Schizophrenia

Question 1

Schizophrenia

Answer 1

• Chronic, severe disabling thought disorder
• Sxs: hallucinations, delusions, disorganized thought/behavior
• Top rate of suicide amongst psych conditions

Question 2

Positive Sxs

Answer 2

• Hallucinations
• Delusions (often auditory)
• Disorganized thinking/behavior

Question 3

Negative Sxs

Answer 3

(Think Depression)

• Flat affect
• Anhedonia
• Avolition (not moving)
• Alogia (not talking)
• Withdrawal

Question 4

Antipsychotics

Answer 4

• Block dopamine receptors (due to increased DA levels in SCZ)
• 1st gen block DA-2, BUT some respond better
• SGA: block DA2 & 5HT2A, 1st line due to decreases incidence in EPS
• Environment, genetics, stressors, and drugs can also contribute
• Good at treating positive sxs > negative
• Box Warning: NOT indicated for elderly with dementia psychosis (increased mortality), many also have stroke risk
• Need 4-6 weeks trial before failing med

Question 5

Extrapyramidal Sxs

Answer 5

• Painful dystonia - give prophylaxis, esp. in young males
• Dyskinesia
• Tardive dyskinesia - D/C drug
• Akathisia

Question 6

Natural Products for Psych

Answer 6

• Fish oil
• Used for many psych conditions
• Rx drugs usually needed additionally

Question 7

Formulation Options for Antipsychotics

Answer 7

• LA injections: given IM
• ODT tablets: prevents cheeking
• Oral susp/soln: good for kids/feeding tubes
• Acute IM inj: stat relief (often given in cocktail to decrease dystonias)

Question 8

Haldol Decanoate

Answer 8

• Haloperidol
• LA inj
• Q4w

Question 9

Risperdal Consta

Answer 9

• Rispeidone
• LA inj
• Q2w

Question 10

Invega Sustenna/Trinza

Answer 10

• Paliperidone
• LA inj
• Sustenna: q4w
• Trinza: q3mo

Question 11

Abilify Maintena

Answer 11

• Aripiprazole
• LA inj
• Q4w

Question 12

Fast Acting Inj Options

Answer 12

• Haloperidol - usually given with Ativan + Benzo OR Diphenhydramine (latter two prevent painful dystonia)
• Fluphenazine
• Zyprexa - olanzapine, NEVER give with BZD
• Geodon - ziprasidone

Question 13

ODT Antipsychotics

Answer 13

• Aripiprazole
• Clozapine
• Risperidone
• Olanzapine
• Saphris - asenaphine

Question 14

FGA Examples

Answer 14

• Haloperidol - high potency, QT prolongation,

- Fluphenazine - LA option**

Question 15

SGA Examples

Answer 15

• Aripiprazole
• Clozapine
• Lurasidone
• Ziprasidone
• Olanzapine
• Paliperidone
• Quetiapine
• Risperidone

Question 16

Clozapine Box Warning

Answer 16

Box Warning:

• Severe neutropenia - need ANC > 1500 to start and D/C if ANC < 1000
• Seizures
• Dose related: myocarditis and cardiomyopathy
• Need to have failed other AP, bad AEs, or tardive dyskinesia

Question 17

QT Prolongation in AP

Answer 17

ALL AP but some have higher risk:

• Thioridazine (FGA) - Box warning for QT prolongation
• Haloperidol (FGA)
• Chlorperazine (SGA)
• Ziprasidone (SGA) - highest risk in SGAs
• *D/C if QT > 500; higher risk with hypoK/Mg, higher risk with high doses**

Question 18

Tardive Dyskinesia Tx

Answer 18

• uUncontrollable movements
• Stop drug: Stopping usually more tapered and starting new agent
• Valbenazine - first line (VMAT2i)
• Warning for somnolence!
• Alt: Deutetrabenazine (VMAT2i)
• CI with hepatic impairment

Question 19

Clozapine SE

Answer 19

• High risk metabolic SE (weight gain, increased TG/BG)
• Highest hematologic SE risk
• Use when ALL other options fail
• Highest seizure risk (Dose-dependent)
• Smoking decreases levels of clozapine

Question 20

Zyprexa SE

Answer 20

• Olanzapine, SGA
• High risk for metabolic SE (weight gain, increased TG/BG)
• Smoking reduces level of olanzapine
• Don’t give with BZD EVER (resp. depression risk)
• QHS

Question 21

Seroquel

Answer 21

• Quetiapine, SGA
• High risk for metabolic SE (weight gain, increased TG/BG)
• Lowest EPS risk (recommended with PD)
• IR w/o regards to food; XR w/o food OR 300 kcal max

Question 22

Increase Prolactin Risk in…

Answer 22

• Risperidone
• Palideridone
• *Increased levels of prolactin can cause EPS and decrease sex hormones/sexual dysfxn/amenorrhea/galactorrhea**

Question 23

Psychotic Sxs Causing Rx Drugs

Answer 23

• Anticholinergics (central acting, high dose)
• Dextromethorphan
• DA or DA agonists (Requip, Mirapex, Sinamet) - use quetiapine if locked up and maxed out
• Interferons
• Stimulants
• Systemic steroids

Question 24

Psychotic Sxs Causing Illicit Drugs

Answer 24

• Cannabis
• Bath salts
• Cocaine, crack
• LSD - lysergic acid diethylamide
• Meth
• PCP

Question 25

Neuroleptic Malignant Syndrome

Answer 25

• Rare, lethal syndrome due to DA blockade (usually in FGA)
• Usually a more acute response (w/in two weeks of starting or post-high dose inj)
• Medical EMERGENCY: muscles freeze up and can’t breathe
• Sxs: hyperthermia, muscle rigidity (muscles breakdown and cause rhabdo/acute renal failure)
• STOP antipsychotic and use dantrolene for muscle relaxation

Question 26

Reglan

Answer 26

• DA blocker
• Metoclopramide
• Used to help move food through gut
• Can worsen EPS sxs and cause parkinsonism

Question 27

Saphris

Answer 27

• Tongue becomes numb after taking med
• SL tab, under tongue and dissolve
• Don’t eat or drink for 10 minutes afterwards

Question 28

Latuda

Answer 28

• SGA
• Lurasidone
• Take with at least 350 kcal

Question 29

Geodon

Answer 29

• SGA
• Ziprasidone
• Take with food

Question 30

Invega

Answer 30

• Paliperidone
• SGA
• Leaves ghost tablet

Question 31

Lithium DDI

Answer 31

• NSAIDs increase levels (use ASA or suldinac instead)
• Caffeine and theophylline decrease levels
• Increased 5HT syndrome risks with other antidepressants
• Increased neurotoxicity with non-DHP CCBs, phenytoin, and carbamazepine

Question 32

Lithium Counseling

Answer 32

• GI issues - titrate slowly, move dose to QHS
• Take with food - at end of meal
• Drink lots of water
• Do NOT get pregnant
• 5mL lithium citrate = 8 mEq lithium
• 8 mEq = 300 mg lithium carbonate tabs/caps