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PHA333 > Schizophrenia (AS) > Flashcards

Schizophrenia (AS) Flashcards

1
Q

mortality with schizophrenia

A

mortality rate is higher

20% shorter life expectancy

causes of inc mortality:

  • inc suicide
  • inc circulatory conditions, infections, endocrine disorders
  • higher rates of CVD (MI)
  • inc physical health problems (smoking, obesity, diabetes)
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2
Q

2 factors that lead to the aetiology of schizophrenia

A

genetic

environmental

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3
Q

environmental factors that cause schizophrenia

A
  1. biological
    - advanced paternal age (>45yrs)
    - prenatal and perinatal events
    - > maternal infection
    - > maternal malnutrition
    - > pregnancy/birth complications, gestational diabetes, hypoxia, low birth weight, premature birth
    - season of birth
    - cannabis use
  2. psychosocial
    - urban birth/upbringing
    - migration
    - social disadvantage
    - exposure to engative life events
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4
Q

3 models of schizophrenia

A
  1. the dopamine hypothesis
  2. the glutamate hypothesis
  3. neurodevelopmental model
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5
Q

the dopamine hypothesis

A

schizophrenia results from the dysregulation of DAergic system in brain

positive Sx are a result of overactivity in the mesolimbic DAergic pathway

negative Sx from dec activity in mesocortical DAergic pathway

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6
Q

the glutamate hypothesis

A

schizophrenia results from the hypofunction of NMDA receptors in the brain

dec stimulation of GABA interneurons - disinhibition and hyperactivity of the mesolimbic DA pathway - positive Sx

dec stimulation and hypoactivity of mesocortical DA pathway - negative and cognitive Sx

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7
Q

3 types of schizophrenia Sx

A
  1. positive
  2. negative
  3. cognitive impairment
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8
Q

positive Sx of schizophrenia

A

hallucinations - audidory, visual, tactile

delusions - grandiosity, persecution, control

speech and thought disorder

disorganised motor behaviour - movements/mannerisms

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9
Q

negative Sx of schizophrenia

A

social withdrawal

anhedonia - inability to experience pleasure

flattening of emotional responses

loss of motivation and reluctance to perform everyday tasks (avolition)

impoverished speech and mental creativity (algogia)

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10
Q

cognitive impairment Sx of schizophrenia

A

disturbances in

  • memory
  • attention
  • sensory information processing
  • fluency of speech
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11
Q

2 diagnostic criteria for schizophrenia

A
  1. ICD-10 (internationl statistical classification of diseases)
  2. DSM-V (diagnostic and statistical manual of mental disorders
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12
Q

2 classes of antipsychotic drugs

A

1st generation - typical

2nd generation - atypical

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13
Q

What type of drugs are antipsychotics?

A

antagonists at DA receptors - schizophrenia inc activity in mesolimbic/mesocortical DAergic pathways

most effective against positive Sx (hallucinations, delusions)

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14
Q

FGAs classes

A
  1. phenothiazines
    - propylamine - chlorpromazine
    - piperidine - thioridazine
    - piperazine - fluphenazine
  2. butyrophenones
    - haloperidol
  3. thioxanthenes
    - flupentixol
    - zuclopentixol
  4. substituted benzamides
    - sulpride
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15
Q

MOA of FGAs

A

block DA receptors

  • D2 receptor blockade in mesolimbic pathway responsible for antipsychotic action
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16
Q

D2 receptor blockade in other parts of CNS (FGAs)

A

responsible for major adverse reactions

basal ganglia - acute extrapyramidal symptoms, movement disorders

hypothamalus-pituitary gland - inc prolactin secretion (endocrine effects)

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17
Q

blockage of other neurotransmitters (FGAs)

A

responsible for other major adverse effects

block alpha-adrenoceptor - postural hypotension, sexual dynfunction

block histmaine H1 receptor - sedation, weight gain

block muscarinic receptors - dry mouth, blurred vision, constipation, urinary retention, memory deficits

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18
Q

4 ‘on target’ adverse effects (of FGAs)

A

acute extrapyramidal s/e (EPSE)

tardive dyskinesia (TD)

hyperprolactinaemia and sexual dysfunction

neuroleptic malignant syndrome (NMS)

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19
Q

acute EPSE

A

D2 blockade in basal ganglia

early onset in 50-90% of patients

several forms:
- akathisia/motor restlessness: repeptitive purposeless actions, pacing, rolling -> reduce dose

  • dystonic reactions: abnormal movements of fact and body (procyclidine)
  • psrudoparkinsonsm: tremor, bradykinesia, rigidity, gradual onset over weeks
20
Q

tardive dyskinesia

A

late onset movement disorder
prolonged use of antipsychotic
rhythmical, involuntary movements
can sometimes worsen on Tx withdrawal

21
Q

hyperprolactinaemia and sexual dysfunction

A

D2 receptor blockade in pituitary gland

inc prolactin and reduced gonadotropin release

men - gyaecomastia, failure of ejactulation, dec libido, impotence

women - lactation/galactorrhoea, anovulaton, amenorrhoea, dec libido, infertility

22
Q

NMS - neuroleptic malignant syndrome

A

rare, life threatening syndrome

90% of cases within 10 dyas of starting antipsychotic

most commonly associated with high potency agents

characterised by catatonis, rigidity, stupor, fever, autonomic instability

myoglobinaemia and death in 10%

related to DA D2 receprot polymorphism

possibly due to receptor blockade in corpus striatum and hypothalamus

23
Q

mesolimbic pathway fxn and Da antagonism action

A

emotion and sensations of pleasure

hyperactivity responsible for psychosis

-> reduction in posive Sx

24
Q

mesocortical pathway fxn and Da antagonism action

A

cognitive fxn

hypoactivity can casue negative and cognitive Sx

-> worsening of negitive and cognitive Sx

25
nigrostriatal pathway fxn and Da antagonism action
controls movement -> EPSE, akathisia, dystonai, tardive dyskinesia
26
tuberoinfundibular pathway fxn and Da antagonism action
controls prolactin release -> hyperprolactinaemia and sexual dysfunction
27
off targer adverse effects
blockade of muscarinic receptors - memory deficits and sedation, constipation, dry mouth, blurred vision,urinary retention, tachycardia blockade of alpha-adrenoceptors - postural hypotension, faulire of ejaculation, sedation blockade of central histamine receptors - sedation, weight gain
28
exammples of SGAs
``` clozapine risperidone olanzapine quetiapine aripipazole paliperidone amisuplride ```
29
PD classification of SGAs
1. serotonin-DA antagonisis SDA - high selecitvity for 5-HT2A, D2 receptors (and alpha1-adR) - risperidone, paliperidone 2. multi-acting R targeted antipsychotics MARTA - affinity for 5-HT2A, D2 R and R in other systems (cholinergic, H, 5HT1A, 5HT1C) - clozapine, olanzapine, quetiapine 3. combined D2/D3 DDA receptor antagonists - preferentially block D2 and D3 subtypes of D2-like R - amisulpride 4. partial DA R antagonists - aripipazole
30
MOA of SGAs
block D2 receptors - antipsychotic effects block 5-HT2 receptors - antipsychotic effectcs (relief of -ve Sx?)
31
Why are SGAs better than FGAs?
SGAs have low affinity for binding or rapid dissociation from D2 receptor in the basal ganglia significantly milder extrapyramidal symptoms bettter adverse effect profile and patient compliance
32
4 major groups of adverse efects
1. neurological s/e (EPSE) - assocated with most FGAs and some SGAs - more pornounced with high potency FGAs *haloperidol), some SGAs (risperidone) 2. cardiometabolic s/e - weight gain, induction of DM, hyperlipidaemia - both FGAs and SGAs - most pronounced with some SGAs (clozapine, olanzapine, quetiapine, risperidone) 3. prolactin elevation and sexualdysfunction - most pornounced with high potency FGAs and some SGAs (esp amisulpride, risperidone) 4. cardiovascular s/e - ECG abnormalities, AQ prolongation, tachycardia, orthostatic hypotension - FGAs and SGAs - significant QT prolongation with some SGAs (sertindole, ziprasidone)
33
investigations to undertake before starting antispychotic
- weight (plotted on chart) - waist circumference - pulse, BP fasting blood glucose, HbA1c, blood lipid profile, prolactin levels - assessment of any movement disorders - assessment of nutritional status, diet, level of physical activity
34
When to offer ECG before antipsychotic Tx?
- if specified on SPC - physical exam ID specific CV risk (hypertension) - Hx of CVD - pt admitted as an inpatient
35
monitiring during antipsychotic Tx
- repsonse to Tx, changes in Sx/behaviour - s/e of Tx and impact on functioning - emergence of movement disorders - weight: weeky for first 6 weeks, than at 12 weeks, at 1yr, annually (plotted on chart) - waist circumference (plotted on chart) - pulse, BP at 12 weeks, 1yr, annually - fasting blood glucose, HbA1c, blood lipid levels at 12 weeks, 1yr, annually - adherence - overall physical health
36
depot/long acting antipsychotic formulations (LAIs)
slow release formulations given by deepIM inhection every 1-4 weeks used in maintenance Tx for schizophrenia FGAs and SGAs available
37
FGAs available as depot/long acting antipsychotic formulations
``` haloperidol flupenthixol fluphenazine zuclopenthixol pipothiazine ```
38
SGAs available as depot/long acting antipsychotic formulations
olanzapine riperidone paliperidone aripiprazole
39
advantages of depot/long acting antipsychotics
- consistent bioavailability and predictable dosage plasma drug level relationship - imporved PK profile, lower dose, reduced risk of s/e - anhanced medication adherance and avoidanc of covert non-adherance - rule out poor med adherance as possible cause fo ecaxerbation of pt Sx/relapse - reduced risk of inadvertent/deliberate OD - regular contact with hc prof, review opportinuty for Sx/s/e, rpovision of psychosicial support
40
disadvantages of depot/long acting antipsychotics
- mainly rlated to PK properties - dose titration against reponse proteacted process - inc risk relapse after ereduction in dose/extension of injection interval not immediatelt evident - long elim half life, lack of flexibility in dealing with emergent s/e uncmfortable local reactions at site of injection, painful, inflammation
41
important practice points for antipsychotics
- avoid high dose antipsychotic drug therapy - except after adequate sequential trial of 2+ diff drugs - avoid antipsychotic drug combination (except for short periods when cross-tapering) - when switching antipsychotic meds, gradual cross-tapering of dosages of 2 drugs - ensure regular monitirong of effect of antipsychotic Tx on physical health of pt
42
When is clozapine offered?
when schizophrenia not responsed to Tx despite sequential use of 2+ diff antipsychotics at least one should be non-clozapine SGAs
43
serious adverse effects with clozapnie
agranulocytosis neutropenia myocarditis - full physical exam and MHx before initiation
44
counselling for clozapine
stick to same brand report signs of infection leucocyte and differential blood counts must be normal before starting - every week for 18 weeks - then at least every 2 mths - after 1yr, at least every 4 weeks - 4 weeks after discontinuation
45
leukocyte and neutrophil count with clozapine
if leukocyte count below 3x10^9/L or absolute neutrophil count below 1.5x10^9/L - discontinue permamently and refer to haematologist

PHA333 (27 decks)

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