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Psychiatric Pharmacotherapy > Schizophrenia > Flashcards

Schizophrenia Flashcards

1
Q

Iatrogenic causes of Schizophrenia can be due to __.

A

excessive thyroid or corticosteroids

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2
Q

The misuse of __ and __ can cause Schizophrenia.

A

alcohol and psychoactive substances

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3
Q

All antipsychotics work by __.

A

post-synaptic block of dopamine receptors

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4
Q

Drugs, particularly __ may precipitate Schizophrenia

A

dopamine agonists

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5
Q

A lack of __ and __ may prolong the course of schizophrenia.

A

support and adherence

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6
Q

Under the DSM-5 Criteria for diagnosis of Schizophrenia, there must be __ with each persisting for a significant portion of at least 1 month. Continuous signs of the disorder should occur for at least __.

A
  1. 2 or more symptoms (DHDGN)

2. 6 months

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7
Q

*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The 1st ‘D’ refers to __.

A

Delusions

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8
Q

*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The ‘H’ refers to __.

A

Hallucinations

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9
Q

*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The 2nd ‘D’ refers to __.

A

Disorganized speech

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10
Q

*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The ‘G’ refers to __.

A

Grossly disorganized or catatonic behavior

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11
Q

*Under the DSM-5 Criteria for diagnosis of Schizophrenia patients will present with DHDGN symptoms. The ‘N’ refers to __.

A

Negative symptoms e.g. Affective flattening, Alogia , Anhedonia, Avolition
(AAAA)

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12
Q

It is important to rule out __, __, __ and __ as causes of Schizophrenia.

A

Schizoaffective, Mood disorder, Medical disorder and substance use.
(SMMS)

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13
Q

The effects of relapse often occur only __ after stopping treatment.

A

several weeks

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14
Q

*Methods to improve compliance in schizophrenic patients include: ICP. ‘I’ refers to __.

A

IM long acting injections

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15
Q

*Methods to improve compliance in schizophrenic patients include: ICP. ‘C’ refers to __.

A

Community psychiatric nurse

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16
Q

*Methods to improve compliance in schizophrenic patients include: ICP. ‘P’ refers to __.

A

Patient and family (caregiver) education

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17
Q

An antipsychotic blocking dopamine receptors in the Mesolimbic tract leads to __.

A

reduction of positive symptoms of Schizophrenia (efficacy)

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18
Q

An antipsychotic blocking dopamine receptors in the Mesocortical tract leads to __.

A

negative symptoms (adverse effect)

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19
Q

An antipsychotic blocking dopamine receptors in the Nigrostriatal tract leads to __.

A

Extrapyramidal Side Effects (EPSE) (adverse effect)

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20
Q

An antipsychotic blocking dopamine receptors in the Tuberoinfundibular tract leads to __.

A

hyperprolactinemia (adverse effect)

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21
Q

The main dopamine receptor modulated by antipsychotics is the __.

A

dopamine 2 receptor

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22
Q

*An adequate trial of antipsychotics for Schizophrenia is generally defined as __ + __ + __.

A

compliance + at least 2-6wks + optimal therapeutic doses

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23
Q

*Clozapine should be considered for treatment resistant Schizophrenia. What defines ‘treatment resistant’?

A

failure of 2 or more adequate trials of different antipsychotics (at least 1 SGA)

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24
Q

Routine hematological monitoring is required for __ due to __.

A

patients on clozapine due to risk of agranulocytosis

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25
Q

Antipsychotics are to be used with caution in patients with cardiovascular disease due to __.

A

QTC prolongation (contraindication)

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26
Q

Antipsychotics are to be used with caution in __ due to EPSE.

A

patients with Parkinson’s Disease

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27
Q

Antipsychotics are to be used with caution in patients with blood dyscrasias, especially for __.

A

Clozapine

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28
Q

Antipsychotics are to be used with caution in __, due to increased risk (2-3x) for mortality and stroke.

A

Elderly patients with dementia

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29
Q

*In acute agitation (psychiatric emergency), what should be the treatment plan if the patient is cooperative?

A

Consider PO:
Lorazepam 1-2mg or
Antipsychotic i.e. risperidone 1-2mg

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30
Q

*In acute agitation (psychiatric emergency), what should be the treatment plan if the patient is uncooperative and remains agitated/aggressive?

A 
Consider fast acting IM injection: 
Haloperidol 2.5-10mg /Lorazepam 1-2mg or both (common)
Olanzapine (uncommon)
Promethazine (sedating effect only)
Aripriprazole 
(CHLOPA)
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31
Q

The use of haloperidol in acute agitation requires a __ which may be hard to do.

A

pre-treatment ECG

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32
Q

The concurrent use of __ and __ can lead to cardio-pulmonary collapse. Therefore, a lock out period of 1 hr in between use should be observed.

A

IM Olanzapine

IM Lorazepam

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33
Q

The use of __ is appropriate for a patient presenting with catatonia.

A

BZDs i.e. PO/IM Lorazepam

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34
Q

*For PO Haloperidol (serenance/haldol), state for adults:

The Usual starting dose

A

0.5-3mg BD/TDS or 3-5mg BD/TDS (severe symptoms)

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35
Q

*For PO Haloperidol (serenance/haldol), state for adults:

The Usual Dose range

A

5-15mg/day

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36
Q

*For PO Haloperidol (serenance/haldol), state for adults:

The Max dose

A

20mg/day

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37
Q

*For fast acting Haloperidol IM Injection, state for adults:

The Usual starting dose

A

2-5mg/dose

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38
Q

*For fast acting Haloperidol IM Injection, state for adults:

The Usual Dose range

A

2-10mg/dose/day

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39
Q

*For fast acting Haloperidol IM Injection, state for adults:

The Max dose

A

18mg/day

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40
Q

*For Clozapine (clozaril), state for adults:

The Usual Starting dose

A

12.5 MG on/bd (Day 1)
25-50 MG (day 2)
*increase gradually if well tolerated in steps of 25-50 mg/day

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41
Q

*For Clozapine, state for adults:

The Usual Dose range

A

200-450mg/day

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42
Q

*For Clozapine, state for adults:

The Max dose

A

900mg/day

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43
Q

*For Olanzapine, state for adults:

The Usual Starting dose

A

PO: 10 mg/day
IM: 2.5-10mg q2-4hrs, Max 3 doses/day.

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44
Q

*For Olanzapine, state for adults:

The Usual Dose range

A

5-20mg/day

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45
Q

*For Olanzapine, state for adults:

The Max dose

A

20mg/day

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46
Q

*For Quetiapine (seroquel), state for adults:

The Usual Starting dose

A

25 MG bd (Day 1), 50 MG bd (Day 2),

100 MG bd (Day 3), 150 MG bd (Day 4)

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47
Q

*For Quetiapine (seroquel), state for adults:

The Usual Dose range

A

150-500mg/day

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48
Q

*For Quetiapine (seroquel), state for adults:

The Max dose

A

800mg/day

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49
Q

*For PO Risperidone (risperdal), state for adults:

The Usual Starting dose

A

2 mg/day in 1 or 2 divided doses

50
Q

*For PO Risperidone (risperdal), state for adults:

The Usual Dose range

51
Q

*For PO Risperidone (risperdal), state for adults:

The Max dose

52
Q

*For IM Haloperidol decanoate (haldol), state for adults:

The Usual Starting dose

A

Test dose 25 – 50 mg

At least 3-7 days interval before top up dose

53
Q

*For IM Haloperidol decanoate (haldol), state for adults:

The Usual Dose range

A

50 - 300mg / 4 weeks

doses halved if given every 2 weeks

54
Q

*For IM Haloperidol decanoate (haldol), state for adults:

The Max dose

A

300mg/ 4 wks

55
Q

*For IM Risperidone (risperdal consta), state for adults:

The Usual Starting dose

A

25 mg/ 2 wks (if on oral dose of up to 4 MG/day)

37.5 mg/ 2 wks (if on oral dose > 4 MG/day)

56
Q

*For IM Risperidone (risperdal consta), state for adults:

The Usual Dose range

A

25 – 37.5 MG / 2 WK

57
Q

*For IM Risperidone (risperdal consta), state for adults:

The Max dose

A

50 MG / 2 WK

58
Q

*What should we note when initiating IM Risperidone (risperdal consta)?

A

Supplement with oral dose during 1st 3 weeks upon initiating 1st injection

59
Q

*For IM Palperidone (invega sustenna), state for adults:

The Usual Starting dose

A

Initiate 150mg -> 100mg 1 wk later -> 25-50mg/4wks (if on oral 3mg/day) or 75mg/4wks (if on oral 6mg/day)

60
Q

*For IM Palperidone (invega sustenna), state for adults:

The Usual Dose range

A

25-150mg/ 4wks

61
Q

*For IM Palperidone (invega sustenna), state for adults:

The Max dose

A

150mg/ 4wks

62
Q

*For IM Palperidone (invega trinza), state for adults:

The Usual Starting dose

A 
Invega sustenna --> Invega Trinza
50MG -> 175MG
75MG -> 263MG
100MG -> 350MG
150MG -> 525MG
63
Q

*For IM Palperidone (invega trinza), state for adults:

The Usual Dose range

A

175-525mg/3months

64
Q

*For IM Palperidone (invega trinza), state for adults:

The Max dose

A

525mg/3months

65
Q

When can patients use IM Palperidone (invega trinza) to take advantage of its 3monthly dosing?

A

For patients stabilized on monthly IM paliperidone (invega sustenna) over past ≥ 4 months

66
Q

*For patients concerned with weight gain i.e. DM/obese/hyperlipidemia patients, what are good antipsychotic choices?

A

No weight gain: Lurasidone, aripriprazole, brexipiprazole and ziprasidone (LABZ)
Minimal weight gain: haloperidol

67
Q

*Which antipsychotics will induce the most weight gain and should be avoided in DM/obese/hyperlipidemia patients?

A

Clozapine and Olanzapine

68
Q

*Which antipsychotics should we choose if the patient is very concerned with EPSE?

A

SGAs > FGAs

69
Q
  • The patient presents with Muscle spasms, e.g. oculogyric crisis, torticollis. The onset of symptoms was within minutes (if IM/IV) or hrs (if PO) of taking antipsychotics.
    1. What is the adverse effect the patient is suffering from ?
    2. how can we manage it?
A
  1. EPSE: Dystonias

2. IM cholinergics i.e. benztropine, diphenhydramine

70
Q

What are the risk factors for dystonias (EPSE) in a patient using antipsychotics?

A

High potency antipsychotics i.e. haloperidol
Young Males
Neuroleptic naïve patients
(HYN)

71
Q
  • The patient presents with Tremors, rigidity, bradykinesia, bradyphrenia, salivation. The onset of symptoms was within days or weeks of taking antipsychotics.
    1. What is the adverse effect the patient is suffering from?
    2. How can we manage it?
A
  1. EPSE: Pseudo-parkinsonism
  2. lower antipsychotic dose, or switch to SGA
    Add Anticholinergics PRN, e.g. benzhexol (aka trihexyphenidyl),
72
Q

What are the risk factors for Pseudo-parkinsonism (EPSE) in a patient using antipsychotics?

A

Elderly females

Previous neurological damage (e.g. head injury, stroke)

73
Q
  • The patient presents with restlessness. The onset of symptoms was within hours to weeks of taking antipsychotics.
    1. What is the adverse effect the patient is suffering from?
    2. How can we manage it?
A
  1. Akathesia
  2. lower antipsychotic dose, or switch to SGA
    Add Clonazepam (low dose) PRN
    Add Propranolol 20mg TDS (max 160mg/day)
74
Q

*The patient presents with Orofacial movements (lip
chewing, tongue protrusion), choreiform hand movements pelvic thrusting. The onset of symptoms was after months/years of antipsychotic use and is 50% irreversible.
1. What is the adverse effect the patient is suffering from?
2. How can we manage it?

A
  1. Tardive Dyskinesia
  2. Discontinue any anticholinergics
    Lower antipsychotic dose, or switch to SGA (Clozapine possibly effective)
    Add Reversible inhibitor of vesicular monoamine transporter 2 (VMAT2): Valbenazine 40-80mg/day
    Add Clonazepam PRN
75
Q

What are the risk factors for Akathesia (EPSE) in a patient using antipsychotics?

A

High potency antipsychotics > Risperidone > Olanzapine > Quetiapine/Clozapine
(HROQC - HR Owes QC)

76
Q

The use of anticholinergic agents is not helpful in the management of which EPSE?

77
Q

What are the (FACA) risk factors for Tardive dyskinesia (EPSE) in a patient using antipsychotics?

A
  • FGA > SGA
  • Patients who develop acute EPSEs when initiated on FGA
  • Chronic use: 5% of patients per year of antipsychotic exposure
  • Worsen with anticholinergic drugs
78
Q
  • The patient presents with Galactorrhea, Amenorrhea, reduced libido and Gynecomastia (males).
    1. What is the adverse effect the patient is suffering from?
    2. How can we manage it?
A
  1. Hyperprolactinemia
  2. Lower FGA dose
    Add Dopamine agonist (e.g. amantadine, bromocriptine)
    Switch to Aripiprazole
79
Q

What are the risk factors for Tardive dyskinesia (EPSE) in a patient using antipsychotics?

A

FGAs, Paliperidone => Risperidone > other SGAs

FPRS

80
Q

*How can antipsychotic induced weight gain be managed?

A

Switch to lower risk agents
Lifestyle modification: diet, exercise
Treat diabetes (e.g. with metformin), hyperlipidemia
(SLT)

81
Q

*How can orthostatic hypotension be managed in schizophrenia patients?

A
  1. Get up slowly from a sitting/lying position

2. Switch to lower risk agents i.e. Aripriprazole, Sulpiride, Olanzapine, Ziprasidone (ASOZ)

82
Q

*How should we manage QTC prolongation in schizophrenia patients?

A
  1. if >500ms refer

2. Switch to lower risk agents i.e. Quetiapine > Risperidone> Olanzapine (QRO)

83
Q

*How should we manage DVT/PE in schizophrenia patients?

A
  1. Anticoagulation

2. Prefer high potency drugs

84
Q
  • The patient presents with Muscle rigidity, fever, autonomic dysfunction, increased HR, labile BP, diaphoresis), altered consciousness, increased CK. Onset: hours to 3 days (within 30 days)
    1. What is the adverse effect the patient is suffering from?
    2. How can we manage it?
A
  1. Neuroleptic malignant syndrome (NMS)
  2. IV Dantrolene 50mg TDS
    Oral dopamine agonist (e.g. amantadine, bromocriptine), supportive measures.
    Switch to SGA
85
Q

What are the risk factors for Neuroleptic malignant syndrome (NMS) in a patient using antipsychotics?

A

High potency antipsychotics (i.e. fast acting IM Haloperidol)

86
Q

*How should we manage lowered WBC, Absolute neutrophil count (ANC) and agranulocytosis in schizophrenia patients?

A

Discontinue antipsychotic if severe (WBC < 3 x10^9/L or ANC < 1.5 x10^9 /L)

87
Q

What are the risk factors for agranulocytosis in a patient using antipsychotics?

A 
Clozapine use (1%)
- very rare for other antipsychotics < 1 in 10,000
88
Q

*How often should we monitor the BMI of a patient initially started on antipsychotics?

A

Weekly for 1st 6 weeks OR
at least monthly x 3 months for SGA
x 6 months
- or every visit

89
Q

*How often should we monitor the BMI of a patient who antipsychotic dose is stabilized?

90
Q

*How often should we monitor the fasting blood sugar of a patient on antipsychotics, if the patient has low risk for DM?

91
Q

*How often should we monitor the fasting blood sugar of a patient on antipsychotics, if the patient has high risk for DM?

A

4 months after initiating new antipsychotic (or 3 months after initiating SGA) –> then annually

92
Q

*How often should we monitor the lipid panel of a patient on antipsychotics, if the patient has low risk for hyperlipidemia?

A

q2-5 years

93
Q

*How often should we monitor the lipid panel of a patient on antipsychotics, if the patient has high risk for hyperlipidemia?

A

3 months after initiating SGA –> then q6 months

94
Q

*How often should we monitor the blood pressure of a patient on antipsychotics?

A

3 months after initiating SGA –> then annually

95
Q

*How often should we conduct an EPSE Exam for rigidity, tremors, akathisia, tardive dyskinesia for a patient initially started on antipsychotics?

A

Weekly for 1st 2 weeks after initiation or until dose stabilized

96
Q

*How often should we conduct an EPSE Exam for rigidity, tremors, akathisia, tardive dyskinesia for a low-risk patient dose stabilized on antipsychotics?

A

FGA q6 months

SGA q12 months

97
Q

*How often should we conduct an EPSE Exam for rigidity, tremors, akathisia, tardive dyskinesia for a high-risk patient dose stabilized on antipsychotics?

A

FGA q3 months

SGA q12 months

98
Q

*How often should we monitor the WBC and ANC of a patient on Clozapine?

A

Weekly for first 18 weeks –> then monthly.

99
Q

*What should we note for elderly schizophrenia patients when initiating pharmacological treatment?

A
  1. Avoid Orthostatic hypotension –> Prefer ASOZ
  2. Avoid Anticholinergic SEs –> prefer SGAs (except clozapine)
  3. Simplify regime
    AAS
100
Q

What should we note when using antipsychotics in patients with parkinson’s disease?

A

Disease interactions: antipsychotics worsen Parkinson’s Disease Symptoms

101
Q

What are some antipsychotics that have interaction with CYP1A2 inducers i.e. smoking, Rifampicin, Phenobarbitone, Phenytoin?

A

Ziprasidone, Clozapine*, Haloperidol, Olanzapine, Phenothiazines
(ZCHOP)
*Seizures and death

102
Q

What are some antipsychotics that have interaction with CYP1A2 inhibitors?

A

Ziprasidone, Clozapine, Haloperidol, Olanzapine, Phenothiazines
(ZCHOP)

103
Q

What are some CYP1A2 inhibitors?

A

Quinolones, Macrolides, Fluvoxamine

QMF

104
Q

What drug can worsen Clozapine’s agranulocytosis SE?

A

Carbamazepine

105
Q

Common DDIs with antipsychotics based on their side effects?

A 
Additive effects based on: 
- Anticholinergic
- Antihistamine 
- Alpha-1 adrenergic blockade 
- Dopamine blockade 
- CNS depressant effects
(AAADC)
106
Q

How is efficacy monitored in Schizophrenia?

A

Mental State Examinations (non-specific)

Psychiatric rating scales

107
Q

How is toxicity monitored in Schizophrenia?

A

Metabolic parameters

EPSE: presence of symptoms

108
Q

How is Drug induced pseudo parkinsonism (EPSE) monitored in Schizophrenia?

A

Simpson Angus Rating Scale

109
Q

How is Akathisia (EPSE) monitored in Schizophrenia?

A

Barnes Akathisia Scale

110
Q

How is Tardive Dyskinesia (EPSE) monitored in Schizophrenia?

A

AIMS (Abnormal Involuntary Movement Scale)

DISCUS (Dyskinesia Identification System: Condensed User Scale)

111
Q

When a patient is newly initiated on antipsychotics, what kind of benefits can they expect in the 1st week?

A

Lowered: agitation, aggression, hostility

*Patients will feel sleepy

112
Q

When a patient is newly initiated on antipsychotics, what kind of benefits can they expect by the 2nd-4th week?

A

Lowered: paranoia, hallucinations, bizarre behaviors
Improved: organization in thinking

113
Q

When a patient is newly initiated on antipsychotics, what kind of benefits can they expect by the 6th week?

A

Lowered: delusions
Improved: Negative Symptoms

114
Q

When a patient is newly initiated on antipsychotics, what kind of benefits can they expect by the 3rd-6th month?

A

Improved: maybe Cognitive Symptoms (with SGAs)

115
Q

What kind of benefits can a Schizophrenic patient expect if they are on FGAs only?

A

Improvement in positive symptoms

116
Q

What kind of benefits can a Schizophrenic patient expect if they are on SGAs only?

A

Improvement in both positive and mood symptoms

117
Q

What is the main difference between FGAs and SGAs in terms of their side effects?

A

FGAs: More ‘muscle’ SEs
SGAs: More metabolic SEs

118
Q

Which SGAs have the least metabolic side effects?

A

Lurasidone, Aripiprazole, Brexpiprazole, Ziprasidone

LABZ

119
Q

What can we generally observe for SGAs ending with ‘-ines’? (e.g. Cloza pine , Olanza pine , Quetia pine

A

Relatively more sedating and more weight gain

120
Q

What can we generally observe for SGAs ending with ‘-ones’ or ‘-piprazoles’? (e.g. Risperidone, Lurasidone, Ziprasidone, Aripiprazole)

A

Relatively less sedating and less weight gain

Psychiatric Pharmacotherapy (5 decks)

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