Schizophrenia Flashcards
Schizophrenia abnormalities in what 5 domains
delusions hallucinations disorganized thinking and speech grossly disorganized and abnoraml motor behavior negative symptoms
schizophrenia is more common in what gender
equal
onset on schizophrenia
men - early 20s
women late 20s to early 30s
positive symptoms of schizophrenia
hallucinations delusions disorganized speech unusual behavior combativeness and agitation
negative symptoms of schizophrenia
blunted affect alogia anhedonia avolition asociality loss of emotional connectedness
define alogia
no spontaneous talking
define anhedonia
inability to experience pleasure
define avoloition
lack of drive
cognitive impairments seen in schizophrenia
impaired attention
impaired working memory
impaired executive function
features associated with schizophrenia
inappropriate affect dysphoric mood (depression, anger, anxiety) disturbed sleep pattern lack of interest in food anosognosia hostility and aggression
define anosognosia
lack insight or awareness of disorder
to be diagnosed schizophrenic a patient must have 2+ or these for at least 1 month
delusions hallucinations disorganized speech grossly disorganized or catatonic behavior negative symptoms
to be diagnosed with schizophrenia how long must symptoms be present
6 months
define catatonia
marked psychomotor disturbance that may involve decreased motor activity, depressed engagement during interview or exam, or excessive and peculiar motor activity
catatonia is 3+ of the following symptosm
stupor catalepsy waxy flexibility mutism negativism posturing mannerism stereotypy agitation grimacing echolalia echopraxia
other psychiatric illness to rule out for diagnosis of schizophrenia
major depression schizoaffective disorder brief reactive psychosis schizophreniform disorder delusional disorder induced psychotic disorder panic disorder depersonalization disorder OCD personality disorders factitious disorders malingering
general medical illnesses to rule out for schizophrenia
temporal lobe epilepsy tumor, stroke, brain trauma endocrine/metabolic disorders B12 deficiency infections (neurosyphallis) autoimmune toxins (heavy metal poisining)
Drugs to rule out for schizophrenia
stimulants hallucinogens anticholingerics alcohol withdrawal barbituate withdrawal phencyclidine ketamine
black box warning on all atypical antipsychotics
increased mortality with dementia related psychosis
What is the principle difference between typical and atypical antipsychotics
type and severity of AEs including antihistaminic, antiserotoninergic, anti dopaminergic, anticholinergic, anti alpha 1 adrenergic
typical or atypical: aripiprazole
atypical
typical or atypical: asenapine
atypical
typical or atypical: clozapine
atypical
typical or atypical: iloperidone
atypical
typical or atypical: lurasidone
atypical
typical or atypical: olanzapine
atypical
typical or atypical: paliperidone
atypical
typical or atypical: quetiapine
atypical
typical or atypical: risperidone
atypical
typical or atypical: ziprasidone
atypical
aripiprazole brand name
abilify
asenapine brand name
saphris
clozapine brand name
clozaril
fazaclo
iloperidone brand name
fanapt
lurasidone brand name
latuda
olanzipine brand name
zyprexa
zydus
relprevv
paliperidone brand name
invega
quetiapine brand name
seroquel
risperidone brand name
risperdal
ziprasidone brand name
geodon
All typical antipsychotics pregnancy category
C
typical or atypical: chlorpromazine
typical
typical or atypical: fluphenazine
typical
typical or atypical: thioridazine
typical
typical or atypical: perphenazine
typical
typical or atypical: trifluoperazine
typical
typical or atypical: haloperidol
typical
typical or atypical: pimozide
typical
typical or atypical: thiothixene
typical
chlorpromazine brand name
thorazine
fluphenazine brand name
prolixin
thioidazine brand name
mellaril
perphenazine brand name
trilafon
trifluoperazine brand name
stelazine
haloperidol brand name
haldol
pimozide brand name
orap
thiothixene brand name
navane
usual dosage range of aripirazole
15-30 mg /day
max dosage of aripiprazole
30 mg/day
usual dosage range of olanzepine
15-20 mg/day
max dosage of olanzepine
30-40 mg/day (manufacturer says 20)
usual dosage range of quetiapine
300-800 mg/day
max dosage of quetiapine
800 mg/day (see 1000-1200 in practice)
usual dosage of risperidone
3-6mg/day
max dosage of risperidone
6-8 mg/day
usual dosage of ziprasidone
100-120 mg/day
max dosage of ziprasidone
160-240 (200)
starting dose of aripiprazole and frequency
10-15 mg/day given once daily
AEs of aripiprazole
headache dizziness weight gain agitation anxiety insomnia somnolence
aripiprazole pregnancy category
C
Drug interactions with aripiprazole
metoclopropamide fluoxetine/paroxetine quinidine carbamazepine valproic acid
Aripiprazole shouldn’t be given with this medicaiton
metoclopropamide
aripiprazole dose should be decreased 50% with this medication/s
fluoxetine
paroxetine
quinidine
apriprazole dose should be doubled with this medication
carbamazepine
ariprazole dosage forms
PO or IM
aripriprazole frequency
QD or Q month (IM)
A poor CYP 2D6 metabolizer should get what dose of abilify maintena
300 mg
what is the normal dose of abilify maintena
400 mg
what is the dose of abilify maintena for a cyp2D6 poor metabolizer taking CYP3A4 inhibitors
200 mg
What is the dose of abilify maintena for those taking 400 mg normally on stong cyp 2D6 or cyp 3A4 inhibitors for > 14 days
300 mg
What is the dose of abilify maintena for those taking 400 mg normally on stong cyp 2D6 AND cyp 3A4 inhibitors for > 14 days
200 mg
What is the dose of abilify maintena for those taking 400 mg normally on stong cyp 3A4 inducers for > 14 days
Avoid use
What is the dose of abilify maintena for those taking 300 mg normally on stong cyp 2D6 or cyp 3A4 inhibitors for > 14 days
200 mg
What is the dose of abilify maintena for those taking 400 mg normally on stong cyp 2D6 and cyp 3A4 inhibitors for > 14 days
160 mg
What is the dose of abilify maintena for those taking 400 mg normally on stong cyp 3A4 inducers for > 14 days
avoid use
how does aripiprazole interact with metoclopropamide
increased risk f EPS
how does aripiprazole interact with fluoxetine/paroxetine
increased aripiprazole concentration
how does aripiprazole interact with quinidine
increased aripiprazole concentration
how does aripiprazole interact with carbamazepine
increased aripiprazole clearance
how does aripiprazole interact with valproic acid
decreased aripiprazole concentration
How to calculate ANC
total WBC * (% neutrophils + % bands) /100
Asenapine dose for schizophrenia
5 mg BID
Asenapine dosage form
sublingual!
AEs of asenapine
weight gain, hyperglycemia, EPS, insomnia, somnolence, orthostatic hypotension, prolonged QTC, HA, dizziness, increased triglycerides/cholesterol, increased prolactin levels, increased LFTs
Asenapine pregnancy category
C
Drugs to avoid with asenapine
Quinolone antibiotics Phenothiazines TCAs Pimozide Class IA and III antiarhytmics Quetiapine Haloperidol Risperidone Ziprasidone
Why avoid drugs with asenapine
increased QTC
Clozapine dose
12.5 BID increased gradually by 25-50 mg to 300 mg by day 14.
Clozapine max dose
900 mg /day
Black box warning with clozapine
agranulocytosis
myocarditis
seizures
AEs with clozapine
drowsiness, dizziness hypersalivation orthostatic hypotension tachycardia hyperglycemia weight gain increased triglycerides/cholesterol constipation
clozapine pregnancy cat
B
Clozapine interaction with benzos
delirium, sedation
resp. collapse
clozapine interaction with smoking
decreased clozapine concentration
clozapine interaction with carbamazepine
increased risk of bone marrow depression
What medications should be avoided with clozapine
carbamazepine
ritonavir
tramadol
clozapine interaction with ritonavir
increased clozapine concentration
clozapine interaction with tramadol
increased risk of seizure
How often is CBC drawn with clozapine
QW x 6 months,
QOW for months 7-12,
1 QM after 12 months,
QW x 1 month after d/c
Risk factors for agranulocytosis with clozapine
female,
40+
low initial WBC
signs/symptoms of agranulocytosis
malaise fatigue fever/chills arthralgias myalgias
Iloperidone dose
1 mg BID day 1, 2 mg BID day 2, 4 mg BID day 3, 6 mg BID day 4, target dose of 12-24 mg BID
AEs of iloperidone
dizziness, dry mouth nasal congestion orthostatic hypotension weight gain tachycardia hyperglycemia increased prolactin levels neutropenia/leucopenai
which medications should be avoided with iloperidone
class 1A and II antiarrhythmics
quinolone antibiotics
phenothiazine antipsychotics
Iloperidone pregnancy cat
c
Lurasidone dose
40 mg QD w/food.
lurasidone max dose
80 mg/day
Lurasidone pregnancy cat
B
AEs of lurasidone
somnolence akathisia nausea parkinsonism agitation
lurasidone should be avoided with what medications
ketoconazole
rifampin
lurasidone interaction with ketoconazole
increased lurasidone levels
lurasidone interaction with rifampin
decreased lurasidone levels
Olanzapine dose
5-10 mg initially. target 10 mg/day up to 30-40 mg/day
long acting injection of olanzipine brand name
relprevv
dosing of relprevv for the first 8 weeks if the target oral dose is 10 mg
210 mg Q2 weeks or 405 mgQ4 weeks
dosing of relprevv for the first 8 weeks if the target oral dose is 15mg
300 mg Q 2 week
dosing of relprevv for the first 8 weeks if the target oral dose is 20 mg
300 mg Q 2 weeks
dosing of relprevv for the after 8 weeks if the target oral dose is 10 mg
150 mg Q 2 weeks or 300 mg Q 4 weeks
dosing of relprevv for the after 8 weeks if the target oral dose is 15 mg
210 Q 2 weeks or 405 Q 4 weeks
dosing of relprevv for the after 8 weeks if the target oral dose is 20 mg
300 mg Q 2 weeks
AEs of olanzipine
sedation, weight gain, dry mouth, increased LFTs,
orthostatic hypotension, hyperglycemia, increased triglycerides/cholesterol, increased prolactin, tachycardia
olanzipine pregnancy cat
C
olanzepine interaction with smoking
decreased olanzepine concentration -> adjust dose
olanzepine interaction with caffeine
inreased olanzepine concentration -> may require dec. dose
olanzepine should be avoided with what medications
alcohol, benzos, clomipramine
olanzepine interaction with clomipramine
increased risk of seizures
olanzepine interaction with alcohol/benzo
orthostatic hypotension
paliperidone is the active metabolite of what
risperidone
paliperidone AEs
sedation, dizziness, increased prolactin, hyperglycemia, weight gain
Paliperidone preg cat
C
Paliperidone dose
6 mg PO QD
paliperidone dose in moderate renal impairment
3 mg PO QD
paliperidone max dose
12 mg QD
Invega Sustenna is injected where
deltoid/glute
Invega sustenna dose if on 3 mg daily oral
39-78 mg
Invega sustenna dose if on 6 mg daily oral
117 mg
Invega sustenna dose if on 12 mg daily oral
234 mg
How often is invega sustenna injected
Q4 weeks
Avoid paliperidone with what drugs
Class 1A, III anti arrhythmics
Quinolone antibiotics
Why avoid paliperidone with other drugs
increased QTC
Risperidone dose
0.5 mg BID to 3 mg BID
AEs of risperidone
sedation, dizziness, tachycardia, sexual dysfunction, rhinitis, nausea, menstrual disturbances, weight gain, hyperglycemia, increased prolactin levels
Risperidone interaction with antihypertensives
inceased orthostasis -> monitor BP
Risperidone preg. Cat
C
Risperidone consta starting dose
25 mg Q 2 weeks
risperidone consta oral supplementation is given how long
first 3 weeks
Where is risperidone consta injected
IM upper outer gluteal quadrant
Quetiapine IR dose
25 mg BID day 1 50 mg BID day 2 100 mg BID day 3 100 mg AM + 200 mg PM day 4 increase up to 800 mg/day as needed
Quetiapine ER dose
300 mg QD in evening up to 400-800 /day
AEs of quetiapine
somnolence, agitation, weight gain, dizziness, orthostatic hypotension, increased triglycerides, hyperglycemia
quetiapine preg cat
C
Quetiapine drug interactions
3A4 inhibitors (ketoconazole, erythromycin)
Ziprasidone dose
20 mg BID to 80 BID
ziprasidone dose IM for acute psychotic agitation
10 mg @ 2 hour intervals or 20 mg @ 4 hour intervals
max ziprasidone IM dose
40 mg
Ziprasidone effect on weight
neutral
ziprasidone effect on prolactin levels
none
AEs of ziprasidone
dyspepsia, constipation, nausea, abdominal pain, increase QTC, hyperglycemia
Ziprasidone drugs to avoid
quinolone antibiotics macrolide antibiotics azole antifungals TCA Phenothiazines Clindamycin Class 1A, III antiarrhythmics
Why avoid drugs with ziprasidone
increased QTC
Ziprasidone preg Cat
C
Which atypical antipsychotics cause the most sedation
clozapine
lurasidone, olanzapine, quetiapine
Which atypical antipsychotics cause the most EPS
paliperidone, risperidone, ziprasidone
Which atypical antipsychotics cause the most anticholinergic effect
clozapine, iloperidone
Which atypical antipsychotics cause the least anticholinergic effects
aripiprazole, asenapine, ziprasidone
Which atypical antipsychotics cause the most orthostasis
clozapine, iloperidone
which atypical antipsychotics cause the least orthostasis
aripiprazole, ziprasidone
which atypical antipsychotics cause the most weight gain
clozapine, olanzapine
which atypical antipsychotics cause the least weight gain
aripiprazole, lurasidone, ziprasidone
which atypical antipsychotics cause the more increase in prolactin levels
riperidone, paliperidone
which atypical antipsychotics have negligible effects on glucose
aripiprazole, asenapine, iloperidone, lurasidone, ziprasidone
which atypical antipsychotics have increased effects on lipids
clozapine, olanzapine
which atypical antipsychotics have negligible effect on QTC
aripiprazole, paliperidone, risperidone
baseline monitoring for all atypical antipsychotics
AIMS, CBC, Chem 7, TFTs, Lipids, A1C, EKG, BP, Pulse, Wt, Pregnancy test, BMI
Baseline monitoring for quetiapine
atypical antipsychotics + eye exam
Basline monitoring for ziprasidone
atypical antipsychotics + hypo mg++ and K+
monitoring for all atypical antipsychotics monthly
resolution of symptoms, BP, pulse, Wt, BMI
monitoring for all atypical antipsychotics quarterly
lipid panel, fasting glucose, a1C
monitoring for all atypical antipsychotics twice a year
AIMS
monitoring for quetiapine twice a year
AIMS + eye exam
Monitoring for all atypical antipsychotics annually
EKG, Chem 7, TFTs, CBC
Monitoring for clozapine at baseline
AIMS, CBC with diff, Chem 7, TFTs, Lipids, A1C, EKG, BP, Pulse, weight, Pregnancy test
What antipsychotics are preg cat B
clozapine, lurasidone
monitoring for clozapine for first 2 weeks
daily BP + pulse
monitoring for clozapine weekly for first 6 months
WBC+ ANC
weight
if > 5% weight gain = FBS, vitals, resolution of symptoms
monitoring for clozapine biweekly for months 6-12
WBC+ANC
monitoring for clozapine every 4 weeks for months 12+
WBC+ANC
monitoring for clozapine monthly
BP, pulse
monitoring for clozapine quarterly
lipids, glucose, A1C
monitoring for clozapine twice a year
AIMS
monitoring for clozapine annually
EKG, CBC, chem 7, TFTs
Pregnancy cat for all typical antipsychotics
C
name high potentcy typical antipsychotics
thiothixene, haloperidol, fluphenazine
name low potentcy typical antipsychotics
chlorpromazine
high potentcy antipsychotics have more what
EPS
low potency antipsychotics have more what
sedation, hypotension, and anticholinergic effects
baseline monitoring for typical antipsychotics
AIMS, CBC, chem 7, TFTs, A1C, EKG, BP, pulse, temp, weight, BMI, pregnancy
monitoring for typical antipsychotics monthly
resolution of symptoms, BP, pulse, weight, BMI
monitoring for typical antipsychotics quarterly
A1C
monitoring for typical antipsychotics twice a year
AIMS
monitoring for typical antipsychotics annually
EKG, chem 7, CBC, eye exam if doses > 2000 mg/day
monitoring for fluphenazine annually
EKG, chem 7, CBC
5 indicators of a good response for schizophrenia
acute onset good premorbid adjustment late age of onset (late 20s) short duration of illness presence of precipitating factors
3 indicators of a poor response for schizophrenia
primarily negative symptoms
cognitive deficits
dual diagnosis
5 indicators for hospitalization
risk of harm to others? risk of suicide risk of accidental injury severe disorganization severe psychotic symptoms (catatonia)
treatment goals for the first 7 days of hospitalization
decrease agitation
decrease hostility and aggression
normalize eating and sleeping
how long to treat first psychotic episode
until remission of symptoms plus 24 months
how long to treat those with multiple psychotic episodes
usually life long therapy
5 years then consider lower dose
aburpt discontinuation of antipsychotics leads to what symptoms
salivation lacrimation insomnia vivid dreams N/V/diarrhea sweating rebound cholinergic outflow - SLUD
factors that favor a more gradual taper of antipsychotics
history of violence/aggression suicide attempts high doses severe course of illness switching to or from clozapine
conversion from oral fluphenazine to depot injection dose
1.2 x total daily dose to nearest 12.5 mg weekly for 4-6 weeks
conversion from oral haloperidol to depot injection dose
10 x total daily dose to nearest 50 mg monthly (max dose 100 mg) if higher than 100 mg given rest 4-7 days later
given oral dose how long after starting depot for haloperidol
first month
given oral dose how long after starting depot for fluphenazine
first week
fluphenazine depot dose
25-50 mg Q 2 weeks
haloperidol depot dose
150 mg Q 4 weeks
mood stabilizers used to augment antipsychoticss
lithium, valproic acid, carbamazepine, gabapentin, lamotrigine
SSRIs used to augment antipsychotics
paroxetine, fluoxetine, sertraline, fluvoxamine, citalopram
adequate trial of propranolol to augment antipsychotics
6-8 weeks
what is considered an adequate trial of an antipsychotic
6-8 weeks at upper end of dosage range
Medications to consider with new diagnosis of schizophrenia
single atypical antipsychotic aripiprazole olanzapine quetiapine risperidone ziprasidone
medications to consider if failed first schizophrenia therapy
different atypical or typical antipsychotic
medication to consider if failed two schizophrenia therapies
clozapine
AEs of typical antipsychotics
sedation, EPS, anticholinergic, orthostasis, weight gain, increased prolactin
Which atypical causes the most sedation
clozapine
Which atypicals cause moderate sedation
lurasidone
olanzipine
quetiapine
Which atypicals cause moderate EPS
paliperidone
risperidone
ziprasidone
which atypicals have negligible effects on EPS
aripiprazole
iloperidone
Which atypicals have neglible anticholinergic effects
aripiprazole
asenapine
ziprasidone
which atypicals have the most anticholinergic effects
clozapine
which atypicals have moderate anticholinergic effects
iloperidone
olanzipine
Which atypicals have the most orthostasis
clozapine
iloperidone
which atypicals have low orthostasis
aripiprazole
ziprasidone
which atypicals have the most weight gain
clozapine
olanzipine
which atypicals have the least weight gain
aripiprazole
lurasidone
ziprasidone
which atypical has no effect on prolactin
aripiprazole
which atypicals have the most effects on prolactin
paliperidone
risperidone
Which atypicals have neglible effect on glucose
aripiprazole asenapine iloperidone lurasidone ziprasidone
which atypicals have moderate effect on glucose
clozapine
olanzipine
which atypicals have neglible effects on lipids
aripiprazole asenapine iloperidone lurasidone ziprasidone
which atypicals have the most effect on lipids
clozapine
olanzipine
which atypical has a moderate effect on lipids
quetiapine
which atypicals have negligable effects on QTC
aripirazole
paliperidone
risperidone
which typical antipsychotics are phenothiazines
chlorpromazine fluphenazine thioridazine perphenazine trifluoperazine
which typical antipsychotics are butyrophenones
haloperidole
which typical antipsychotics are diphenylbutylpiperadines
pimozide
which typical antipsychotics are thioxanthenes
thiothixene
which typical antipsychotics are high potency
fluphenazine
haloperidol
thiothixene
which typical antipsychotics are low potency
chlorpromazine
which typical antipsychotics are medium potency
perphenazine
which augmenters are used for mood stabilization (labile mood and aggression)
lithium valproic acid carbamazepine gabapentin lamotrigine
how long is an adequate trial of an augmenter
2 weeks
EXCEPTION propranolol 6-8 weeks
which SSRIs are used to augment antipsychotics
paroxetine fluoxetine fluvoxamine citalopram sertraline
When is propranolol used to augment antipsychotics
aggressive especially in demented
which antipsychotics should be started after diagnosis of schizophrenia
aripiprazole olanzapine quetiapine risperidone ziprasidone
After a patient fails one atypical antipsychotic in schizophrenia what should be started
any antipsychotic
when should clozapine be started
after failing 2 antipsychotics
which typical antipsychotics cause high sedation
chlorpromazine
thioridazine
which typical antipsychotics cause moderately high sedation
lozitane
which typical antipsychotics cause moderate sedation
perphenazine
trifluoperazine
which typical antipsychotics cause low sedation
thiothixene
fluphenazine
haloperidol
which typical antipsychotics cause high EPS
fluphenazine
haloperidol
perphenazine
thiothixene
which typical antipsychotics cause moderately high EPS
chlorpromazine
loxitane
thioridazine
trifluoperazine
which typical antipsychotics cause high anticholinergic effects
thioridazine
which typical antipsychotics cause moderately high anticholinergic effects
chlorpromazine
which typical antipsychotics cause moderate anticholinergic effects
loxitane
perphenazine
which patients have higher incidence of acute dystonic reactions
male
> 40
high potency typical
what is given to treat acute dystonic reactions
benztropine 2 mg IV or lorazepam 2 mg IM
define acute dystonic reactions
acute muscle rigidity of face, neck, tongue
when is an acute dystonic reaction likely to occur
first week of treatment
when is akathisia likely to occur
within the first 3 months
define akathisia
inability to sit still
how to you manage antipsychotic induced akathisia
lower dose, switch to atypical AP, or beta blocker (atenolol 50 mg/day)
how to manage AP induced akinesia
decrease dose or d/c
define akinesia
lack of spontaneous activity
when is pseudo parkinsonism likely to occur
1-2 weeks after start up to 3 months
who is more likely to get pseudo parkinsonism
female
older
how to mange AP induced pseudo parkinsonism
atypical or bentropine 1 -4 mg BID
What is neuroleptic malignant syndrome
fever altered conciousness autonomic dysfunction lead pipe rigidity lactic acidosis, renal failure, rhabdomylisis
how to treat NMS
stop AP
ICU
supportive care
which is more likely to get NMS
high potency antipsychotics depot antipsychotics dehydrated physical exhaustion organic mental disorders
When does tardive dyskinesia occur
months to years
define tardive dyskinesia
abnormal involuntary movements; irreversible
risk factors for tardive dyskinesia
older organic mental disorder DM mood disorders Female long term use daily dosage
how to treat tardive dyskinesia
prevent -> regular AIMS (Q6Mo)
clonazepam?
Which typical antipsychotics lower seizure threshold
phenothizaines
clozapine + chlorpromazine
Typical antipsychotics should be used with caution with what other medications due to increased orthostasis
antihypertensives
Oral anticoagulants should be avoided with which typical antipsychotics
phenothiazines
