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Schizophrenia/Psychosis Flashcards

1
Q

Positive symptoms:

A
  • Hallucinations: sensing something that is not present, such as imaginary voices (ex. auditory)
  • Delusions: ex. paranoia
  • Disorganized thinking/behavior: inability to focus attention and communicate.
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2
Q

Negative symptoms:

A
  • flat affect
  • anhedonia
  • avolition (lack of motivation)
  • alogia (decreased thought and speech)
  • withdrawal
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3
Q

Increased dopamine can trigger hallucinations or delusions. Up to 50% of patients with PD will…

A

experience hallucinations or delusions

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4
Q

Antipsychotics primarily block…

A

dopamine receptors. Newer ones also block serotonin.

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5
Q

Medications/drugs that can cause psychotic symptoms:

A
  • anticholinergics (centrally-acting, high doses)
  • dextrometorphan
  • dopamine or dopamine agonists (e.g Requip, Mirapex, Sinemet)
  • interferons
  • stimulants
  • systemic steroids (typically with lack of sleep- ICU psychosis)
  • Illicit substances (bath salts, cannabis, cocaine, LSD, meth, PCP)
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6
Q

First-gen antipsychotics (FGAs) have a high incidence of EPS…

A

including painful dystonias (muscle contractions), dyskinesias (abnormal movements), tardive dyskinesias (repetitive, involuntary movements, such as grimacing and eye blinking), and akathisia (restlessness, inability to remain still)

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7
Q

Tardive dyskinesia (TD) can be irreversible; the drug causing the TD should be…

A

d/c’ed

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8
Q

Olanzapine and benzodiazepines should not be given together…

A

due to risk of excessive sedation and breathing difficulty

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9
Q

IM antipsychotics are often mixed with other drugs (in “cocktails”), such as…

A

benzos for anxiolytic/sedative effects, and anticholinergics to reduce dystonias (eg. the “Haldol cocktail” contains haloperidol, lorazepam, and diphenhydramine)

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10
Q

BBW: Elderly patients with dementia-related psychosis

A

increased risk of death from antipsychotics

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11
Q

Low potency FGA: thioridazine

A

300-800 mg/day, divided. QT prolongation.

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12
Q

Low potency FGA: chlorpromazine

A

300-1000 mg/day, divided.

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13
Q

Mid potency: loxapine (Loxitane, Adasuve)

A

30-100 mg/day, divided. Inhalation powder for acute agitation. REMS: bronchospasm. S/s: bad, bitter, or metallic taste in mouth

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14
Q

Mid potency: perphenazine

A

8-64 mg/day, divided.

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15
Q

High potency: haloperidol (Haldol, Haldol decanoate). Oral, IV, decanoate IM. Class: butyrophenone. Also used for Tourette’s syndrome.

A
  • oral (tablet, solution): start 0.5-2 mg BID-TID (up to 30 mg/day)
  • IV: usually 5-10 mg.
  • Decanoate (monthly): IM only;
  • for conversion from IM to PO, use 10-20x the PO dose
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16
Q

High potency: fluphenazine (tablet, elixir, injectable, IM,)

A

6-12 mg/day, divided. Decanoate: (Q 2 weeks); IM only

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17
Q

High potency: thiothixene

A

15-60 mg/day; divided

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18
Q

High potency: trifluoperazine

A

15-50 mg/day; divided

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19
Q

Lower potency FGAs have…

A

less sedation, more EPS

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20
Q

Higher potency FGAs have…

A

less sedation, more EPS

21
Q

Second-generation antipsychotics (SGAs) block…

A

dopamine (D2) and serotonin (5-HT2A) receptor

22
Q

Unique MOAs: D2 and HT1A2 partial agonists are…

A

Aripiprazole, brexpiprazole, cariprazine

23
Q

aripiprazole (Abilify, Abilify Maintena, Aristada injection) Tablet, ODT, IM suspension

A
  • 10-30 mg PO QAM
  • Abilify Maintena- IM suspension (give monthly)
  • Aristada- IM suspension, give Q 4-8 weeks
  • SEs: akathisia, headache, anxiety, sedating or activating
  • Lower risk of weight gain, some QT prolongation, EPS (in children)
24
Q

clozapine (Clozaril, FazaClo ODT, Versacloz suspension)

A

Very effective and has decreased risk of EPS/TD, but only used 3rd line due to severe side effect potential.
BBW: significant risk of potentially life-threatening neutropenia/agranulocytosis (REMS program)

25
Q

clozapine s/e

A

S/Es: agranulocytosis, seizures (dose-related), constipation, somnolence, metabolic syndrome, sialorrhea (hypersalivation), hypotension
Monitoring: prescribers and pharmacies must be certified to dispense. To start tx, baseline ANC must be ≥ 1,500/mm3. Check ANC weekly x 6 months, then every 2 weeks x 6 months, then monthly. Stop therapy if ANC <1000/mm3.

26
Q

lurasidone (Latuda)

A

40-160 mg/day, divided. Counsel to take with food (≥ 350 kcal). CIs: use with strong CYP450 3A4 inducers/inhibitors. Almost weight, lipid, and BG neutral.

27
Q

olanzapine (Zyprexa, Zyprexa Zydis ODT, Zyprexa Relprevv injection)

A
  • 10-20 mg QHS (counsel to take at night).

- IM injection (acute agitation)

28
Q

olanzapine + fluoxetine (Symbyax)

A

for treatment-resistant depression

29
Q

Zyprexa Relprevv injection. **Must be given in a registered healthcare facility, and patients must be monitored for 3 hours post-injection (REMS program)

A
  • IM gluteal injection
  • suspension lasts 2-4 weeks (restricted use).
  • BBW: sedation (including coma), and delirium (agitation, anxiety, confusion, disorientation) have been observed following injection
30
Q

paliperidone (Invega, Invega Sustenna, Invega Trinza). Active metabolite of risperidone (similar SEs)

A
  • PO: 3-12 mg daily
  • Invega Sustenna (IM injection, give monthly)
  • Invega Trinza (IM injection, give Q 3 months; start only after receiving Invega Sustenna x 4 months)
  • SEs: increased prolactin (sexual dysfunction, galactorrhea, irregular periods)
  • EPS (especially at higher doses)
  • tachycardia, QT prolongation
  • metabolic syndrome (weight gain, BG, increased lipids)
31
Q

Invega can leave a ghost tablet…

A

in the stool (OROS delivery). Counsel.

32
Q

quetiapine (Seroquel, Seroquel XR)

A

400-800 mg/day; divided BID or XR QHS

  • Take XR at night, without food or with a light meal (≤300 kcal)
  • Lowest EPS risk- often used for psychosis in Parkinson’s
  • S/Es: somnolence, metabolic syndrome, orthostasis, possible ocular effects (cataracts)
33
Q

risperidone (Risperdal, Risperdal Consta, Perseris). Active metabolite is paliperidone.

A
  • Also approved for irritability associated with autism
  • 4-16 mg/day, divided
  • Risperdal Consta: IM injection; give Q 2 weeks; 25-50 mg
  • Perseris: SC injection, give monthly
34
Q

ziprasidone (Geodon)

A
  • 40-160 mg/day, divided BID
  • Take with food (counsel)
  • CIs: QT prolongation; do not use with QT risk
35
Q

Acute injection: Geodon IM

A
  • 10 mg Q2 hrs or 20 mg Q4hrs

- Max: 40 mg/day IM

36
Q

asenapine (Saphris, Secuado). Saphris (SL tablet); Secuado (patch)

A
  • 10-20 mg/day, divided BID.
  • No food/drink for 10 min after dose (counsel)
  • Secuado patch: apply daily
  • CIs: severe liver impairment
  • SEs: somnolence, tongue numbness (SL tablet), EPS (5 % more than placebo), QT prolongation
37
Q

brexpiprazole (Rexulti)

A

2-4 mg daily

38
Q

cariprazine (Vraylar)

A

1.5-6 mg daily

39
Q

lloperidone (Fanapt)

A

12-24 mg/day, divided. Titrate slowly due to orthostasis/dizziness.

40
Q

lumateperone (Caplyta)

A

42 mg daily

41
Q

Cardiac risk/QT risk (d/c with QT>500 msec)

A

do not choose ziprasidone, haloperidol, thioridazine, chlorpromazine

42
Q

History of movement disorder (ex. Parkinson’s disease)

A
  • Do not choose FGAs, risperidone, paliperidone

- Quetiapine is preferred.

43
Q

Overweight/metabolic risk (eg. increased TG)

A
  • Do not choose clozapine, olanzapine, quetiapine. - Lower risk with aripiprazole, ziprasidone, lurasidone, and asenapine.
44
Q

pimavenserin (Nuplazid): approved for psychosis with Parkinson disease (does not affect dopamine)

A
  • inverse agonist and antagonist at serotonin 5-HT2A receptors
  • 34 mg PO daily (two 17 mg tablets)
    Warnings: not approved for dementia-related psychosis. QT prolongation.
  • SEs: peripheral edema, confusion
45
Q

Smoking can reduce plasma levels of…

A

olanzapine and clozapine

46
Q

Risperidone oral solution

A

given directly from the calibrated pipette, or mixed with water, coffee, OJ and low-fat milk; it cannot be mixed with cola or tea.

47
Q

velbenazine (Ingrezza). First med approved for the treatment of TD.

A
  • MOA: Reversibly inhibits vesicular monoamine transporter 2 (VMAT2)
  • Dosing: Start 40 mg PO daily, increase in 1 week to 80 mg PO daily
  • Moderate-severe liver impairment: adjustment required. CYP2D6 PM: consider dose reduction.
  • Warnings: somnolence, QT prolongation
48
Q

deutetrabenazine (Austedo). Another VMAT2 inhibitor approved for TD.

A
  • Also, approved for chorea associated with Huntington’s disease
  • Dosing: Start 6 mg PO BID, increased weekly based on response (max 48 mg/day)
  • Concurrent strong CYP2D6 inhibitors or PM (max dose 36 mg/day)
  • CIs: liver impairment, administration with tetrabenazine or velbenazine, administration with an MAO inhibitor (within 14 days)
  • Warnings: somnolence, QT prolongation
49
Q

Neuroleptic Malignant Syndrome Tx (signs include hyperthermia, extreme muscle rigidity, mental status changes) Labs: increased CPK and WBCs

A
  • Taper off antipsychotic quickly and consider another choice (quetiapine or clozapine)
  • Provide supportive care
  • Cool the patient down: cooling bed, antipyretics, cooled IV fluids
  • Muscle relaxation with benzos or dantrolene (Ryanodex, Dantrium, Revonto)

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