Pharmacology

Question 1

4 Phases of schizophrenia

Answer 1

Prodromal (gradual - can go unnoticed)
Acute (crisis)
Stabilization (getting better)
Stable (declined or absent symptoms. Some residual might exist).

Question 2

Negative symptoms

Answer 2

Supposed to be there but they’re aren’t.

Social withdrawal
Lack of motivation
Poor self care
Blunted affect

Question 3

Three goals of schizophrenic drug therapy

Answer 3

Supression of acute episodes (pt goes back to daily life)
Prevention of remissions/acute exacerbation
Maintain highest possible level of functioning

Question 4

Positive symptoms

Answer 4

Symptoms that ARE there that shouldn’t be

Hallucinations
Delusions
Hostility
Paranoia

Easier to suppress these with drug therapy (usually the target) as opposed to negative symptoms.

Question 5

What are residual symptoms (schizophrenia)

Answer 5

Depression
Anxiety
Poor self-care

Remain even when schizophrenia is in remission

Question 6

DSM-5 Criteria for schizophrenic diagnosis

Answer 6

Include: 
Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behavior
Negative symptoms

At least two symptoms for at least one month.
At least one should be delusions, hallucinations or disorganized speech.

Question 7

What is a first line drug?

Answer 7

The drug that should be tried first (most preferred)

Question 8

What is the first line drug for schizophrenia?

Answer 8

Atypical Antipsychotics (2nd generation)

Question 9

How do first generation anti psychotics work?

Answer 9

Block receptors for dopamine in the CNS

Question 10

What are the side effects for first generation antipsychotics?

Answer 10

Movement disorders - extrapyramidal symptoms

Question 11

Second-generation antipsychotics

Answer 11

(AKA atypical antipsychotics)
Only partially block dopamine receptors, block serotonin even more.

We use these first.
Fewer Extrapyramidal Symptoms (movement disorders)

Question 12

Black box warning

Answer 12

The strongest warning from the FDA.

All antipsychotics have this warning to NOT USE with older adults with dementia.

ALSO, there is a risk for increased risk of suicidal thinking in children, adolescents and young adults.

Question 13

What can you assume if your patient is on both first and second generation antipsychotics?

Answer 13

That their symptoms weren’t easily controlled by the first line options.

Question 14

QT prolongation

Answer 14

Longer intervals between Q and T.
Higher risk of ventricular arrythmias.

Be particularly careful if pt is on multiple drugs with this caution.

Question 15

Early Extrapyramidal Symptoms

Answer 15

Akathesia (difficulty staying still. Subjective sense of restlessness)

Dystonia (involuntary muscle contractions - usually repetitive movement or abnormal postures)

Parkinsons-like symptoms (“drug-induced Parkinsonism)
Stooped posture.

Question 16

Late EPS

Answer 16

Tardive diskinesia (involuntary, repetitive body movements)

Happens with long-term use (diagnosed in 20s or 30s and have been using meds for decades)

Question 17

Neuroleptic malignant syndrome

Answer 17

Sudden elevated temperature (high fever - above 40C)
Unstable blood pressure
Profuse sweating
Dyspnea
Muscle rigidity 
Incontinence

Question 18

Anticholinergic side effects

Answer 18

Dry mouth
Blurred vision
Photophobia
Urinary hesitance
Constipation
Tachycardia

(Can’t see, can’t cry, can’t spit, can’t pee, can’t poop)

Question 19

Adverse reactions for antipsychotics

Answer 19

EPS
Neuroleptic Malignant Syndrome
Anticholinergic effects
Orthostatic Hypotension

Question 20

How does potency of antipsychotics relate to EPS?

Answer 20

If potency is high, likelihood of EPS is high.

Question 21

How does potency of antipsychotics relate to anticholinergic effects, sedation and orthostatic hypotension?

Answer 21

Low potency means it’s more likely to hit other receptors, thereby creating these adverse effects in higher frequency.

Question 22

When should Clozapine be used?

Answer 22

Only as a last resort. It’s the most potent and one of the best 2nd generation medications.

Must have tried and failed at least 1 first generation and 1 second generation medication.

Question 23

What should we worry about with Clozapine?

Answer 23

Black box warnings: 
Severe neutropenia (high risk for infections)
OH, bradycardia, syncope, cardiac arrest
Seizures
Myocarditis and cardiomyopathy

Question 24

What does the patient have to remember with Lurasidone

Answer 24

Must be taken with at least 350 kcal of food for absorption.

Question 25

Depot formulations (define)

Answer 25

Medication is available as an injectable for long-term therapy

Good for patients with compliance issues.

Question 26

What does it mean if smoking is an inducer?

Answer 26

It “induces” the activity of the enzyme - metabolizes the drug faster, and it’s therefore less effective.

Question 27

What enzyme does smoking interact with?

Answer 27

1A2

Question 28

What enzymes are associated with drug interactions?

Answer 28

1A2
2D6
3A4

Question 29

Major Depressive Disorder (MDD)

Criteria

Answer 29

Aka “unipolar disorder” or “depression”
At least five symptoms almost every day for at least two weeks

Depressed mood* (must have)
Anhedonia
Sleep disturbances
Weight/appetite changes
Decreased energy
Guilt/worthlessness
Psychomotor retardation/agitation
Decreased concentration
Suicidal ideation
Interferes with ability to function* (must have)

Question 30

Persistent Depressive Disorder

Answer 30

Aka dysthymia

Chronic depressed mood
More days than not
At least two years
(But doesn’t meet the criteria for MDD - might not have the same severity)

Question 31

Monoamine hypothesis of depression

Answer 31

Depression caused by the functional insufficiency of monoamine transmitters (norepinephrine, serotonin, dopamine)

Question 32

What are the five classes of antidepressants

Answer 32

Tricyclics (TCAs)
SSRIs
Serotonin/norepinephrine reuptake inhibitors
MAO inhibitors
Atypical antidepressants

Question 33

TCAs/Trycyclic antidepressants

Answer 33

Effective, but have adverse effects 
Newer ones (the metabolites) have less

More often used for off-label problems (pain syndromes, migraine prevention, anxiety disorders).

Might not mean that the patient is depressed.

Question 34

How do TCAs work?

Answer 34

They prevent the pump that pulls the NTs out of the synapse for recycling. Therefore, the NT stays in the synapse so it’s available for the post-synaptic neuron’s receptors.