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Therapeutics IV > Mngt Schizo - Concepts > Flashcards

Mngt Schizo - Concepts Flashcards

1
Q

What are some causes to rule out when diagnosing schizophrenia

A
  1. Iatrogenic causes

2. Alc and substance abuse

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2
Q

Three broad etiological factors for schizophrenia and one example for each

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

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

A

Similar to depression

  • Assess for suicidal/homicidal ideations and risks
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4
Q

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

A

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

  1. Prevent psychosis for “at risk” group
  2. Schizo
  3. First episode psychosis
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5
Q

List other non-pco tx in schizo

A
  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)
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6
Q

What are the tx goals for ACUTE stabilisation

A
  1. Minimise threat to self and others

2. Minimise acute sx

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7
Q

What are the tx goals for STABILISATION

A
  1. Prevent relapse
  2. Promote adherence
  3. Optimise dose vs AE
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8
Q

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

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

Most impt phase coz Schizo is CHRONIC

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9
Q

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

A

“Neuroleptics”

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

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10
Q

Purpose of Antipsychotics in Schizophrenia

A
  1. Relieve sx of psychosis

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

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11
Q

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

A

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

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12
Q

Why is long term tx for Schizo necessary?

A
  1. Prevent illness from becoming chronic

2. Prevent relapse from withdrawn meds

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13
Q

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

A
  1. IM long-acting injections (dose every few weeks)
  2. Community psychiatric nurse
  3. Patient and family education
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14
Q

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

A
  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)
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15
Q

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

A
  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
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16
Q

General Tx algorithm for Schizo after the dx of Schizo

A
  1. Use single FGA/SGA, except Cloz
  2. Use ANOTHER SINGLE FGA/SGA, except cloz
  3. CLOZ + Augmenting agent if required
  4. Combination Therapy
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17
Q

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?

A
  1. Adequate response
  2. No intolerable SE
  3. Compliant
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18
Q

The five main Pco Tx principles of Schizo (IMPORTANT)

A
  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
19
Q

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

A

Clozapine-induced Agranulocytosis

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

(note: ANC = Absolute neutrophil count)

20
Q

Precautions in some Comorbidities when using Antipsychotics

A
  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)

21
Q

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

A

PO Lorazepam 1-2mg

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

22
Q

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

A

IM Lorazepam 1-2mg

Others (Fast acting antipsycho)

  • IM Promethazine (Very sedating)
  • IM Haloperidol/Olanzapine (Rapid-acting)
23
Q

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

A

BZD: PO/IM Lorazepam

24
Q

List the Purpose of adjunctive treatments in Schizo

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

(Note: tx for -ve sx not confirmed)

25
Q

SGA(s) that are strongly associated with weight gain

A
  1. Cloz

2. Olan

26
Q

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

A 
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
27
Q

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

A
  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
28
Q

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

A

1: Dystonia: IM Anti-M

  1. Akathisia:
    - Reduce dose, or switch to SGA
    - Clonazepam low dose PRN (or Propranolol)
  2. Pseudo-Parkinsonism
    - Reduce dose, or switch to SGA
    - Anti-M PRN
29
Q

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

A

Rule out that EPSE is NOT Tardive dysK

anti-M worsens tardive dysK

30
Q

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

A

SE: Weight gain, DM, HLD

  • High risk: Cloz, Olan
  • Low risk: Aripiprazole, Lurasidone, Brexipiprazole
31
Q

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

A
  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)
32
Q

Describe Neuroleptic Malignant Syndrome.

  • What is its lab indicator?
  • What is the drug that has the highest risk of causing it?
A

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)
33
Q

Management of neuroleptic malignant syndrome

A

IV Dantrolene 50mg TDS (emergency) + PO DA agonist as SUPPORT

THEN, switch to SGA

34
Q

Main difference(s) between FGA and SGA?

i.e. advantages of SGA over FGA

A
  1. EPSE: SGA < FGA
  2. Hyperprolactinemia: SGA < FGA
  3. SGA can improve mood on top of +ve sx (unlike FGA)
35
Q

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

A
  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
36
Q

Special precaution(s) when treating Schizo in Elderly

A

MAINLY: Avoid drugs with a1 block or anti-M SE

Others

  • Simplify regime
  • Start low go slow
37
Q

Common drug classes that interact with antipsycho

A
  1. CNS depressants (Excess CNS AE)
  2. MAHD blockade (add AE)
  3. DA-augmenting agents (antagonise antipsycho)
  4. AntiHTN agents (Hypoten effects)
38
Q

Drugs that SHOULD NOT be used with Clozapine and why?

A

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

39
Q

CYP1A2 inhibitors interact with which antipsycho? State:

  • The common 1A2 inhibitors
  • The antipsycho whose effect is potentiated
A

1A2: Fluvoxamine, Quinolones, Macrolides

Antisychos: CLOZ, halo, Olan, Zip

40
Q

Describe the two main things to monitor in antipsycho tx

A
  1. Effectiveness of therapy: MSE (not specific)

2. AE: Metabolic params (Cloz, Olan ++), EPSE

41
Q

Onset of antipsycho tx

A
  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)
42
Q

Disadvantage of SGA over FGA

A

Can cause metabolic SE

43
Q

SGA has “-ines” and the “-ones” and “piprazoles”

What is one disadvantage over the “ines” compared to the others?

A

More sedating and Weight Gain

Therapeutics IV (9 decks)

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