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Schizophrenia/ Psychosis Flashcards

1
Q

What is schizophrenia?

A

chronic/severe/disabling thought disorder

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2
Q

What are s/sx of schizophrenia?

A
  1. Hallucinations: sensing something not present/voices
  2. Delusions: a belief about something real that is not true
  3. Disorganized thinking/behavior: inability to focus/ communicate organized thoughts
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3
Q

What are extrapyramidal side effects (EPS)?

A

Group of side effects related to irregular movement:
Dystonia: prolonged muscle contraction during drug initiation, including painful spasms and fatal if airway closes
Akathisia: inability to remain still with anxiety, restless
Parkinsonism: tremor, abnormal gait, bradykinesia
Tardive dyskinesia: abnormal facial movements (tongue/mouth)
Dyskinesia: abnormal movement more common with DA replacement

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4
Q

What population is at higher risk of developing dystonias?

A

young males

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5
Q

How are dystonias prevented/treated?

A

Centrally-acting anticholinergics (diphenhydramine, benztropine)

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6
Q

How is akathisia treated?

A
  1. Benzodiazepines
  2. Propranolol
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7
Q

How is parkonsonianism treated?

A

If tremor is main sx:
Anticholinergics
Propranolol

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8
Q

How are tardive dyskinesias treated?

A

D/C drug and replace with second-gen antipsychotic with lower risk (quetiapine/clozapine)

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9
Q

What population is at higher risk of tardive dyskinesia?

A

elderly females

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10
Q

How is schizophrenia dx?

A

must have positive and negative symptoms; delusions, hallucinations, and disorganized speech must be present

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11
Q

What neurotransmitters are involved in schizophrenia?

A
  1. 5HT
  2. DA
  3. Glutamate
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12
Q

What are negative s/sx?

A
  1. loss of interest in everyday activities
  2. Lack of emotion (apathy)
  3. Social withdrawal
  4. Loss of motivation (avolition)
  5. Lack of speech (alogia)
  6. inability to plan/carry out activities
  7. poor hygiene
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13
Q

What are positive s/sx?

A
  1. Hallucinations: can be auditory, visual, or somatic
  2. Delusions
  3. Disorganized thinking/behavior: incoherent speech, unrelated topics, purposeless behavior, stopping mid-sentence , or jumbling together words
  4. difficulty paying attention
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14
Q

What drugs can cause/worsen psychotic symptoms?

A
  1. Anticholinergics (centrally acting, high dose)
  2. Dextromethorphan
  3. Dopamine/DA agonists
  4. Interferons
  5. Stimulants (esp. if already at risk)/Methamphetamine
  6. Systemic steroids (lack of sleep-ICU psychosis
  7. Cannabis
  8. Cocaine
  9. LSD (lysergic acid diethylamide)
  10. PCP (phencyclidine)
  11. Synthetic cathinones (bath salts/MDPV)
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15
Q

What are preferred treatments for schizophrenia/psychosis?

A

1st line: second-gen antipsychotics (block DA and 5HT)
2nd line: first-gen antipsychotics (more SEs but treat positive sx)

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16
Q

Why are first-gen antipsychotics not favored?

A
  1. high incidence of EPS
  2. tardive dyskinesia (grimacing/eye blinking) can be irreversible D/C drug
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17
Q

What are dosage forms used to increase adherence in schizo?

A
  1. Long-acting injections
  2. ODT; prevent cheeking and spitting out
  3. oral solution/suspension
  4. Acute IM inj: stat relief
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18
Q

Which antipsychotic cannot be given in a cocktail with benzos due to risk of sedation/ breathing difficulty?

A

Olanzapine

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19
Q

What is an example of a drug cocktail used for stat relief of psychosis?

A
  1. antipsychotics (haldol)
  2. benzodiazepine (lorazepam)
  3. anticholinergic (diphenhydramine to reduce distonia)
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20
Q

What is a BBW with all antipsychotics?

A
  1. NOT indicated for agitation in elderly with dementia-related psychosis; increased risk of mortality usually due to CV conditions and infection
  2. Fall risk
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21
Q

What is the MOA of first-gen antipsychotics (phenothiazine)?

A

block D2 receptors

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22
Q

What are BBWs with first-gen antipsychotics?

A
  1. Elderly patients with dementia related psychosis, increased risk of death
  2. Thioridazine: QT prolongation
  3. Adasuve: bronchospasms (REMS program)
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23
Q

What are warnings with first-gen antipsychotics?

A
  1. CV effects: QT prolongation (esp. thioridazine, haloperidol, chlorpromazine), Orthostasis/Falls, tachycardia
  2. Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
  3. CNS depression
  4. EPS (increased with injections)
  5. Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea, galactorrhea (abnormal breast discharge), erectile dysfunction/decreased libido
  6. Neuroleptic malignant syndrome: monitor for mental status changes, fever, muscle rigidity, autonomic instability
  7. blood dyscrasias (leukopenia, neutropenia, agranulocytosis)
  8. ocular effects
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24
Q

What are SEs with first-gen antipsychotics?

A
  1. Sedation
  2. Dizziness
  3. Anticholinergic effects
  4. EPS: can give anticholinergic (benztropine, diphenhydramine) to limit painful dystonia
  5. elevated prolactin
  6. Adasuve: dysgeusia (bad/bitter/metallic taste)
  7. injection site pain/redness
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25
Q

Which first-gen antipsychotics have less EPS?

A

Low potency: more sedation, less EPS
High potency: less sedation, more EPS

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26
Q

What first-gen antipsychotics are low potency?

A
  1. Chlorpromazine
  2. Thioridazine
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27
Q

What first-gen antipsychotics are medium potency?

A
  1. Loxapine
  2. Perphenazine
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28
Q

What first-gen antipsychotics are high potency?

A
  1. Haloperidol
  2. Fluphenazine
  3. Thiothixene
  4. Trifluoperazine
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29
Q

What drug class is haloperidol in? What are other uses for the drug?

A
  1. Butyrophenone
  2. Tourette syndrome (tis/vocal outbursts)
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30
Q

Loxapine

A

Adasuve (inhalation powder for acute agitation)

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31
Q

Haloperidol

A

Haldol
Haldol Decanoate

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32
Q

What is the MOA of second-gen antipsychotics?

A

Block D2 and 5HT2A receptors

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33
Q

Which antipsychotics are D2 and 5HT1A partial agonists?

A
  1. Aripiprazole
  2. Brexpiprazole
  3. Cariprazine
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34
Q

Which antipsychotic is a 5HT2A antagonist?

A

Brexpiprazole

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35
Q

What are SEs with aripiprazole?

A
  1. Akathesia
  2. Activating or sedating
  3. headache
  4. anxiety
  5. constipation
  6. some QT prolongation
  7. EPS (in children)
  8. lower risk of weight gain
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36
Q

How often should IM abilify be given?

A

4-8 weeks (dose-dept): Aristada
Monthly: Abilify Maintena
2 months: Abilify Asimtufi

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37
Q

Which IM abilify injection can be given as a 1x IM loading dose (along with PO aripiprazole) when starting/restarting Aristada treatment?

A

Aristada Initio

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38
Q

Which aripiprazole tablets have an embedded ingestable sensor to track adherence?

A

Abilify MyCite

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39
Q

Aripiprazole

A

Abilify
Abilify MyCite
Abilify Maintena
Abilify Asimtufi
Aristada
Aristada Intuvio

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40
Q

What are other indications for aripiprazole?

A

Tourette syndrome
iriitability with autism

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41
Q

What are BBWs with clozapine?

A
  1. Neutropenia/ Agranulocytosis; potentially life-threatening (used to be REMS)
  2. Myocarditis (D/C if suspected)
  3. Cardiomyopathy (D/C if suspected)
  4. Seizures (dose related)
  5. bradycardia
  6. orthostatic hypotension
  7. syncope
  8. cardiac arrest; risk highest during initial titration period
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42
Q

How should clozapine be titrated to avoid seizures?

A
  1. Start no higher than 12.5mg QD or BID; titrate slowly using divided doses
  2. Titrate off; abrupt D/C increases seizures
  3. Slower titration in seizure risk (hx seizures, head trauma, alcoholism, meds that reduce seizure threshold)
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43
Q

What are SEs with clozapine?

A
  1. Agranulocytosis
  2. Seizures
  3. Constipation
  4. Hypersalivation (sialorrhea)
  5. somnolence
  6. metabolic syndrome (weight gain, elevated BG/lipids)
  7. hypotension
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44
Q

What needs to be monitored while taking clozapine?

A
  1. Baseline ANC ≥ 1,50/mm3
  2. ANC weekly for 6 months
  3. ANC every 2 weeks for 6 months
  4. Monthly
  5. STOP therapy if ANC <1000
  6. got rid of REMS program
  7. Smoking status (reduces drug levels)
45
Q

When is clozapine used for schizo?

A

No sooner than 3rd line due to risks; must fail 2 standard antipsychotics

46
Q

Clozapine

A

Clozaril
Versacloz (suspension)

47
Q

Lurasidone

48
Q

What are CIs with latuda?

A

Use with strong CYP3A4 inducers/inhibitors

49
Q

What are SEs with lurasidone?

A
  1. Somnolence
  2. EPS (dystonias)
  3. Nausea
  4. Less risk of metabolic syndrome
50
Q

How is lurasidone dosed?

A

40-160 mg/d divided; Take with ≥350 cal of food

51
Q

What are BBWs with olanzapine?

A

Zyprexa Relprevv: Sedation (including coma) and Delirium (agitation, anxiety, confusion, disorientation)
Must be administered in a registered healthcare facility
Must be monitored for 3 hours post-injection (REMS)

52
Q

What are SEs with olanzapine?

A
  1. Somnolence
  2. Metabolic syndrome (weight, BG, lipids)
  3. orthostasis
  4. smoking reduced drug levels
53
Q

Which olanzapine product is CI in anyone taking opioids or in acute opioid withdrawal?

A

Lybalvi: contains samidorphan (opioid receptor antagonist) to prevent weight gain

54
Q

How often is Relprevv injection suspension administered?

A

lasts 2-4 weeks; use is restricted

55
Q

Olanzapine

A

Zyprexa
Zyprexa Zydis ODT
Zyprexa Relprevv (inj)

56
Q

Olanzapine + Samidorphan

57
Q

What are SEs with paliperidone?

A
  1. Elevated prolactin (sexual dysfxn, galactorrhea, irregular/missed periods)
  2. EPS (esp at high doses)
  3. Metabolic syndrome (weight, BG, lipids)
  4. QT prolongation
  5. tachycardia
  6. somnolence
  7. ghost tablet in stool (Invega)
  8. active metabolite of risperidone (similar SEs)
58
Q

How is paliperidone dosed?

A

PO: OROS delivery allows QD dosing, do not break/crush
IM: must be established before starting Invega Trinza/ Hafyera on adequate IM paliperidone treatment (monthly or every 3 mo)
Invega Sustenna: Monthly
Invega Trinza: every 3 months
Invega Hafyera: every 6 months

59
Q

Paliperidone

A

Invega (tablet)
Invega Sustenna (IM)
Invega Trinza (IM)
Invega Hafyera (IM)

60
Q

What are SEs with quetiapine?

A
  1. Somnolence
  2. Metabolic syndrome
  3. orthostasis
  4. possible ocular effects (cataracts)
  5. Low EPS risk (used in Parkinsons)
61
Q

How is quetiapine dosed?

A

400-800mg/d
IR: divided doses
XR: QHS without food or light meal ≤300 cal

62
Q

Quetiapine

A

Seroquel
Seroquel XR

63
Q

What are SEs with risperidone?

A
  1. Elevated prolactin (sexual dysfunction, galactorrhea, irregular/missed periods)
  2. EPS (especially at higher doses)
  3. Metabolic Syndrome
  4. tachycardia
  5. QT prolongation
  6. somnolence
64
Q

How is risperidone dosed?

A

Risperidol Consta and Rykindo (IM): 25-50mg every 2 weeks
Perseris (SC): monthly
Uzedy (SC): every 1-2 months

65
Q

Risperidone

A

Risperdal
Risperdal Consta (IM suspension)
Rykindo (IM suspension)
Perseris (SC prefilled syringe)
Uzedy (SC prefilled syringe)

66
Q

What are CIs to using ziprasidone?

A

QT prolongation; DO NOT use wth QT risk

67
Q

What are SEs with ziprasidone?

A
  1. somnolence
  2. EPS
  3. dizziness
  4. nausea
68
Q

How is ziprasidone dosed?

A

PO: 40-160 mg/d, divided BID WITH FOOD
IM: 10mg Q24H or 20mg Q4H; max 40mg/d IM

69
Q

Ziprasidone

70
Q

What are CIs to using asenapine?

A

severe hepatic impairment

71
Q

What are SEs with asenapine?

A
  1. Tongue numbness (SL tab)
  2. EPS (5% more than placebo)
  3. somnolence
  4. QT prolongation
72
Q

How is asenapine dosed?

A

PO: 10-20 mg/d, divided BID and NO FOOD OR DRINK 10 MIN AFTER DOSE
Patch: 3.8-7.6mg applied QD

73
Q

Asenapine

A

Saphris (SL tab)
Secuado (patch)

74
Q

Cariprazine

75
Q

What are SEs with cariprazine?

A
  1. EPS
  2. dystonias
  3. headache
  4. insomnia
76
Q

Brexpiprazole

77
Q

What are SEs with brexpiprazole?

A
  1. weight gain
  2. dyspepsia
  3. diarrhea
  4. akathisia
78
Q

Iloperidone

79
Q

What are SEs with iloperidone?

A
  1. dizziness
  2. orthostasis (slow titration)
  3. somnolence
  4. tachycardia
  5. QT prolongation
80
Q

Lumateperone

81
Q

What are SEs with lumateperone?

A
  1. somnolence
  2. EPS
82
Q

What drug is approved for psychosis with Parkinsons?

A

Pimavanserin (Nuplazid)

83
Q

What are warnings with pimvanserin?

A
  1. Not approved for dementia-related psychosis
  2. QT prolongation, avoid use with other drugs that prolong or other risk factors for prolonged QT
84
Q

What are SEs with pimvanserin?

A
  1. peripheral edema
  2. confusion
85
Q

What is the MOA of drugs (valbenazine and deuterabenazine) that treat tardive dyskinesia?

A

reversilby inhibit vesicular monoamine transporter 2 (VMAT2) that regulates monoamine uptake

86
Q

What are warnings with valbenazine?

A
  1. Somnolence
  2. QT prolongation (avoid in long QT syndrome)
87
Q

Valbenazine

88
Q

What are CIs to using deutetrabenazine?

A
  1. Hepatic impairment
89
Q

What are warnings with deutetrabenazine?

A
  1. Somnolence
  2. QT prolongation
90
Q

What are DIs with deutetrabenazine and valbenazine?

A
  1. Avoid use with MAO inhibitors
  2. Substrates of CYP3A4 and 2D6; dose reduction required when given with strong inhibitors
  3. P-gp inhibitor and can increase digoxin concentrations; digoxin dose may need adjustment (valbenazine)
91
Q

How is haloperidol decanoate dosed?

A

IM injection given monthly; if converting from PO give 10-20x PO dose

92
Q

How is fluphenazine decanoate dosed?

A

IM injection ever 2 weeks

93
Q

Pimvanserin

94
Q

Which antipsychotics are available IV?

A

Haloperidol 5-10mg

95
Q

Which antipsychotics are available IM?

A
  1. Haloperidol decanoate
  2. Fluphenazine decanoate
  3. Abilify Maintena
  4. Risperdal Consta
  5. Invega Sustenna (paliperidone)
  6. Invega Trinza
  7. Invega Hafyera
  8. Aristada (aripiprazole)
  9. Abilify Asimtufil
  10. Aristada Intuvio (aripiprazole)
  11. Relprevv (olanzapine)
  12. Rykindo (risperidone)
96
Q

Which antipsychotics are available as an SC injection?

A
  1. Perseris (risperidone)
  2. Uzedy (risperidone)
97
Q

What are treatment options for an acute psychotic episode?

A
  1. Haloperidol IV/IM +/- diphenhydramine + lorazepam
  2. Ziprasidone IM
  3. Olanzapine IM
98
Q

What are chronic treatments for patients not adherent to PO?

A
  1. LA inj
  2. ODT
  3. SL
  4. Liquid
  5. Patch
99
Q

What is a safety issue with all antipsychotics?

A

Can prolong the QT interval; use caution with other meds that increase risk

100
Q

What antipsychotic levels are reduced by smoking?

A
  1. Olanzapine
  2. Clozapine
101
Q

What are DIs with risperidone?

A

CYP2D6 inhibitors (fluoxetine, paroxetine) use caution

102
Q

When should respiratory depression be monitored with antipsychotics?

A

When taken with benzos

103
Q

What drugs increase the risk of EPS and tardive dyskinesia?

A

other DA blocking agents (metoclopramide)

104
Q

Counsel on the administration of Risperdal oral solution

A

Administer directly from the calibrated pipette, or mix with water, coffee, orange juice, or low-fat milk only

105
Q

Which antipsychotics are available as an ODT?

A
  1. Abilify ODT
  2. Zyprexa Zydis
  3. Risperidone ODT
106
Q

Which antipsychotics are available as an oral liquid?

A
  1. abilify
  2. fluphenazine
  3. haloperidol
  4. risperidone
107
Q

What is neuroleptic malignant syndrome?

A

medical emergency due to D2 blockade, most common with first-gen agents; intense muscle contractions can lead to acute renal injury due to rhabdomyolysis, suffocation, and death

108
Q

What are s/sx of neuroleptic malignant syndrome?

A
  1. Hyperthermia
  2. Extreme muscle rigidity
  3. mental status change
  4. tachycardia/tachypnea/BP change
  5. Evelvated creatine phosphokinase
  6. Elevated WBCs
109
Q

How is neuroleptic malignant syndrome treated?

A
  1. Stop the antipsychotic
  2. Relax the muscles: benzos, Dantrolene (Ryanodex, Dantrium, Revonto), DA agnonist (bromocriptine)
  3. Supportive care: control temp, hemodynamic supprt, cardioresiratory
  4. Consider a different antipsychotic (quetiapine/clozapine)

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