Mngt Schizo - Concepts

Question 1

What are some causes to rule out when diagnosing schizophrenia

Answer 1

1. Iatrogenic causes

2. Alc and substance abuse

Question 2

Three broad etiological factors for schizophrenia and one example for each

Answer 2

1. Pre-disponsing: Genetics
2. Precipitating: Drugs, injury
3. Perpetuating: Poor adherence with antipsychotics, lack of support

Question 3

What is the general assessment of schizo similar to? What is the one important assessment to make?

Answer 3

Similar to depression

• Assess for suicidal/homicidal ideations and risks

Question 4

Name the most important non-pco tx for schizo and what is it applicable for

Answer 4

Individual Cognitive Behavioural Therapy (CBT): Used in conjunction with meds for:

1. Prevent psychosis for “at risk” group
2. Schizo
3. First episode psychosis

Question 5

List other non-pco tx in schizo

Answer 5

1. Psychosocial rehab programs to improve adaptive functioning containing:
   - Cognitive behavioural: CBT, compliance therapy
   - Individual: vocational sheltered
   - Group: Interactive/social skills
2. Neurostimulation: ECT, rTMS (last resort)

Question 6

What are the tx goals for ACUTE stabilisation

Answer 6

1. Minimise threat to self and others

2. Minimise acute sx

Question 7

What are the tx goals for STABILISATION

Answer 7

1. Prevent relapse
2. Promote adherence
3. Optimise dose vs AE

Question 8

What are the tx goals for Maintenance phase. Why is this phase the most important phase?

Answer 8

1. Improve functioning and QoL
2. Monitor for AE (E.g. tardive dysK)

Most impt phase coz Schizo is CHRONIC

Question 9

What are antipsychotic medications also known as, and what are their purpose?

Answer 9

“Neuroleptics”

Purpose: SHORT term, used to CALM disturbed patients, regardless of psychopathology
- E.g. SCHIZO, mania, toxic delirium, agitated depression

Question 10

Purpose of Antipsychotics in Schizophrenia

Answer 10

1. Relieve sx of psychosis

2. Prevent relapse (because relapse = more tx resist)

Question 11

Onset of Schizo Relapse that may occur after stopping antipsychotic tx, and what is the underlying mechanism?

Answer 11

Delayed for SEVERAL WEEKS after cessation, due to adipose depot after regular use of antipsychotics

Question 12

Why is long term tx for Schizo necessary?

Answer 12

1. Prevent illness from becoming chronic

2. Prevent relapse from withdrawn meds

Question 13

Should patient exhibit poor adherence to Pco tx of schizo, what are some methods to overcome it?

Answer 13

1. IM long-acting injections (dose every few weeks)
2. Community psychiatric nurse
3. Patient and family education

Question 14

Describe the four main tracts of central DA systems. Where do antipsychotics mainly act to give their THERAPEUTIC effect?

Answer 14

1. Mesolimbic Tract: DA blocked by antipsychotics here = less +ve sx
2. Mesocortical Tract: DA block = -ve Sx
3. Nigrostriatal tract: DA blocked = EPSE
4. Tuberoinfundibular Tract: DA block = hyperprolactinemia (Gynaecomastia in males)

Question 15

What are the OTHER receptors that Antipsychotics normally BLOCKS, and their associated SE?

Answer 15

1. 5HT-2C: Weight gain
2. 5HT-2A: Improved -ve sx???
3. MAH1 series
   - Muscarinic: Anti-M SE
   - Alpha 1: Orthostasis
   - Histamine: Sedation, weight gain
4. IKr: QTc prolongation

Question 16

General Tx algorithm for Schizo after the dx of Schizo

Answer 16

1. Use single FGA/SGA, except Cloz
2. Use ANOTHER SINGLE FGA/SGA, except cloz
3. CLOZ + Augmenting agent if required
4. Combination Therapy

Question 17

What are the things to assess for while using FGA/SGA according to the algorithm, before switching FGA/SGA or stepping up tx to Cloz/combi therapy?

Answer 17

1. Adequate response
2. No intolerable SE
3. Compliant

Question 18

The five main Pco Tx principles of Schizo (IMPORTANT)

Answer 18

1. INDIVIDUALISED: past response + efficacy + SE
2. ADEQUATE TRIALS = Compliant for 2-6 wks at OPTIMAL doses
3. INTOLERABLE SE: Try to MANAGE bef switching
4. LONG-ACTING INJ.: For non-compliance, or patient preference
5. CLOZ: if failed ≥2 aequate trials of different antipsychotics (tx-resistant schizo)
   - At least 1 SGA

Question 19

Serious AE of Cloz. What to monitor and how to manage?

Answer 19

Clozapine-induced Agranulocytosis

• Monitor: WBC and ANC weekly for first 18 weeks, then monthly
• Manage: Discontinue if severe

(note: ANC = Absolute neutrophil count)

Question 20

Precautions in some Comorbidities when using Antipsychotics

Answer 20

1. CVD - QTc prolongation
2. Blood Dyscrasias (IMPT!!)
3. Parkinson (EPSE worsened by antipsycho)
4. Elderly with DEMENTIA (Increased mortality/stroke)
5. Others: Prostatic hypertrophy, angle-closure glaucoma, severe resp disease

(Dyscrasias = abnormality)

Question 21

In an acute agitation of Schizo (i.e. psychiatric emergency), what are the tx options if patient is COOPERATIVE?

Answer 21

PO Lorazepam 1-2mg

Others: PO Risperidone 1-2mg (as it is very potent)

Question 22

In an acute agitation of Schizo (i.e. psychiatric emergency), what are the tx options if patient is NOT cooperative?

Answer 22

IM Lorazepam 1-2mg

Others (Fast acting antipsycho)

• IM Promethazine (Very sedating)
• IM Haloperidol/Olanzapine (Rapid-acting)

Question 23

In an acute agitation of Schizo (i.e. psychiatric emergency), that manifests as catatonia, what is the drug of choice?

Answer 23

BZD: PO/IM Lorazepam

Question 24

List the Purpose of adjunctive treatments in Schizo

Answer 24

1. Acute agitation
2. Catatonia
3. Depressive sx: SSRI OR Mirtazapine
4. -ve sx for CHRONIC Schizo

(Note: tx for -ve sx not confirmed)

Question 25

SGA(s) that are strongly associated with weight gain

Answer 25

1. Cloz | 2. Olan

Question 26

Irreversible EPSE of antipsychotic use and management options. Can anti-M be used?

Answer 26

``` Tardive dysK (FGA > SGA) - WORSENS with anti-M drugs ``` Management: 1. Discontinue anti-M 2. Decrease antipsycho dose or switch to SGA 3. Valbenazine 40-80mg/d 4. Clonazepam PRN

Question 27

Describe the EPSE that might occur from antipsycho use, and their onset

Answer 27

1. Dystonia: Muscle spasms, onset within mins-hrs 2. Akathisia: Restlessness, onset hrs to weeks 3. Peudo-parkinsonism: Tremors, Rigidity, bradykinesia onset within days to weeks 4. Tardive dysK: Orofacial movements, hand movements, pelvic thrusting. Onset months - years

Question 28

identify the possible reversible EPSE that can be caused by antipsycho, and their management strategies

Answer 28

1: Dystonia: IM Anti-M 2. Akathisia: - Reduce dose, or switch to SGA - Clonazepam low dose PRN (or Propranolol) 3. Pseudo-Parkinsonism - Reduce dose, or switch to SGA - Anti-M PRN

Question 29

Before administering anti-M for EPSE, what must be ruled out?

Answer 29

Rule out that EPSE is NOT Tardive dysK | anti-M worsens tardive dysK

Question 30

What are possible metabolic SE of Antipsycho, and what are the psychotics that are high and low risk for these metabolic SE?

Answer 30

SE: Weight gain, DM, HLD - High risk: Cloz, Olan - Low risk: Aripiprazole, Lurasidone, Brexipiprazole

Question 31

What are some possible ways to manage METABOLIC SE of antipsychotics?

Answer 31

1. Lifestyle modification: Diet and exercise 2. For DM and HLD: tx with drugs (E.g. Metformin for DM) 3. Switch to lower risk antipsycho (i. e. ari, lura)

Question 32

Describe Neuroleptic Malignant Syndrome. - What is its lab indicator? - What is the drug that has the highest risk of causing it?

Answer 32

Lead-pipe rigidity of muscles with high fever, fluctuating BP, tachycardia and sweating all due to muscle breakdown. - Lab indicator: Increased CK - High risk drug: IM Haloperidol (FAST ACTING AND POTENT)

Question 33

Management of neuroleptic malignant syndrome

Answer 33

IV Dantrolene 50mg TDS (emergency) + PO DA agonist as SUPPORT THEN, switch to SGA

Question 34

Main difference(s) between FGA and SGA? | i.e. advantages of SGA over FGA

Answer 34

1. EPSE: SGA < FGA 2. Hyperprolactinemia: SGA < FGA 3. SGA can improve mood on top of +ve sx (unlike FGA)

Question 35

List the monitoring parameters for SE of Antipsycho and the monitoring frequencies

Answer 35

1. BMI: q3m during STABLE phase 2. FBG/HbA1c: q3m after SGA initiation, then annually 3. BP: same as FBG 4. EPSE Exam: - Weekly for 1st two weeks after initiation till dose stabilised - Low risk patients: FGA q6m, SGA q12m - High risk patients: FGA q3m, SGA q12m

Question 36

Special precaution(s) when treating Schizo in Elderly

Answer 36

MAINLY: Avoid drugs with a1 block or anti-M SE Others - Simplify regime - Start low go slow

Question 37

Common drug classes that interact with antipsycho

Answer 37

1. CNS depressants (Excess CNS AE) 2. MAHD blockade (add AE) 3. DA-augmenting agents (antagonise antipsycho) 4. AntiHTN agents (Hypoten effects)

Question 38

Drugs that SHOULD NOT be used with Clozapine and why?

Answer 38

Carbamazepine: Can cause Agranulocytosis too (additive effect to Cloz-induced agranulocytosis)

Question 39

CYP1A2 inhibitors interact with which antipsycho? State: - The common 1A2 inhibitors - The antipsycho whose effect is potentiated

Answer 39

1A2: Fluvoxamine, Quinolones, Macrolides Antisychos: CLOZ, halo, Olan, Zip

Question 40

Describe the two main things to monitor in antipsycho tx

Answer 40

1. Effectiveness of therapy: MSE (not specific) | 2. AE: Metabolic params (Cloz, Olan ++), EPSE

Question 41

Onset of antipsycho tx

Answer 41

1. Early improvements: - 1st wk: less agitation - 2-4 wks: decreased paranoia and hallucinations 2. Late improvements: 6-12 wk, less delusions (-ve sx, hardest to treat)

Question 42

Disadvantage of SGA over FGA

Answer 42

Can cause metabolic SE

Question 43

SGA has "-ines" and the "-ones" and "piprazoles" What is one disadvantage over the "ines" compared to the others?

Answer 43

More sedating and Weight Gain