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BCPS > Schizophrenia & Antipsychotics > Flashcards

Schizophrenia & Antipsychotics Flashcards

1
Q

Schizophrenia criteria for diagnosis

A

Must have 1 of delusions, hallucinations, or disorganized speech

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2
Q

Anosognosia

A

Patient lack of awareness or insight into schizophrenia illness

Occurs in about 57-98%

Most common predictor of nonadherence

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3
Q

Positive symptoms

A

Antipsychotics most effective

Clinically significant = acute phase schizo

Hallucinations
Delusions
Paranoia/suspiciousness
Conceptual disorganization
Hostility
Grandiosity
Excitement
Loose associations
Thought broadcasting
Thought insertion

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4
Q

Negative symptoms

A

Antipsychotics may not be completely effective

Flat affect
Social withdrawal
Lack of personal hygiene
Prolonged time to respond
Poor rapport
Poor abstract thinking
Lack of spontaneity, flow of convo
Emotional withdrawal
Ambivalence
Asociality
Amotivation
Anhedonia

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5
Q

Cognitive symptoms

A

No current medications effectively treat

Poor executive function
Impaired attention
Impaired working memory (does not learn from mistakes)

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6
Q

Stages of Schizophrenia

A

Prodromal (gradual development of symptoms but not super noticeable)

Acute (clinically significant positive sypmtoms)

Stabilization (acute phase decreasing)

Stable (positive symptoms declined, possible to have negative or cognitive symptoms)

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7
Q

Neurotransmitters involved in schizophrenia

A

Dopamine
Serotonin
Glutamate

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8
Q

Low potency FGA

A

Chlorpromazine
Thioridazine

Low potency = low affinity for DA receptor = more drug available to go to other receptors = more side effects

AC = Sedation = OH > EPS

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9
Q

Moderate potency FGA

A

Loxapine
Perphenazine
Trifluoperazine

Moderate AC, sedative, OH, EPS ADE

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10
Q

High potency FGA

A

Haloperidol
Fluphenazine
Pimozide
Thiothixene

EPS&raquo_space;> AC = sedative = OH

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11
Q

FGA side effect based on receptor

A

Anticholinergic: dry mouth, constipation, blurred vision, urinary hesitancy

Antihistamine: sedation (dose related)

Alpha blockade: orthostatic hypotension

Dopamine blockage (in nigrostriatal pathway): EPS, hyperprolactinemia

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12
Q

SGA Partial dopamine agonists

A

Aripiprazole
Brexipiprazole
Cariprazine

Stabilizes dopamine transmission

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13
Q

SGA with D3 receptor blockade

A

Cariprazine - may have benefit at negative and cognitive symptoms

Aripiprazole

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14
Q

SGA with serotonin 1A partial activity

A

Aripiprazole
Brexipiprazole
Cariprazine
»
Clozapine
Quetiapine
Ziprasidone

May benefit cognition, decrease EPS, and improve mood

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15
Q

Monitoring parameters for ALL SGAs

A

Baseline & periodically

BMI
Blood pressure
Fasting glucose
Lipids
Waist circumference

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16
Q

Antipsychotics with highest risk of weight gain, diabetes

A

Olanzapine
Clozapine

> > >

Quetiapine
Risperidone

Low potency FGA > High potency FGA

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17
Q

SGA with no EPS

A

Lumateperone (caplyta)

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18
Q

SGA with no glucose or lipid effect

A

Lumateperone (caplyta)

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19
Q

Most sedating SGA

A

Clozapine
Quetiapine

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20
Q

SGA with most orthostasis

A

Clozapine
Iloperidone - has strict titration schedule to minimize OH

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21
Q

SGA with warning for suicidal ideation

A

Aripiprazole
Brexipiprazole
Cariprazine
Lumateperone
Lurasidone
Quetiapine

These are also used for treatment of mood disorders (depression)

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22
Q

Pseudoparkinsonism

A

EPS

Bradykinesia, rigidity, tremor, akinesia

  1. Reduce dose
  2. Change to another antipsychotic with less risk
  3. If cannot change, add on diphenhydramine, trihexyphenidyl, benztropine
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23
Q

SGA with highest Parkinsonism risk

A

Paliperidone
Risperidone
Lurasidone
Olanzapine

Parkinsonism Risk Lay On

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24
Q

Dystonia

A

Acute EPS - usually from high dose parenteral agents

Torticollis, laryngospasm, oculogyric crisis (upward deviation of both eyes)

  1. Treat using IM anticholinergics
  2. Prevent with PO anticholinergics
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25
Q

Akathisia

A

EPS

Restlessness, inability to stay calm

  1. Reduce antipsychotic dose
  2. Change to agent with less risk
  3. If unable, lipophilic BB
  4. If cannot do BB, then benzo, mirtazapine, trazodone, cyproheptadine

Responds POORLY to anticholinergics!

26
Q

SGA with low akathisia

A

Clozapine
Iloperidone
Quetiapine

27
Q

Tardive Dyskinesia

A

EPS

Abnormal, involuntary movements of orofacial muscles. May be irreversible.

Risk highest with high doses, >54 y/o, women

  1. Lower dose
  2. Change agent - but caution as their disease may be stable at the current agent
  3. Use Valbenazine or Deutetrabenazine

DO NOT GIVE ANTICHOLINERGICS

28
Q

Agents with lowest Tardive Dyskinesia Risk

A

Clozapine – not associated with TD.

SGAs have low potential

29
Q

Valbenazine (Ingrezza)

A

VMAT2 inhibitor used for TD

Adjust for strong CYP3A4, 2D6 inhibitors

ADR: sleepiness, depression, QTc prolongation

30
Q

Deutetrabenazine (Austedo)

A

VMAT2 inhibitor for TD

Adjust for strong CYP2D6 inhibitors

ADR: sleepiness, depression, QTc prolongation

BBW: increased risk of suicide

31
Q

Neuroleptic Malignant Syndrome

A

Medical Emergency

Agitation, confusion, muscle rigidity, fever, tachycardia, autonomic instability, diaphoresis

  1. D/C Antipsychotic
  2. Supportive cares
  3. Bromocriptine or dantrolene
  4. Wait at least 14 days before restarting antipsychotic

Highest risk with high potency FGAs

32
Q

Hyperprolactinemia highest risk and lowest risk

A

Breast enlargement, galactorrhea, sexual dysfunction, infertility, menstrual changes

Highest risk: FGAs, risperidone, paliperidone

Aripiprazole may lower prolactin concentrations

33
Q

QTc prolongation

A

Chlorpromazine
IV haloperidol
Thioridazine

Clozapine
Ziprasidone
Iloperidone

34
Q

Antipsychotics that lower seizure threshold

A

Chlropromazine
Cariprazine
Clozapine

35
Q

Antipsychotics with lowest seizure risk

A

Aripiprazole
Fluphenazine
Haloperidol
Pimozide
Rispseridone
Thioridazine
Trifluoperazine

36
Q

CYP1A2 substrates, inducer, inhibitor

A

Sub:
Clozapine
Asenapine
Ziprasidone
Olanzapine

Inducer:
Cannabis
Tobacco

Inhibitor:
Caffeine

37
Q

CYP2D6 sub, inhib

A

Substrate:
Brexipiprazole
Iloperidone
Perphenazine
Aripiprazole
Risperidone

Inhibitor
Cannabis
Chlorpromazine
Fluphenazine

38
Q

CYP3A4 subs

A

CHILL ZAP QB

Cariprazine
Haloperidone
Iloperidone
Lumateperone (avoid with inducers, inhibitors)
Lurasidone

Ziprasidone
Aripiprazole
Pimavanserin

Quetiapine
Brexipiprazole

39
Q

Haldol & Fluphenazine decanoate

A

Require bridging with oral therapy

Made with sesame oil

40
Q

BBW for clozapine

A

Agranulocytosis
OH, Bradycardia, syncope, cardiac arrest (titrate slowly)
Seizure
Myocarditis, cardiomyopathy

41
Q

ANC monitoring for normal ANCs (>1500, or >1000 (BEN)) on clozapine

A

Initiation - 6 months: weekly

6 mo-12 mo: every 2 weeks

> 12 mo: monthly

If >30 day treatment interruption, will restart monitoring

42
Q

Mild neutropenia on clozapine

A

ANC 1000-1499

Continue treatment

Monitor ANC 3x weekly until >1500 then resume normal monitoring

43
Q

Severe neutropenia on clozapine

A

ANC <500

Stop and do not rechallenge

Monitor ANC daily until >1000 (or >500 for BEN)

Monitor 3x weekly until >1500 (or >baseline for BEN)

44
Q

Unique side effect from aripiprazole & brexipiprazole

A

Pathological gambling, other compulsive behavior

45
Q

Aripiprazole LA-I and overlap

A

Ability Maintena, Asimtufi: 14 days

Aristada Initio: 1 dose of 30mg

Aristada: if not given with Initio, then needs 21 day overlap

46
Q

Can you bathe or swim with asenapine patch?

A

Unknown
But you can shower

47
Q

Brexipiprazole dose reduction needed when..

A

CrCl < 60
Moderate hepatic impairment

48
Q

Antipsychotics CI with severe hepatic impairment

A

LICAR (b/c liquor is bad for liver)

Lumateperone
Iloperidone
Cariprazine
Asenapine
Risperidone

49
Q

Cariprazine half life

A

2-4 days, metabolites have longer

Dose changes may not be clinically seen for a while

50
Q

Lumateperone unique MOA

A

-Presynaptic partial agonism for D2
-Postsynaptic antagonism D2
-60x more affinity for Serotonin 2A than D2
-Glutamatergic activity moderator

May be why low incidence of EPS

51
Q

Lurasidone administration

A

At least 350kcal of food

52
Q

Olanzapine-samidorphan

A

Combination to help mitigate weight gain

Delay for a minimum of 7 days after opioids (14 days if long acting)

53
Q

Paliperidone LA-I

A

Establish tolerability with paliperidone first but no bridging required

Must have one-time pretreatment with Sustenna before going to 3-month (Trinza) or 6-month (Hafyera) form

54
Q

Renal adjustments needed

A

Brexpiprazole (<60ml/min)
Lurasidone
Paliperidone
Risperidone (<30ml/min)

55
Q

Risperidone LA-I

A

Establish tolerability first

Risperdal Consta (IM) requires 3 week bridge with oral risperidone

SC Perseris and Uzedy do not require oral overlap

56
Q

Ziprasidone administration

A

Must be taken with 500 calories

57
Q

Ziprasidone warning

A

DRESS – can be fatal

Cutaneous skin reactions, eosinophilia, fever

Hepatitis, nephritis, pneumonitis, myocarditis, pericarditis

58
Q

Treatment initiation

A

FGA or SGA is reasonable, individualize approach

If has history of use with antipsychotics, can be more aggressive

Older adults with other physical issues may need 1/4-1/2 normal starting dose

59
Q

Time to effect

A

2-4 weeks - reassess 2-4 weeks after reaching therapeutic dose

60
Q

Changing or discontinuing antipsychotics

A

Gradual discontinuation to avoid withdrawal

61
Q

Treatment resistant schizophrenia DOC

A

Clozapine

62
Q

Adjunctive options

A

Lamotrigine (add to clozapine if partial response)

Benzos during acute phase

Antidepressants if depressed

Precedex in acute setting for agitation

BCPS (27 decks)

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