Psychosis - Tx Guidelines, EPS Flashcards
First episode psychosis: What should be used?
2nd generation antipsychotic (less AEs and equal efficacy relative to first-gens)
First episode psychosis: tx duration?
Min 18 mths
T or F: First episode psychosis: indefinite tx is absolutely unnecessary
F
Indef tx is not unreasonable
First episode psychosis: All antipsychotics are essentially equally effective
T (you would choose the one with the best AE profile, and you would use the lowest effective dose)
First episode psychosis: how long would an adequate trial be?
4-6 weeks
T or F: 2nd gen antipsychotics are better tolerated than 1st gens
T
Acute exacerbation: what should we do first when tx’ing this?
Screen for nonadherence, substance use (e.g. cannabis), and drug interactions
Acute exacerbation: Assuming no nonadherence, substance use, or drug interactions, what do we do next?
Increase antipsychotic dose OR change antipsychotic
Trial for 6-8 wks to determine effect
(if switching, cross taper is usually the preferred method to prevent AP withdrawal)
Maintenance and relapse prevention: How to tx mood changes?
Mood stabilizers or antidepressants
Maintenance and relapse prevention: How long should maintenance tx be?
2 yrs (possibly up to 5 yrs)
Treatment resistant schizophrenia: When do we determine that someone’s schizophrenia is treatment-resistant?
≥ 2 positive sx’s of mod severity
OR
1 positive sx of severe severity
…after ≥ 2 adequate antipsychotic trials (6-8 wks long = ea. trial period) for po
OR
…after 6 weeks of steady state for long-acting injection
Treatment resistant schizophrenia: Before tx’ing this, what should we do?
Ensure
- adherence
- no substance use
- no DIs
- appropriate dose
Treatment resistant schizophrenia: 1st line tx?
Clozapine (an atypical antipsychotic)
What drug is most effective for tx-resistant schizophrenia?
Clozapine
Clozapine: important AEs
agranulocytosis, myocarditis, constipation
Clozapine: Why is continuous blood monitoring req’d?
Risk of agranulocytosis
Clozapine: Re-titrate up if doses are missed for how long?
> 48h
Clozapine: When does clozapine become non-rechallengeable?
if total WBC < 2.0 x 10^9
OR
ANC (absolute neutrophil count) < 1.5 x 10^9
…during clozapine tx
When a pharmacist is dispensing clozapine for tx-resistant schizophrenia, what must the pharmacist make sure of?
That the pt is enrolled with the A.A. Clozapine Program and ensure most recent bloodwork is in green or yellow zone
T or F: Augmenting clozapine with an antipsychotic is well supported in the literature for partial responses to clozapine for clozapine-resistant schizophrenia
F
Evidence is mixed
What’s last line tx if clozapine-resistance isn’t overcome with antipsychotic augmentation?
ECT
What comorbidity should we screen all psychosis pts for?
substance use disorder (since substances like stimulants and cannabis are assoc w/ psychosis and worse outcomes)
Tx for psychosis + substance use disorder?
Any antipsychotic (limited data saying clozapine)
Most EPS’s are due to what?
DA blockade (MOA of antipsychotics)
What’re acute dystonias?
Torsions and spasms of muscle groups
1st line tx for acute dystonias?
IM benztropine
What’s akathisia?
Inner restlessness; can’t sit still
Akathisia tx
Reduce dose of antipsychotic OR change antipsychotic
and/or
benzos, BBs, mirtazapine
What’s pseudoparkinsonism?
Parkinson-like sx’s: tremor (pill-rolling type), cogwheel rigidity, bradykinesia
Acute pseudoparkinsonism tx?
Reduce/change antipsychotic
and/or
use an antiparkinsonian drug (benztropine, diphenhydramine, procyclidine, trihexyphenidyl)
What’s pisa syndrome?
Leaning to one side
Tx for pisa syndrome?
antiparkinsonian drug (benztropine, diphenhydramine, procyclidine, trihexyphenidyl)
What’s rabbit syndrome?
fine tremor of lower lip
Tx for rabbit syndrome?
antiparkinsonian drug (benztropine, diphenhydramine, procyclidine, trihexyphenidyl)
What’s tardive dyskinesia
INVOLUNTARY abnormal movements
Tardive dyskinesia tx
Best tx = second/third gen antipsychotics
and
stop offending agents
Tx for tardive dystonia?
switch to 2nd/3rd gen antipsychotic
Tx’s for tardive akathisia?
a. switch to 2nd/3rd gen antipsychotic
b. antichols
c. benzos, BBs
What’s the name of the acute, life-threatening EPS?
Neuroleptic malignant syndrome
What can cause neuroleptic malignant syndrome?
ANY antipsychotic
Tx for neuroleptic malignant syndrome?
Stop antipsychotic IMMEDIATELY
+ supportive care + bromocriptine
