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Pre reg > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

List and describe the four dopaminergic pathways and if disrupted can cause?

A

Mesocortical pathway - underactivity causes negative Sx

Mesolimbic pathway - overactivity causes positive Sx

D2 antagonism of tuberfundibular pathway - hyperprolactinaemia

D2 antagonism of nigrostritial pathway - EPSE

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2
Q

What is the advice of the Royal College of Psychiatrists on doses of antipsychotic drugs above the BNF upper limit?

A
  1. Consider alternatives e.g. adjuvants, newer or 2nd gen
  2. Be aware of risk factors e.g. elderly, obesity
  3. Consider potential drug interactions
  4. ECG to exclude QT interval prolongation
  5. Increase dose slowly and once weekly
  6. Regular pulse, BP and temperature check
  7. Consider high-dose therapy for limited period only and review regularly. Stop if no improvement after 3 months
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3
Q

What to consider when administering antipsychotic drugs in an emergency?

A

IM dose should be lower than oral dose as avoids first-pass metabolism. Especially in active patients

Prescription should specify dose for each route

Review dose at least daily

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4
Q

What do consider when prescribing antipsychotics in elderly?

A

Small increased risk of stroke/TIA

Susceptible to postural hypotension and hyper/hypothermia

  1. Do not treat mild-moderate psychotic symptoms
  2. Initial dose should be half adult dose
  3. Review treatment regularly
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5
Q

What do consider when prescribing antipsychotics in patients with learning difficulties?

A

If patient not experiencing psychotic symptoms:

  • Reduce dose or stop long-term antipsychotic treatment
  • Review condition after dose reduced or if treatment stopped
  • Refer to psychiatrist experienced in treating mental health problems in patients with LD
  • Annual documentation of reasons for continuing antipsychotic prescription if dose not reduced/treatment discontinued
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6
Q

What side effects are first generation antipsychotics more likely to cause?

A

Hyperprolactinaemia and EPSE

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7
Q

What are the categories of first generation antipsychotics and specific side effects?

A

Group 1 (Phenothiazines): MOST SEDATIVE

  • Chlorpromazine*
  • Levomepromazine*
  • Promazine*

Group 2: LEAST EPS

Pericyazine

Group 3: MOST EPS

  • Fluphenazine*
  • Perphenazine*
  • Prochlorperazine*
  • Trifluoroperazine*

Butyrophenones: MOST EPS

  • Haloperidol (QT interval prolongation)*
  • Benperidol*

Thiaxanthenes

  • Flupentixol* (alerting effect so do not take in evening)
  • Zuclopenthixol*
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8
Q

What is the difference in receptors antipsychotics block?

(1st vs 2nd gen)

A

1st gen = D2

2nd gen = D1-D4 and act on wide range of other receptors

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9
Q

What side effects do 2nd generation antipsychotics cause more?

A

Metabolic side effects

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10
Q

What are the 2nd generation antipsychotics?

A

Amisulpride
Aripiprazole
Clozapine
Olanzapine
Quetiapine
Risperidone

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11
Q

Which 2nd gen antipsychotics cause the most hypoprolactinaemia?

A

Risperidone and amisulpride

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12
Q

Which 2nd generation antipsychotic doesn’t cause hyperprolactinaemia and why?

A

Apiprazole - dopamine agonist

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13
Q

Which antipsychotics cause hyperglycaemia

Which antipsychotics cause most weight

A
  • Risperidone, quetipaine, olanzapine, clozapine
  • Olanzapine and clozapine
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14
Q

When are depot antipsychotics prescribed?

A

To aid compliance

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15
Q

What do depot antipsychotic preparations typically end in?

A

Deconate

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16
Q

When are depot preparations administered?

A

1-4 weeks IM

17
Q

What do EPSE consist of?

A

ð Parkinsonian: Such a tremor, more common in the elderly. Anti-muscarinic drugs not indicated as they may worsen tardative dyskinesia

ð Dystonia: Abnormal face and body movements, more common in children and YA

ð Akathisa: Restlessness after large initial dosesdoses

ð Tardative dyskinesia: Involuntary jaw or face movements which develops on long term or high dose therapy. Elderly most common

Stop at first sign of fine vermicular movements of tongue

18
Q

When do patients with schizophrenia have to be monitored?

A

Yearly physical health monitoring including CVS risk assessment

19
Q

What are the side effects of antipsychotics?

A

Extrapyridamidal symptoms

Occurs more with 1st gen

Hyperprolactinaemia

More likely with riseridone, amisulpride and 1st gen

  • Breast symptoms: enlargement, pain, glactorrhoea
  • Reduced BMD
  • Menstrual irregularities
  • Sexual dysfunction/Reduced libido

Metabolic side effects

Occurs more with 2nd gen

  • Hyperglycaemia and sometimes diabetes. Most with CiROQ
  • Weight gain. Most with COW
  • Lipid changes

Sexual dysfunction

Most with haloperidol and risperidone

Consider switching to alternative

Cardiovascular side effects

Tachycardia, arrhythmias and hypotension

QT interval prolongation

Hypotension and interference with temperature regulation

Elderly at risk of falls, hypothermia and hyperthermia

Neuroleptic malignant syndrome

Others:

Blood dyscrasias, drowsiness, photosensitivity at high doses, jaundice & antimuscarinic side effects

20
Q

When to monitor prolactin levels

A

initial, 6 months and then yearly (and where clinically appropriate - APD that causes hyperprolactinaemia)

21
Q

What is neuroleptic malignant syndrome? Treatment

A

Fatal condition reaction to antipsychotics

Muscle rigidity, fluctuating consciousness, hyperthermia and autonomic dysfunction with pallor, tachycardia, sweating, urinary incontinence and labile bp

Discontinue antipsychotic immediately

Can treat with bromocriptine or dantrolene

Lasts 5-7 days after stopping but longer with depot preparations

22
Q

What antipsychotic prolongs the QT interval the most?

A

Pimozide + haloperidol + IV antipsychotics

Monitor ECG before treatment and yearly

Stop or reduce dose if occurs

Do not give concomitant drugs that prolong QT interval

Do not give concomitant drugs that cause electrolyte imbalance

23
Q

What antipsychotics are hepatotoxic and cause acute dystonic reactions?

A

Phenothiazines

24
Q

Monitoring requirements of antipsychotics

A
  • Blood lipids and weight - before, 3 months and then yearly
  • Fasting blood glucose - before, 6 months and then yearly
  • FBC, LFTs, UeAs - before and then yearly

ECG and BP - before and after every dose titration

25
Q

Are second gen antipyschotics more effective at treating pos or neg sx than first gen

A

Negative

26
Q

What is the advice surrounding antipsychotics and sunlight?

A

As photosensitisation may occur with higher dosages, patients should avoid direct sunlight

27
Q

In schizophrenia, are antipsychotics more effective on the negative or positive symptoms?

A

More effective on the positive symptoms

28
Q

Which antipsychotics may need their dose adjusting according to smoking status during therapy?

A

Clozapine, Haloperidol, Chlorpromazine and Olanzapine

29
Q

Which antipsychotic can cause contact sensitisation so should be handled with care?

A

Chlorpromazine tablets should NOT BE CRUSHED

30
Q

What is the MHRA warning regarding prescribing antipsychotics in elderly patients with dementia?

A

Increased risk of stroke and a small increased risk of death If needed, use the lowest effective dose and for the shortest time

Review every 6 weeks

Pre reg (45 decks)

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