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neurology/psychiatry > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

age of onset

A

late teens to early thirties
earlier in men

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2
Q

what does positive symptoms mean

A

abnormally PRESENT:
hallucination, paranoia, delusion, hostility, disorganized speech, ideas of reference

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3
Q

what does negative symptoms mean

A

abnormally ABSENT
affect, alogia, avolition, asociality, anhedonia
the five As

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4
Q

other symptoms of schizophrenia

A

attention and memory deficits, poor hygiene, poor psychosocial function

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5
Q

dopamine hypothesis

A

brain of a patient with schizophrenia produces more dopamine than a typical brain

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6
Q

mesolimbic pathway effects of D2 blockade

A

decrease in positive symptoms

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7
Q

mesocortical pathway effects of D2 blockade

A

increase in negative symptoms

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8
Q

nigrostriatal pathway effects of D2 blockade

A

increase in EPS

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9
Q

tuberoinfundibular pathway effects of D2 blockade

A

increase in prolactin

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10
Q

differential diagnosis: things to rule otu

A

meds (dopa agonists, steroids, overdose, withdrawal, hallucinogens)
medical conditions like thyroid, infectious, epilepsy, wilson’s disease, SLE

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11
Q

goals of therapy

A

reduce/eliminate symptoms
promote/maintain recovery
reduce medication adverse effects
improve QOL

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12
Q

APA recommendations

A

treat with an antipsychotic and monitor for effectiveness and side effects. no evidence that one antipsychotic is superior to another (except clozapine)

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13
Q

when do you qualify for clozapine

A

after 2 failed trials of a FGA or SGA

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14
Q

factors to consider when selecting treatment

A

side effect profile, past response, health conditions, med formulations, drug interactions

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15
Q

antipsychotic response seen in hours to days

A

agitation, aggression, motor activity

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16
Q

antipsychotic response seen in 2-6 weeks

A

hallucinations
disorganized thinking

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17
Q

antipsychotic response seen in months or longer

A

delusions
negative symptoms

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18
Q

receptor targets

A

D2, M1, H1, alpha1, serotonin

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19
Q

effects of D2 receptor antagonism

A

therapeutic
EPS
hyperprolactinemia

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20
Q

effects of M1 receptor antagonism

A

anticholinergic

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21
Q

effects of H1 receptor antagonism

A

weight gain, sedation

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22
Q

effects of alpha1 receptor antagonism

A

syncope, orthostatic hypotension, reflex tachycardia

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23
Q

effects of serotonin receptor antagonism

A

reduce EPS, improve cognition, antidepressant

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24
Q

what is the optimal occupancy of D2 receptors

A

60-80%

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25
Q

general adverse effects of FGAs

A

extrapyramidal: akathisia, parkinsonism, dystonia, tardive dyskinesia

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26
Q

general adverse effects of SGAs

A

metabolic

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27
Q

FGAs

A

haloperidol
fluphenazine
trifluoperazine
thiothixene
loxapine
perphenazine
thioridazine
chlorpromazine

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28
Q

FGAs are characterized by

A

strong D2 affinity

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29
Q

low potency FGAs

A

chlorpromazine, thioridazine

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30
Q

high potency FGAs

A

haloperidol
fluphenazine
thiothixene
trifluoperazine
loxapine
perphenazine

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31
Q

implications of low potency FGAs

A

need a higher dose to get the D2 blockade
anticholinergic, sedation, orthostasis

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32
Q

implications of high potency FGAs

A

stronger D2 antagonism so stronger EPS

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33
Q

haloperidol pearls

A

IM:PO 1:2

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34
Q

fluphenazine pearls

A

IM:PO 1:2, dilute oral liquid prior to use

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35
Q

chlorpromazine pearls

A

weight gain, sedation (less potent)
IM:PO 1:4

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36
Q

thiothixene and trifluoperazine pearls

A

smoking may reduce levels due to CYP1A2 induction from hydrocarbons in cigarette smoke

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37
Q

thioridazine pearls

A

highest Qt prolongation risk

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38
Q

which FGAs have long acting injection forms

A

haloperidol and fluphenazine

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39
Q

describe dystonia

A

happens within 24-96 hours, involuntary muscle contraction results in slow repetitive movements or abnormal postures

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40
Q

dystonia risk factors

A

high potency antipsychotics, high dose, young men

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41
Q

dystonia treatment

A

diphenhydramine, benztropine
consider dose reduction

42
Q

describe akathisia

A

happens within days to weeks, inner motor restlessness

43
Q

akathisia risk factors

A

fast titration, middle aged females

44
Q

akathisia treatment

A

propranolol, anticholinergic, benzodiazepine, consider dose decrease/medication change

45
Q

describe pseudoparkinsonism

A

happens within days to weeks, stooped posture, shuffling gait, rigid, tremors, pill rolling hand motion

46
Q

pseudoparkinsonism risk factors

A

high potency antipsychotics, high dose, older age, females

47
Q

pseudoparkinsonism treatment

A

benztropine, diphenhydramine, amantadine, consider dose decrease

48
Q

describe dyskinesia

A

months to years, rapid, repetitive, involuntary movements such as rolling tongue, smacking lips, chewing

49
Q

dyskinesia risk factors

A

older age, females, other EPS, chemical abuse, mood disorders

50
Q

dyskinesia treatment

A

VMAT inhibitors
switch to clozapine
pyridoxine
weak: ginko, clonazepam, amantadine

51
Q

SGAs

A

aripiprazoke, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone

52
Q

which SGAs have long acting injection forms

A

aripiprazole, olanzapine, paliperidone, risperidone

53
Q

quetiapine pearls

A

sedation: dose at bedtime
XL formation once daily, <300 calories

54
Q

olanzapine pearls

A

high metabolic risk
smoking induces CYP1A2 metabolism
do not give IM olanzapine within 2 hours of IM lorazepam (cardiorespiratory depression, excessive sedation)

55
Q

risperidone pearls

A

strong D2 affinity
renal dose adjustments
hyperprolactinemia risk

56
Q

paliperidone pearls

A

active metabolite of risperidone
renal dose adjustments
hyperprolactinemia
increased bioavailability with food
ghost tablet (shell of tablet in poop)

57
Q

aripiprazole pearls

A

activating at low dose
low risk weight gain
dose adjustments for CYP inhibitors/inducers
may assist in antipsychotic-induced hyperprolactinemia

58
Q

brexpiprazole pearls

A

renal dose adjust, hepatic dose adjust, CYP dose adjust

59
Q

cariprazine pearls

A

avoid CrCL<30

60
Q

lurasidone pearls

A

take with 350 calories
renal/hepatic dose adjust
low weight gain risk

61
Q

ziprasidone pearls

A

take with 500 calories
QT prolongation (especially IM)
low weight gain risk

62
Q

iloperidone pearls

A

significant orthostasis– titrate by no more than 4 mg/day

63
Q

pimavanserin pearls

A

no D2 activity
only used in Parkinson Disease Psychosis

64
Q

asenapine pearls

A

SL tablet: no food/drink for 10 mins
contraindicated in severe hepatic impairment

65
Q

lumateperone

A

take with food
dose adjust in hepatic impairment

66
Q

metabolic syndrome criteria

A

must meet at least 3 criteria:
waist circumference >40 inches male, 35 female
triglycerides >150
HDL <40 male, 50 female
fasting blood glucose >110
BP>130/85

67
Q

SGAs with highest risk of EPS, hyperprolactinemia

A

risperidone, paliperidone

68
Q

SGAs with highest risk of seizures, anticholinergic

A

clozapine, olanzapine

69
Q

SGA with highest risk of orthostatic hypotension, sedation, weight gain, increased blood glucose, lipid abnormalities

A

clozapine

70
Q

5 black box warnings for clozapine

A

severe neutropenia
seizure
myocarditis
orthostatic hypotension, bradycardia, syncope
increased mortality in elderly patients with dementia related psychosis

71
Q

what is the black box warning on ALL antipsychotics

A

increased mortality in elderly patients with dementia related psychosis

72
Q

what is REMS monitoring requirement for clozapine

A

severe neutropenia, agranulocytosis

73
Q

how is clozapine dosed (starting and titration)

A

start at 12.5 mg once or twice daily
increase by 25-50 mg/day inpatient or per week outpatient

74
Q

what do do if you missed a dose of clozapine for >48 hours

A

re-initiate with 12.5-25 mg/day

75
Q

what is the risk with missing clozapine doses

A

hypotension, bradycardia, syncope
associated with the alpha antagonism & building a tolerance to it

76
Q

therapeutic drug monitoring for clozapine: what is the target trough level

A

350-500 ng/mL
but really we are targeting how they respond, not an exact level

77
Q

what must the ANC count be before initiating clozapine

A

> 1500

78
Q

what is the ANC monitoring schedule for clozapine

A

weekly x 6 months
biweekly x 6 months
then monthly

79
Q

what is the recommendation for clozapine if ANC 1000-1499 (mild neutropenia)

A

monitor 3x/week and resume normal schedule once ANC >1500

80
Q

what is the recommendation for clozapine if ANC 500-999 (moderate neutropenia)

A

interrupt therapy and monitor daily ANC until >1000 (may resume at this point)
then monitor 3x/week until ANC>1500

81
Q

what is the recommendation for clozapine if ANC <500 (severe neutropenia)

A

interrupt therapy & do not rechallenge unless prescriber determines benefit outweighs risk
daily ANC until >1000 then 3x/week until >1500

82
Q

what are TITRATION-DEPENDENT adverse effects of clozapine

A

orthostasis
tachycardia
sedation
myocarditis

83
Q

what are DOSE-DEPENDENT adverse effects of clozapine

A

seizures

84
Q

what are DOSE-INDEPENDENT adverse effects of clozapine

A

sialorrhea (drooling), constipation, urinary incontinence

85
Q

how can you treat sialorrhea with clozapine?

A

atropine eye drops SL or ipratropium nasal spray SL
glycopyrrolate, benztropine, clonidine

86
Q

how can you treat constipation with clozapine?

A

osmotic laxatives (miralax), stimulant laxatives (senna(, stool softeners (colace)

87
Q

how can you treat seizures with clozapine?

A

seizure prophylaxis when levels reach >1000 mcg/L

88
Q

what is neuroleptic malignant syndrome?

A

rare life-threatening syndrome that involves fever, lead-pipe rigidity, mental status changes, leukocytosis, elevated creatinine kinase, AST/ALT

89
Q

how is neuroleptic malignant syndrome managed?

A

-straight to the hospital
-discontinue antipsychotic for at least 2 weeks
-no other psychotropic (except benzos) for 2 weeks
-bromocriptine and dantrolene

90
Q

when to use caution with antipsychotics for QT prolongation

A

pre-existing abnormalities, other QT prolonging agents, patients with baseline QT ~500

91
Q

monitoring for QT prolongation?

A

baseline & annual EKG, K+, Mg2+

92
Q

which antipsychotics cause the most QT prolongation

A

thioridazine, ziprasidone

93
Q

which antipsychotics are used for acute psychotic agitation

A

haloperidol
fluphenazine
clorpromazine
olanzapine
ziprasidone
risperidone, aripiprazole

94
Q

what agents are used for anxiety-related agitation

A

benzos like lorazepam*, diazepam
non-benzo hydroxyzine
* note separate IM olanzapine and IM lorazepam by at least 2 hours

95
Q

which agents are used for extrapyramidal symptoms and sedation for acute agitation?

A

benztropine, diphenhydramine

96
Q

what are the key principles to initiation of LAIAs

A

establish oral tolerability first
screen for dose adjustments/contraindications to LAIA
identify if loading dose or oral overlap needed
determine maintenance dose & frequency

97
Q

which FGAs are available as injectables

A

haloperidol decanoate and fluphenazine decanoate

98
Q

which SGAs are available as injectables

A

aripiprazole
olanzapine
paliperidone
risperidone

99
Q

are there any allergy considerations for LAIAs

A

fluphenazine decanoate and haloperidol decanoate are suspended in sesame oil– check for sesame allergy

100
Q

which LAIA has a rems program?

A

olanzapine pamoate: for post-injection delirium/sedation syndrome, increased mortality in elderly patients with dementia-related psychosis
MUST OBSERVE FOR AT LEAST 3 HOURS AFTER INJECTION, BE ACCOMPANIED UPON LEAVING FACILITY
aka a lot of paperwork

neurology/psychiatry (22 decks)

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