Schizo

Question 1

First line therapy for schizophrenia

Answer 1

Monotherapy FGA or SGA, except clozapine

Question 2

If first antipsychotic fails to show response or improvement, what is the next line of therapy?

Answer 2

Use another monotherapy FGA or SGA, except clozapine (switch FGA/SGA)

Question 3

Goals of pharmacological treatment of schizophrenia?

Answer 3

• Relieve symptoms of psychosis
• Prevent relapse (because more relapse = more treatment resistant)

Question 4

Describe the four tracts of the central dopamine system that antipsychotics target

Answer 4

1. Mesolimbic tract: Blocks dopamine receptors here. Responsible for positive symptoms in schizophrenia

The following causes AEs of antipsychotics
1. Mesocortical tract: Dopamine blockage here result in negative symptoms
2. NIgrostriatal tract: EPSE
3. Tuberoinfundibular tract: hyperprolactinemia from dopamine blockage

Question 5

What is an adequate trial of antipsychotic?

Answer 5

Try a new antipsychotic on a patient for 2-6 weeks before determining if it is useful for the patient or not

Question 6

In an acute agitation, state the drug class to manage the patient

Answer 6

BZD

Question 7

If patient is cooperative in an acute agitation, what is the first line option?

Answer 7

ORAL lorazepam 1-2mg
or
- Haloperidol 2-5mg, risperidone 1-2mg, quetiapine 50-100 mg, olanzapine orodispersible 5-10mg

Question 8

If patient is Uncooperative in an acute agitation, what is the first line option?

Answer 8

IM lorazepam 1-2 mg
OR
- IM olanzapine 5-10 mg
- IM aripiprazole 9.75 mg
- IM haloperidol 2.5 - 10 mg (with pre-treatment ECG)
- IM promethazine 25-50 mg

Question 9

First line treatment for acute agitation related to catatonia?

Answer 9

BZDs (because catatonia involves deactivation of GABA, so BZD is very effective since it is a GABA activator)

Question 10

Common adverse effect of FGAs (and is more prominent than SGAs)

Answer 10

• EPSE
• Hyperprolactinemia

Question 11

Usual dosage range of haloperidol

Answer 11

5 - 15 mg a day
(0.5 - 3 mg/ BD - TDS)
(3-5 mg BD-TDS for severe symptoms)

Question 12

Usual dosage range of olanzapine. State one important adverse effect

Answer 12

5 - 20 mg a day (usual 10 mg OD)

• Weight gain (hence balanced diet is important)

Question 13

Management of dystonia in patients taking antipsychotics

Answer 13

IM anticholinergics (e.g. benztropine)

Question 14

Management of dystonia in patients taking antipsychotics

Answer 14

• Decrease or switch to SGA
• Anticholinergics PRN (e.g. benzhexol)

Question 14

Management of Akathisia in patients taking antipsychotics

Answer 14

• Decrease or switch SGA
• Low dose clonazepam PRN

Question 14

Management of tardive dyskinesia in patients taking antipsychotics

Answer 14

• Discontinue anticholinergics (important!!)
• Decrease or switch antipsychotics to SGA
• Valbenazine 40-80mg/day
• Note: symptom worsen with anticholinergic drugs

Question 15

Management of hyperprolactinemia in patients taking antipsychotics

Answer 15

Switch to aripiprazole if it is a problem

Question 16

Antipsychotics with metabolic side effects and sedation. What are the metabolic side effects?

Answer 16

Drugs: Olanzapine, clozapine, quetiapine

Metabolic side effects: Weight gain, diabetes, increased lipids

• Management: treat conditions. Switch to aripiprazole or lurasidone if really necessary

Question 17

One prominent CNS side effects of antipsychotics characterised by muscle rigidity, fever, altered consciousness, etc. How to manage?

Answer 17

Neuroleptic malignant syndrome (muscle rigidity, fever, autonomic dysfunction, altered consciousness etc.)

Treatment: IV dantrolene 50 mg TDS, or oral dopamine agonist

Question 18

Important side effect of clozapine

Answer 18

Agranulocytosis.
- Monitor weekly for the first 18 weeks, then monthly

Question 19

Drug interaction with clozapine which may increase the risk of agranulocytosis?

Answer 19

Carbamazepine (coz it also can cause agranulocytosis)

Question 20

SGA are able to improve mood sx and negative symptoms via what kind of mechanism of action?

Answer 20

5HT2A antagonism

Question 21

A long acting FGA given via the IM route. State its dosing range.

Answer 21

IM Haloperidol decanoate 50 - 300 mg/4 weeks
(or 25 - 150 mg / 2 weeks)

Question 21

A long acting FGA given via the IM route. State its dosing range.

Answer 21

IM Haloperidol decanoate 50 - 300 mg/4 weeks
(or 25 - 150 mg / 2 weeks)