Schizophrenia and atypical antipsychotics Flashcards
circumstantiality
apparently unnecessary detail and irrelevant remarks make it take forever to get to the point
tangential thinking
moving from thought to thought without ever getting to the point. thoughts are somewhat connected to
perseverative thinking
continuous negative thinking about future or past events
neologisms
new word, expression, or usage
echolalia
repetition of another’s speech
verbigeration
compulsive repetition of meaningless words, phrases, or sentences
loss of ego boundaries
no sense of where they end and something else begins
types of ego boundary loss
ideas of reference
thought control
thought broadcasting
fused with an external object
disintegrated and fused with the universe
thought broadcasting
thinking others can read their mind or they can broadcast thoughts through TV or radio
cenesthetic hallucinations
sensation of an altered state of bodily organs like burning in the brain or pushing in the blood vessels
what is the leading cause of death among schizophrenics
suicide
risk factors for violent/impulsive behavior in schizophrenics
persecutory delusions
previous episodes of violence
neurologic deficits
what are the 3 subgroupings of symptoms for schizophrenia
positive sx
negative sx
cognitive sx
quick way to remember difference between positive and negative symptoms
positive sx are abnormal behavior
negative sx are the absence of normal behavior
which two antipsychotics cause the most weight gain and development of DM
olanzapine and clozapine
what are some labs you should check prior to prescribing antipsychotics
weight/height = BMI
waist circumference
BP
fasting plasma glucose
fasting lipids
main indications for antipsychotic use
schizophrenia and schizoaffective
mood disorders
other indications for antipsychotic usage
aggressive/violent behavior
AIDS dementia
Autism
Tourette’s
Huntington’s
Lesch-Nyhan syndrome
Indications for clozapine other than failed treatments
severe TD
low threshold for EPS
what increases the effectiveness of clozapine
risperidone
indications for risperidone
-acute and maintenance of schizophrenia
-acute manic/mixed episodes of bipolar 1
-irritability associated w/ autism
half life for risperidone
20 hours
when does risperidone reach peak plasma levels
1 hour for parent and 3 hours for metabolite
available formulations for risperidone
oral solution
disintegrating tablet
depot
PO
how should you start depot of risperidone
give PO with depot for first few weeks
dosage for PO risperidone
1-2mg at hs which can be increased to 4mg
what can happen with risperidone SSRI combo
marked elevation in prolactin
what drugs inhibit CYP2D6 and should not be given with risperidone
paroxetine
fluoxetine
other name for risperidone
risperidal
other name for paliperidone
invega
indications for paliperidone
acute/maintenance of schizophrenia
acute schizoaffective disorder
adjunct to mood stabilizers
adjunct to antidepressants
peak plasma and steady state for paliperidone
24 hours and 4-5 days
recommended dosage for paliperidone
6mg daily with or w/o food
half life of IM paliperidone
24-49 days
how do you initiate IM paliperidone
first 2 in deltoid then you can alternate between deltoid and gluteal
indications for olanzapine
schizophrenia
acute tx of manic/mixed episodes in bipolar 1
maintenance of bipolar 1
other name for olanzapine
zyprexa
how can zyprexa be used for bipolar 1
as monotherapy
adjunct to valproate or lithium
combo w/ fluoxetine (Symbyax)
zyprexa as monotherapy for tx resistant depression
No
peak concentration of olanzapine
5 hours
half-life of olanzapine
31 hours
daily dosing
available formulations of olanzapine
disintegrating tablet
IM
PO
what should you not administer with olanzapine
benzodiazepines
starting dose for PO olanzapine
5-10mg
starting dose for olanzapine in acute mania
10-15mg
how fast can you titrate olanzapine
weekly intervals
why would you use an IM olanzapine
acute agitation
what is the name of olanzapine depot
Relprevv
where do you administer relprevv
gluteal only
not approved for deltoid
how often do you give relprevv and how do you monitor
q2-4 weeks
monitor for 3 hours post injection d/t risk of delirium sedation
other name for quetiapine
seroquel
indications for quetiapine
-schizophrenia
-acute mania in bipolar 1
-monotherapy for depression associated with bipolar 1
-maintenance for bipolar 1
-adjunct to antidepressants for MDD
peak plasma and steady state for quetiapine
1-2 hours and 7 hours
how often do you dose quetiapine
2-3x daily
dosage for quetiapine
start 25mg BID and increase by 25-50mg q2-3 days up to 300-400mg daily
why can quetiapine be dosed daily if it has a short half-life
receptor occupancy remains when concentration has markedly declined
dosage of quetiapine for insomnia
25-300mg
when should you dose quetiapine
evening with food
when should you NOT give quetiapine
-with other drugs that increase QT interval
-hx of cardiac arrythmia
-hypokalemia or hypomagesemia
which antipsychotic other than clozapine is least likely to cause EPS
quetiapine
other name for ziprasidone
geodon
indications for ziprasidone
schizophrenia
monotherapy for acute manic/mixed episode of bipolar 1
adjunct to lithium or valproate
peak plasma and steady state for ziprasidone
2-6 hours and 1-3 days
BID dosing
what doubles bioavailability of ziprasidone
food
peak concentration and half life of ziprasidone IM
1 hour and 2-5 hours
available formulations of ziprasidone
PO
IM
dosage of IM ziprasidone
10mg q2h
or
20mg q4h
Max daily dose is 20mg
initial dose of PO ziprasidone
40mg
what drugs interact with ziprasidone
ones that prolong QT interval
the other name for aripiprazole
abilify
indications for aripiprazole
schizophrenia
acute manic/mixed and maintenance for bipolar 1
adjunct to antidepressants for MDD
irritability associated w/ autism
peak concentration and half-life of aripiprazole
3-5 hours and 75 hours
once daily dosing
how does aripiprazole work
as a modulator rather than a blocker
can you give aripiprazole as an adjunct to lithium or valproate? why?
No because interaction prevents them from reaching steady state
starting dose for aripiprazole
10-15mg but 5mg may improve tolerability
weight gain, prolactin, QT interval with aripiprazole
not significantly effected
other name for asenapine
saphris
indications for asenapine
schizophrenia
acute/mixed episodes of bipolar 1 with or w/o psychotic features
peak plasma concentration of asenapine
1 hour
route of asenapine
SL because bioavailability so low with digestion
dosage of asenapine for schizophrenia
5mg BID
dosage of asenapine for bipolar
10mg BID
asenapine effect on QT interval and prolactin
elevate and prolong
other name for clozapine
clozaril
indications for clozapine
schizophrenia
sever psychotic depression
huntington’s disease
idiopathic parkinson’s disease
tx resistant mania
peak levels and steady state of clozapine
2 hours and less than 1 week
half-life of clozapine
12 hours
initial dosage of clozapine
25mg once or twice daily
titration of clozapine
can increase by 25mg q2-3 days up to 300mg daily in divided doses
clozapine and lithium
increased risk for seizures
monitoring of clozapine
weekly WBC for first 6 months then q 2 weeks
when to dc clozapine
WBC<3000
or
granulocyte <1500
other name for iloperidone
fanapt
indications for iloperidone
schizophrenia in adults
does clozapine prolong QT interval
yes
titration of clozapine
comes in titration pack
effective dose reached in 4 days
start 1mg and increase by 1mg each day for 4 days
other name for lurasidone
latuda
indications for lurasidone
schizophrenia
titration of lurasidone
not required
dosage and range of lurasidone
start at 40mg
effective 40-120mg
adjustments to lurasidone for renal and hepatic impairment
renal NTE 80mg daily
hepatic NTE 40mg daily
other name for lumateperone
caplyta
how long until you have to restart titration of an atypical
if you miss for 36 consecutive hours
what drugs need tapered down when discontinuing to avoid cholinergic rebound
olanzapine and clozapine
which atypical requires informed consent
clozapine
which atypicals lack anticholinergic effects
risperidone, ziprasidone, and quetiapine
how do you mitigate the risk of cholinergic rebound
give anticholinergic temporarily while weening off antipsychotic
which atypical can you give if there has been agranulocytosis with clozapine
olanzapine
what is considered late onset schizophrenia
after age 45
diagnostic rating scales for schizophrenia
PANSS (+ and - sx scale)
BPRS (brief psychiatric rating scale)
rating scales to track EPS
SAS (Simpson Angus scale)
AIMS
BARS (Barnes akathisia rating scale)
what typically predicts patients course of schizophrenia
pattern during first 5 years
schizophrenic sx categories severity over time
positive sx tend to get less severe
negative sx tend to get more severe
antipsychotics most likely to cause EPS
risperidone
olanzapine
ziprasidone
which antipsychotic can actually decrease severe tardive dyskinesia
clozapine
when would you consider using clozapine
after treatment failure of 2 other antipsyhotics
what is an adequate trial of antipsychotic medication
4-6 weeks
seasonality of birth r/t schizophrenia
more likely to be born in winter or early spring
what prenatal infection can predispose to schizophrenia
prenatal exposure to the flu
dopamine hypothesis of schizophrenia
sx result from dopamine excess
serotonin hypothesis of schizophrenia
serotonin excess can cause + and - sx AEB increased efficacy of meds with robust serotonergic activity
cognitive remediation
computer exercises to influence neural networks and improve cognition
GABA in schizophrenia
patients can have a loss of GABA neurons in the hippocampus which leads to an increase in dopamine activity as GABA has regulatory effect on dopamine
