Schizophrenia Flashcards
1
Q
Schizophrenia pearls
A
- Age 20-30 onset
- Same prevalence worldwide
- PANSS scale for mental status
- Patient hx is important to rule out other conditions (drug-induced, comorbidity-induced)
2
Q
When should clozapine be considered?
A
- Treatment-resistant patients
- Substantial risk of, or attempted suicide
3
Q
T/F: SGA and FGA can be mixed without issues
A
F: FGA can negate efficacy of SGA
4
Q
FGA Side Effects
A
- EPS
- QTc prolongation
- Prolactin elevation
- Dermatologic
- Photosensitivity
- Blue/gray skin
- Orthostatic HTN
- Altered thermoregulation
5
Q
FGA BBW
A
Dementia-related psychosis -> do not use, increased risk of CV death
6
Q
SGA Side Effects
A
- Metabolic syndrome (Hypergly, hypertri, weight gain)
- QTc prolongation
- Blood dyscrasia/neutropenias
- Seizure threshold
- Anticholinergic
- Sedation
- Prolactin elevation
- Ophthalmic effects
7
Q
SGA BBW
A
Dementia-related psychosis
8
Q
Which SGA is approved for agitation in Alzheimer’s?
A
Brexpiprazole
9
Q
Which is the ONLY SGA not approved for schizophrenia?
A
Pimevanserin
10
Q
Which SGAs are approved for MDD augmentation?
A
- Aripiprazole
- Brexpiprazole
- Olanzapine (ONLY with fluoxetine)
- Quetiapine
11
Q
Aripiprazole
A
- Less sedating -> insomnia, akathisia, restlessness
- Impulsivity
Available as tablet, solution, Mycite, Initio injection, LAI
12
Q
Asenapine
A
- Less weight gain
- Less sedating/anticholinergic
- Do not drink/eat 10 min after SL
- CI in hepatic disease
- High QTc risk
- Monitor for anaphylaxis after 1st dose
- Skin site reactions, do not apply heat to patch
Available as SL, topical patch
13
Q
Brexpiprazole
A
- Long t1/2 (91h)
- Akathisia reported (dose related)
- Less metabolic ADEs
- Impulsivity
Available as oral tablet
14
Q
Cariprazine pearls
A
- Long t1/2 (91h) and metabolites contribute to late ADEs (accumulation)
- Akathisia (dose related)
- Less metabolic ADEs
Available as oral capsule
15
Q
Clozapine
A
- Gold standard for refractory/suicide risk
- Metabolic risks (greatest)
- BBW blood dyscrasias (REMS) - dose-independent
- QTc, bradycardia
- Myocarditis
- Seizure with high conc.
- Anticholinergic -> very constipating (can be fatal)
- Hypersalivation
- Hepatotoxicity, fever, PE, anticholinergic toxicity
- Dose interruption >48h needs re-titration
- Respiratory depression with benzos
- Clozapine + carbamazepine = low ANC
- Must trial 2 other drugs before starting
Available oral tablet, ODT, suspension
16
Q
Iloperidone
A
- Orthostatic HTN
- Priapism
- QTc, less sedation
- Avoid in hepatic impairment
- Slow titration
- Not really used
Available as oral tablet
17
Q
Lurasidone
A
- Neuro ADRs in dementia/PD
- No notable metabolic SE or EPS
- Sedation
Available as oral capsule
18
Q
Olanzapine
A
- Second worst for metabolic risk
- FDA BBW post-injection delirium/sedation (REMS) with LAI
- DRESS
- QTc
- anticholinergic
- Respiratory depression with benzos
Available as oral tablet, ODT, short acting IM, LAI
19
Q
Olanzapine + samidorphan
A
- Risk of opioid withdrawal if dependent/using
- Samidorphan is to mitigate metabolic effects of olanzapine
20
Q
Paliperidone
A
- QTc
- GI obstruction
- Priapism
- Metabolite of risperidone -> similar ADE
- Thrombotic thrombocytopenic
purpura, antiemetic effects
Available as oral tablet, LAI
21
Q
Pimavanserin
A
- No dopamine action
- Parkinson’s psychosis
- Avoid renal compromised
Available oral tablet
22
Q
Quetiapine
A
- Metabolic risks, sedating
- Misused for sleep
- IR and XL tablet
23
Q
Risperidone
A
- EPS, prolactin elevation
- TTP, antiemetic
Available oral tablet, ODT, solution, LAI
24
Q
Ziprasidone
A
- DRESS
- SJS
- QTc
- Take with food
- Priapism
- NIOSH
Available as oral tablet, short acting injection
25
LAIs
- Good for nonadherence
- Delayed effect
- Establish oral tolerability before starting
FGA: Fluphenazine, Haloperidol
SGA: Aripiprazole, Olanzapine (monitor for 3 hours afterwards), Risperidone, Paliperidone
26
High potency FGA
- Fluphenazine
- Haloperidol
High EPS risk
27
Low potency FGA
- Thioridazine
- Chlorpromazine
High anticholinergic risk
28
Geriatrics
- Start low, go slow
- Fall risk -> anticholinergics, orthostasis
29
Pregnancy/lactations
- Lowest effective dose
- Better to continue taking so you're not crazy with a baby
30
Can you use another LAI if a patient did not tolerate a first gen LAI?
Yes, newer LAIs are water-based and more tolerable generally
31
Which SGAs are most sedating and have most weight gain?
Clozapine, Olanzapine, Quetiapine
32
Which SGAs are more activating?
Lurasidone, Aripiprazole
33
How can you treat tardive dyskinesia?
DC offending agent
- DONT use anticholinergics, can mask symptoms
- VMAT2 inhibitors - benazines (Valbenazine, Deutrabenazine)
34
How can you treat akathisia?
- Beta blockers
- Dec dose or DC offending agent
35
How can you treat pseudo-parkinsonism?
- Anticholinergics
- Dec dose or DC offending agent
36
How can you treat acute dystonias?
- Anticholinergics
- IM BZDs
- Dec dose or DC offending agent
37
What is AIMS
Involuntary movement scale to monitor symptoms
38
NMS
- Rare, fatal
- High potency drugs (but can be all APS)
- Fever, unstable BP/HR/RR, confusion, muscle rigidity
- Caused by dopamine agonists
39
How can you treat NMS?
- DC offending agent
- DA agonists (bromocriptine)
40
Which drugs have decreased effectiveness while smoking?
CYP1A2: Olanzapine, Clozapine
41
What does acute dystonia look like?
Painful prolonged muscle contractions, larger muscle groups/face
42
What does pseudoparkinsonism?
Bradykinesia, pill rolling, tremor (like normal Parkinson's)
43
Akathisia
Restlessness, pacing, shuffling, can't sit still, very uncomfortable
44
Tardive dyskinesia
Very facial focus, chewing, lip smacking, tongue thrusting
45
Which SGAs have the lowest risk of EPS
Clozapine, quetiapine
46
Why does clozapine have a REMS program?
Blood dyscrasias BBW - monitor for low ANC
47
Which SGAs have the least amount of weight gain?
Aripiprazole, lurasidone, ziprasidone
48
Which SGAs are likely to increase prolactin?
Risperidone, paliperidone
49
Which SGAs are most likely to cause DRESS?
Olanzapine, ziprasidone
50
What is the biggest concern with antipsychotics in afib patients?
Torsades de Pointes
51
Which drugs are most likely to cause NMS?
High potency (fluphenazine, haloperidol), more D2
But can happen with any APS
