Schizophrenia

Question 1

First Generation (Typical)

Answer 1

EPS, Dermatolologic, Photosensitivity, Blue-gray skin, Orthostatic Hypotension, Altered thermoregulation

Question 2

Second Generation (Atypical)

Answer 2

Metabolic Syndrome (Hypertriglyceridemia, Hyperglycemia, Weight Gain/Waist Circumference), Blood Dyscrasia/neutropenias, seizure threshold, anticholinergic effects, sedation, opthalmic effects

Question 3

Both Generations

Answer 3

QTC Prolongation, Prolactin Elevation

Question 4

Black Box Warning

Answer 4

NOT for Schizophrenia – for elderly pt’s w/ dementia receiving these drugs for behavioral problems, not primary SMI

Question 5

Treatment Naive (Stage 1)

Answer 5

Start w/ Aripiprizole, Risperidone, or Ziprasidone (really any APS except Clozapine and Olanzapine)

Question 6

Inadequate Response (Stage 2)

Answer 6

Any APS (from a different class) except Clozapine, Olanzapine can now be used (be wary of metabolic SE/QTc Prolongation)

Question 7

Second Inadequate Response – Treatment Resistant (Stage 3)

Answer 7

Clozapine Monotherapy

Question 8

Third Inadequate Response

Answer 8

Alternative APS, Augmentation (Mood Stabilizers, APS Polypharm, etc.), ECT

Question 9

SERIOUS DDI

Answer 9

Benzos (esp IM Lorazepam) w/ Olanzapine/CLozapine: QTc, Blood Dyscrasias, Anticholinergic Intoxication

Question 10

LAI Considerations

Answer 10

insure nonadherence was NOT due to SE, stabilization on PO therapy 1st is best, PO challenge of same drug before initiation to detect allergy, PO overlap is needed as most do not take immediate effect

Question 11

Aripiprazole (Abilify)

Answer 11

IMPULSIVITY, little weight gain, less sedating (insomnia, akathisia, restlessness); tablet, solution, LAI (maintena, aristada); I: 5-15 mg/d, M: 15-30 mg/d

Question 12

PO Overlap for Abilify LAI

Answer 12

Maintena: 14d (2w)
Aristada: 21d (3w)

Question 13

Dosing for Abilify LAI

Answer 13

Maintena: 400mg qm, can reduce to 300mg
Aristada: many options

Question 14

Asenapine (Saphris)

Answer 14

LEAST sedating/anticholinergic, little weight gain, rare but HIGH risk for QTc prolongation; don’t eat or drink for 10 min after SL dose; CI in hepatic disease; SL tab (I: 5mg BID, M: 10-20 mg/d), patch (3.8/5.7/7.6 mg/d)

Question 15

Brexpiprazole (Rexulti)

Answer 15

IMPULSIVITY, Dose-related Akathisia, long half life, fewer metabolic challenges than others; tablet only (2-4 mg/d)

Question 16

Cariprazine (Vraylar)

Answer 16

Dose-related Akathisia, long half-life; capsule only 1.5-6 mg/d)

Question 17

Clozapine (Clozaril, Fazaclo)

Answer 17

BLOOD DYSCRASIA, METABOLIC RISK, QTc prolongation, seizure, myocarditis, constipation, hypersialorrhea; gold standard treatment for refractory illness (suicide); NEED ANC per REMS monitoring – 1st 6mo: 1w sup + weekly blood draws, 2nd 6mo: 2w sup + biweekly draws, after 1yr: 1 mo supply + draws; tab, ODT, Suspension; I: 12.5 mg BID, inc by 25-50 mg q3d, cont until 450 mg/d or SE tolerability, if interuption >48 hrs restart at lowest dose

Question 18

Iloperidone (Fanapt)

Answer 18

ORTHOSTATIC HYPOTENSION, no notable prolactin elevation, QTc warnings, less sedating, not rec in severe hepatic impairment; tab (I: 1 mg BID, M: 6-12 mg BID) SLOW TITRATION NEEDED

Question 19

Lurasidone (Latuda)

Answer 19

DON’T USE W/ STRONG CYP3a4 INHIB/INDUC, no notable prolactin elevation/weight gain, less sedation/orthostasis; tab (40mg da w/ food)

Question 20

Lumateperone (Caplypta)

Answer 20

not rec in breast feeding, may impair fertility if used in third trimester, not associated w/ inc in EPS; Cap (42 mg da w/ food, dose titration not req)

Question 21

Olanzapine (Zyprexa)

Answer 21

METABOLIC RISKS, DRESS, post injection delirium/sedation syndrome (LAI. req 3hr observation period), Sedation, metabolic issues, QTc, ANC; tab, ODT, short acting IM, LAI (diff oral vs LAI dosing)