aristada initio given first
45
how should aristada initio be dosed?
developed to avoid need for 21-day oral overlap of antipsychotic avoid in pts who are 2D6 poor metabolizer or with strong 3A4/2D6 inhibitors
46
what drugs are used as IR antipsychotic injections or psychiatric emergencies?
haloperidol (most common) chlorpromazine fluphenazine loxapine for inhalation (adasuve)
47
what are the. CP of olanzapine IR IM?
cannot be given at same time as benzodiazepine IR injection due to BW of respiratory depression
48
how should acute dystonia (EPS) be treated?
IM anticholinergic NOW dose benztropine 2 mg, diphenhydramine 50 mg
49
how is drug-induced parkinson (EPS) be treated?
oral anticholinergic (benztropine, trihexyphenidyl, diphenhydramine)
50
how is akathisia (EPS) be treated?
beta blocker (preferable propranolol) benzodiazepine (usually lorazepam)
51
how is tardive dyskinesia (EPS) be treated?
VMAT inhibitors
52
what drugs are VMAT inhibitors?
tetrabenazine (xenazine) valbenazine (ingrezza) deutetrabenazine (austedo)
53
what are the common CP of VMAT inhibitors (not xenazine)?
2D6 (both), 3A4 (V only) QTc prolongation
54
what is associated with neuroleptic malignant syndrome?
life threatening medical emergy hyperpyrexia, tachycardia, labile BP muscle rigidity (elevated CK, myoglobinuria)
55
how should neuroleptic malignant syndrome be treated?
use supportive therapy (like d/c antipsychotics) future antipsych use is allowed
56
what are examples of metabolic adverse effects?
hyperglycemia hyperlipidemia hypertension
57
what are the chances of metabolic AE in each drug?
clozapine = olanzapine > quetiapine = risperidone = paliperidone = asenapine = iloperidone = cariprazine = brexpiprazole > ziprasidone = lurasidone = aripiprazole
58
what are the monitoring parameters for metabolic monitoring?
personal/family history (baseline/yearly) weight (B, 4w, 8w, 12w, 3m) waist circumference (B, Y) BP, FPG, A1c (B, 12w, Y) Fasting Lipids (B, 12w, 5y)

therapeutics 3 - exam 4 (13 decks)

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