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845 > Psychotic Disorders > Flashcards

Psychotic Disorders Flashcards

1
Q

Abbreviations

A
  • FGA: First generation antipsychotics (typicals)
  • SGA: Second generation antipsychotics (atypicals)
  • 5HT: serotonin
  • DA: dopamine
  • NE: norepinephrine
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2
Q

Psychosis

A
  • Mental disorder with severe loss of contact with reality
  • Delusions, hallucinations, disorganized speech, erratic behaviors
  • Difficult to recognize what is real and what isn’t
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3
Q

Schizophrenia Characteristics

A
  • Disturbance in expected or prior level of functioning in one or more major areas (work, relationships, etc)
  • Active symptoms persist for at least one month and residual for at least 6 months
  • Symptoms aren’t consistent with other diagnosis
  • Not attributable to substance use or another medical condition
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4
Q

Schizophrenia Presentation

A

2+ symptoms persist good portion of a month:

  • Delusions*
  • Hallucinations*
  • Disorganized speech*
  • Grossly disorganized or catatonic behavior
  • Negative symptoms

One of the symptoms must be one of the *

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5
Q

Schizoaffective Disorder

A
  • Presence of a major mood episode (mania, depression) concurrently with schizophrenia symptoms
  • Presence of delusions or hallucination for 2+ weeks in the absence of a major mood episode during lifetime of illness
  • Simply, SCZ + Mood disorder
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6
Q

Secondary Psychotic Disorders

A
  • Collective term encompassing psychotic symptoms caused by another medical condition or substance
  • Substance-induced psychosis can occur during active exposure/intoxication or the subsequent withdrawal
  • Symptoms cannot occur exclusively in the context of delirium or another cognitive disorder
  • Delirium fluctuates throughout the day
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7
Q

Positive Symptoms

A
  • Hallucination

- Delusions

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8
Q

Negative Symptoms

A
  • Anhedonia
  • Amotivation
  • Social withdrawal
  • Flat affect
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9
Q

Cognitive Symptoms

A
  • Poor short/long-term memory
  • Speech/communication difficulties
  • Inattention
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10
Q

APA Goals of Therapy

A
  • Reduce/eliminate symptoms
  • Maximize QoL and adaptive functioning
  • Promote/maintain recovery from the debilitating effects of illness to the max extent possible
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11
Q

Acute Treatment Goals

A
  • Ensure safety of all involved
  • Reduce agitation, aggression, hostility
  • Relieve detrimental effects of hallucinations (anxiety)
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12
Q

Chronic Treatment Goals

A
  • Maintain control of symptoms
  • Improve social functioning/community integration
  • Maintain safe and stable living environment
  • Treat and rehabilitate substance abuse
  • Educate and involve caregivers
  • Manage chronic comorbidities
  • Minimize medication side effects
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13
Q

High Potency FGAs (EX/Characteristics)

A
  • Strong D2 antagonism
  • Weaker alpha-antagonism
  • Minimal anticholinergic effects
  • Minimal 5HT2A antagonism (little/no effect on treating negative symptoms)
  • EX: Haloperidol, fluphenazine, perphenazine
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14
Q

Low Potency FGAs (EX/Characteristics)

A
  • Less strong D2 antagonism
  • High alpha-antagonism
  • Strong anticholinergic effects
  • Minimal 5HT2A antagonism (little/no effect on treating negative symptoms)
  • EX: Chlorpromazine
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15
Q

SGAs

A
  • Characterized by higher affinity 5HT2A affinity than D2
  • More varied receptor pharmacology than FGAs
  • Significant difference in AEs between the classes
  • Similar efficacy to FGAs for positive symptoms, possible better efficacy for negative symptoms
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16
Q

EPS

A

Extrapyramidal Symptoms:

  • Akathisia
  • Pseudoparkinsonism
  • Acute dystonia
  • Tardive dyskinesia
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17
Q

Akathisia

A
  • Unknown mechanism
  • Feeling of internal restlessness and anxiety
  • High incidence with all antipsychotics, FGA&raquo_space; SGA
  • Onset: days to weeks
  • Risk factors: high potency FGAs, high doses, rapid dose escalation**
  • Treatment: lower dose or change to low-potency, lipophilic B-blockers, mirtazapine, trazodone, benzos
18
Q

Pseudoparkinsonism

A
  • Mechanism: Excessive DA blockage in the nigrostriatal pathway
  • High incidence with FGAs
  • Onset: 1 to 3 months
  • Risk factors: high-potency FGAs, high dose, >40 y.o., female
  • Treatment: lower dose or change to low potency, short-term anticholinergics (benztropine, diphenhydramine)
  • Avoid chronic anticholinergic use. negative cognitive effects
19
Q

Acute Dystonia

A
  • Mechanism: Excessive DA blockage in the nigrostriatal pathway
  • Occurs in 2-10% of FGA patients
  • Onset: within 3 days in most cases
  • Risk factors: High potency FGAs, high doses, history of dystonias, male, younger age, intramuscular or IV administration*
  • Treatment: stat intramuscular anticholinergics => benzos (Diphenhydramine, bentropine, or lorazepam)
20
Q

Tardive Dyskinesia (TD)

A
  • Mechanism: Induced D2 receptor hypersensitivity
  • Involuntary, repetitive, potentially irreversible, abnormal movements
  • Onset: months to years
  • Risk factors: older age, dose/duration, affective disorder, med non-adherence, use of anticholinergics
  • Treatment: change therapy (works 1/2 the time), clozapine or quetiapine are preferred alternatives
21
Q

QTc Prolongation

A
  • Leads to Torsades de pointes => V. fib => sudden cardiac death
  • Dose dependent effect seen to varying degree with most FGAs/SGAs (Exclusion: aripiprazole, lurasidone)
  • Worst offenders: thioridazine, ziprasidone
  • Prevention: Baseline and ECG follow-up, avoid high risk agents if baseline QTc > 450 msec, D/C therapy if QTc > 500 msec
22
Q

Hyperprolactinemia

A
  • Most prominent with FGAs, risperidone, and paliperidone
  • Symptoms in women: amenorrhea, sexual dysfunction, decreased BMD
  • Symptoms in men: breast pain, gynecomastia, sexual dysfunction, decreased BMD
  • Treatment (only if symptomatic): change antipsychotic (aripiprazole), metformin may reverse amenorrhea, estrogen/progestin/testosterone/bisphosphonate for decreased BMD
23
Q

Metabolic Complications

A
  • Required in label warnings for all SGAs
  • Higher prevalence of smoking, sedentary lifestyle, poor nutritional habits put SCZ patients at a higher risk
  • Higher baseline rates of diabetes and CV mortality than normal (twice)
  • Increased weight, fasting lipids, mean fasting/post-load blood glucose, and possible mortality all associated with SGAs
  • Highest risk: clozapine, olanzapine
24
Q

Metabolic Complication Treatment

A
  • Diet and exercise
  • Metformin: reduces weight gain from antipsychotics
  • Statin therapy if indicated based on ASCVD score
  • Other options have minimal effect
25
Q

Acute Control of Psychotic Agitation

A
  • Provide seclusion with minimal sensory stimulation
  • Avoid use of physical restraints unless combative
  • Always attempt oral medications first to reduce risk of staff harm from forced IM administration
  • Place on direct observation
  • Usually use antipsychotic, benzo, and anticholinergic concurrently
  • 5-2-1: 5 mg haloperidol + 2 mg lorazepam + 1 mg benztropine
  • B52: 50 mg diphenhydramine + 5 mg haloperidol + 2 mg lorazepam
  • Olanzapine and ziprasidone are also options
26
Q

Olanzapine + Benzo Interaction

A
  • Not recommended due to excessive sedation and cardiorespiratory depression
  • IM olanzapine/parenteral benzo specifically
  • Avoid coadministration within one hour of each other
27
Q

APA SCZ Guidelines

A
  • Treat with an antipsychotic and monitor for effectiveness and SE
  • Treatment-resistant SCZ should be treatment with clozapine (2 antipsychotics at appropriate doses for at least 6 weeks)
  • Treat with clozapine if suicidal thoughts/ideation or aggressive behavior remains substantial even after treatments
28
Q

Texas Medication Algorithm

A
  • Stage 1: Single SGA
  • Stage 2: Different SGA or FGA
  • Stage 3: Clozapine
  • Stage 4: Add SGA/FGA or ECT to clozapine
  • Stage 5: Try a single SGA or FGA that hasn’t been tried
  • Stage 6: Combine any of the above options
29
Q

First Episode Psychosis

A
  • Use a team-based, multimodal approach to treatment
  • Consider a SGA
  • Try using lower doses
30
Q

Other Special Consideration

A
  • Clozapine: Comorbid Parkinsons, development of TD
  • ECT: Failure of clozapine, catatonia, persistent suicidality
  • Long-acting injectables: repeated medication non-adherence
31
Q

Long-Acting Injectable Basics

A
  • IM injections administered in addition or in place of oral
  • Formulation for prolonged absorption that lasts weeks
  • Exhibit absorption-dependent kinetics
  • Must verify effects and tolerability with oral agents first
32
Q

Long-Acting Injectable Benefits

A
  • Guaranteed medication adherence (theoretically)
  • Possibly reduced relapse and readmission notes
  • Impossible for patient to intentional overdose
  • Facilitates routine outpatient follow-up
33
Q

Long-Acting Injectable Drawbacks

A
  • Potentially painful
  • Require relatively frequent clinic visits
  • Negative stigma
  • Limited ability to titrate or adjust dose
  • Expensive
34
Q

Haloperidol Decanoate

A
  • FGA LAI
  • Dose: 50-200 mg every 2-4 weeks
  • 10x PO dose = IM Dose
  • Loading strategies for IM/PO dosing
  • Formulated in sesame oil, caution with allergies
35
Q

Fluphenazine Decanoate

A
  • FGA LAI
  • Dose: 12.5-50 mg every 2-4 weeks
  • 1.25x PO dose (daily) = IM dose (every 3 weeks)
  • No loading strategy
  • Overlap PO therapy by 2-6 weeks
  • Formulated in sesame oil, caution with allergies
36
Q

Risperidone

A
  • Risperdal Consta
  • SGA LAI
  • Dose: 12.5-50 mg every 2 weeks
  • Start IM doses at 25 mg and adjust PRN
  • No loading strategy
  • Oral bridge of 3 weeks minimally
  • Adjustment needed for renal and hepatic impairment
37
Q

Perseris

A
  • New LAI form of risperidone approved in 2018
  • First SQ LAI approved
  • Dose: 90-120 mg every 4 weeks
  • No oral bridge needed
  • 3 mg PO => 90 mg SQ, 4 mg PO => 120 mg SQ
38
Q

Invega Sustenna

A
  • Paliperidone
  • SGA LAI
  • Dose: 39-234 mg IM every 4 weeks
  • 12 mg PO daily = 234 IM monthly (same for 6 mg risperidone)
  • Loading strategy
  • No PO overlap
  • Need to adjust for renal impairment (CrCl < 80)
39
Q

Invega Trinza

A
  • Paliperidone
  • First and only 3 month (SGA) LAI
  • Patient must be on Invega Sustenna for at least 4 months prior to switch to Trinza
  • No loading strategy or oral bridge
  • Make dose adjustment to Sustenna before transitioning
40
Q

Aripiprazole

A
  • Abilify Maintena
  • SGA LAI
  • Dose: 400 mg every 4 weeks
  • Lower to 300 mg if AE occur
  • No strong PO to IM conversion data
  • No loading strategy
  • Oral bridge: 2 weeks (10-20 mg daily)
41
Q

Aripiprazole Lauroxil

A
  • Aristada
  • SGA LAI
  • Dose: 441mg, 662mg q 4 weeks, 882mg q 4-6 weeks, or 1064mg q 8 weeks
  • More complicated PO to IM conversion
  • Loading strategy
  • Needs a 3 week oral bridge without Initio administation
  • Dose adjust when used with CYP3A4/2D6 inhibitors/inducers
  • Maintena is more reliable PK/conversion wise
42
Q

Olanzapine

A
  • Zyprexa Relprevv
  • SGA LAI
  • Black box: Post-injection delirium/sedation syndrome (PDSS)
  • REMS criteria to be prescribed and used
  • Must go to a facility for administration, be observed for at least 3 hours, and have transport home after each injection

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