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Psychiatry > Pharm - from Toronto Notes > Flashcards

Pharm - from Toronto Notes Flashcards

1
Q

antipsychotic MOA

A

block dopamine activity in target brain pathways

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2
Q

neuroleptic

A

old name for antipsychotic

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3
Q

antipsychotics indicated for

A

psychotic symptoms!

  • schizophrenia & related
  • manic or depressive episodes
  • substance use
  • medical condition (eg neoplasm)
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4
Q

non-psychosis uses of antipsychotics - conditions

A
  • treatment-resistant MDD
  • severe GAD
  • complex PTSD
  • severe OCD
  • borderline PD
  • behavioural Sx of dementia
  • delirium
  • tic disorder
  • substance abuse in dual Dx
  • Huntington’s disease
  • pervasive developmental disorders
  • impulse control disorders
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5
Q

non-psychosis uses of antipsychotics - symptoms

A

adjunctive for:

  • agitation
  • aggression
  • severe anxiety
  • sleep difficulties when sedative-hypnotics are contraindicated
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6
Q

onset of antipsychotics

A
  • immediate decrease in agitation, calming effect

- 1-4w for thought disorder response

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7
Q

choosing an antipsychotic

A
  • no reason to combine
  • all comparably effective (except: clozapine most effective in treatment-refractory psychosis)
  • 2nd gen antipsychotics as effective as 1st gen, but different a/e profile: mainly lower risk of EPS and TD
  • choose a drug pt or family member has responded to 1st
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8
Q

when to switch antipsychotics

A

if no response in 4-6w, switch drugs

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9
Q

Emergency Treatment of Acute Psychosis - drugs & dosing

A
  • haloperidol 5mg IM ± lorazepam 2mg IM
  • loxapine 25mg ± lorazepam 2mg IM
  • olanzapine 2.5-10 mg PO/IM/quick dissolve
  • risperidone 2mg (M-tab, liquid)
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10
Q

Dopamine pathways affected by antipsychotics

A

Mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular

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11
Q

Mesolimbic pathway

A

dopamine pathway; involved in emotion origination, reward; high dopamine causes delusions, hallucinations (+ sx of schizophrenia)

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12
Q

Mesocortical pathway

A

Dopamine pathway; involved in cognition, executive function; low dopamine causes negative Sx of schizophrenia

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13
Q

Nigrostriatal pathway

A

Dopamine pathway; involved in movement; low dopamine causes EPS (think Parkinson)

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14
Q

Tuberoinfundibular

A

Dopamine pathway; involved in prolactin hormone release; low dopamine causes hyperprolactinemia (–> gynecomastia, galactorrhea)

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15
Q

1st Gen Antipsychotics: MOA, Pros, Cons

A

MOA: Block postsynaptic D2 receptors
Pros: Inexpensive, many injectables available
Cons: EPS, tardive syndromes, not mood stabilizing

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16
Q

2nd Gen Antipsychotics: MOA, Pros, Cons

A

MOA:
- block postsynaptic D2 receptors
- Block serotonin (5-HT2) receptors on presynaptic dopaminergic terminals –> dopamine release; also –> reverses dopamine blockade in some pathways
Pros: Fewer EPS, low risk of tardive syndromes, mood stabilizing effects
Cons: Expensive. Few injectables. Metabolic side effects. Exacerbation (or onset) of obsessive behaviour.

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17
Q

Risperidone pros/cons

A

Pros: Lower EPS compared to 1st gen; less wt gain than clozapine, olanzepine
Cons: Highest risk of EPS/TD among 2nd Gen - avoid if high risk for movement disorder or elderly. Elevated prolactin - sexual dysfunction, galactorrhea, gynecomastia, menstrual disturbance, infertility

18
Q

Olanzepine pros/cons

A

Pros: Better overall efficacy compared to haloperidol. Well tolerated. Low incidence of EPS & TD.
Cons: Wt gain & metabolic effects - avoid in DM. Sedating - avoid if high risk for falls or #.

19
Q

Quetiapine pros/cons

A

Pros: Less wt gain than clozapine & olanzepine. Mood stabilizing.
Cons: Sedating. Orthostatic hypotension - avoid is high risk for falls or #. QT prolongation in high doses.

20
Q

Clozapine pros/cons

A

Pros: Most effective for treatment-resistant schizophrenia. Does not worsen tardive Sx, & may treat them.

Cons: Wt gain, metabolic effects - avoid in DM. Sedating, orthostatic hypotension - risk fo falls & #. Potential severe constipation. Cardiomyopathy. Sz. Agranulocytosis!!! (1% - avoid if exisiting leukopenia/neutropenia, & get blood counts q1w for 6mo then q2w

21
Q

Aripiprazole pros/cons

A

Pros: Less wt gain & metabolic syndrome than olanzapine. Less EPS than haloperidol
Cons: Insomnia

22
Q

Commonly used 2nd gen antipsychotics

A 
Risperidone
Olanzapine
Quetiapine
Clozapine
Aripiprazole
23
Q

Anticholinergic effects

A

Red as a Beet, Hot as a Hare, Dry as a Bone, Blind as a Bat, Mad as a Hatter … … …
or, Anticholinergic: dry mouth, urinary retention, constipation, blurred vision, confusional states

24
Q

How frequently are antipsychotics discontinued?

A

One trial with daily dosing recorded discontinuation rates from 64% to 82% w/in 6mo. So … a lot.

25
Q

What are common side effects of antipsychotics?

- anticholinergic

A

Anticholinergic: dry mouth, urinary retention, constipation, blurred vision, confusional states

26
Q

What are common side effects of antipsychotics?

- beta-adrenergic

A

orthostatic hypotension, erectile dysfunction, failure to ejaculate

27
Q

What are common side effects of antipsychotics?

- dopaminergic blockade

A

EPS, galactorrhea, amenorrhea, ED, weight gain

28
Q

What are common side effects of antipsychotics?

- antihistamine

A

sedation, weight gain

29
Q

What are common side effects of antipsychotics?

- Hematologic

A

Agranulocytosis (! severe)

30
Q

What are common side effects of antipsychotics?

- Hypersensitivity reactions

A

Liver dysfunction, blood dyscrasias, skin rashes, NMS, altered temp regulation (hypo or hyperthermia)

31
Q

What are common side effects of antipsychotics?

- Endocrine

A

Metabolic syndrome

32
Q

What is neuroleptic malignant syndrome?

A

Neuroleptic malignant syndrome is a reaction to antipsychotics (= neuroleptics)
characterized by altered mental status, muscle rigidity, hyperthermia, and autonomic hyperactivity.
Clinically, resembles malignant hyperthermia.

Happens due to strong dopamine blockade.

33
Q

What are common side effects of antipsychotics? (categories)

A

anticholinergic, beta-adrenergic, dopaminergic blockade, antihistamine, hematologic, hypersensitivity reactions, endocrine
Also, QTc prolongation!

34
Q

Which antipsychotics merit ECGs?

A

All antipsychotics can cause QTc prolongation; consider getting ECG prior to initiating any.

Monitor (get baseline and follow up ECGs) in:
1st gen: chlorpromazine, haloperidol
2nd gen: ziprasidone, clozapine

35
Q

What is the clinical presentation of NMS? (& risk factors)

A
  • mental status changes, fever, autonomic reactivity, rigidity
  • develops over 24-72h
  • labs: increased CK, leukocytosis, myoglobinuria

Risk factors: sudden dose increase, new drug; illness, dehydration, exhaustion, poor nutrition, external heat load, young, male.

36
Q

Treatment of NMS

A

supportive:
- d/c antipsychotic
- hydration, cooling blankets
- dantrolene (muscle relaxant)
- bromocriptine (dopamine agonist)

5% mortality

37
Q

EPS: Acute vs tardive

A

Acute: early-onset, reversible
Tardive: late-onset, often irreversible

38
Q

EPS: Dystonia

A

Sustained abnormal posture; torsions, twisting, contraction of muscle groups; muscle spasm (eg oculogyric crisis, laryngospasm, torticollis)

Acute: w/in 5d; Tardive: >90d
Risk: Acute: Young Asian and Black males
Treatment: acute: benztropine, diphenhydramine

39
Q

EPS: Akathisia

A

Motor restlessness; crawling sensation in legs relieved by walking; very distressing (incr risk of suicide, poor adherence)

Acute: w/in 10d; Tardive >90d
Risk: elderly women
Treatment: Acute: lorazepam, propranolol, diphenhydramine; reduce or switch antipsychotic

40
Q

EPS: Pseudoparkinsonism

A

Tremor, Rigidity, Akinesia (bradykinesia, hypokinesia), Postural instability (decr. arm swing, stooped, shuffling gait, difficulty pivoting)

Acute: w/in 30d
Risk: elderly women
Treatment: Acute: benztropine (or benzo); reduce or switch antipsychotic

41
Q

EPS: Tardive dyskinesia

A

Purposeless, constant movements, involving facial and mouth musculature; less commonly, limbs; rarely, diaphragm

Tardive: >90d
No specific risk group
No good treatment; may try clozapine (can help with TD); reduce, discontinue, or switch antipsychotic

42
Q

What medications can be used for EPS, and when would/wouldn’t you use them?

A

Anticholinergics: benztropine, diphenhydramine

Do not routinely Rx: only give if acute EPS develop, or v high risk. Can worsen tardive Sx (do not Rx).

Psychiatry (3 decks)

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