Schizophrenia Spectrum and Antipsychotics

Question 1

Which scale is used to rate pseudoparkinsonism?

Answer 1

Simpson-Angus EPS Rating Scale

Question 2

Which scale is used to rate akathisia?

Answer 2

Barnes Akathisia Rating Scale

Question 3

Which scale is used to rate tardive dyskinesia?

Answer 3

Abnormal involuntary movement scale

Question 4

Comment on the side effect profile of amisulpride

Answer 4

Very low incidence of sedation, anticholinergic side effects and hypotension.

Low incidence of weight gain, akathisia, parkinsonism.

Very high incidence of prolactin elevation.

Question 5

Comment on the side effect profile of Aripiprazole

Answer 5

Low incidence of akathisia

Very low incidence of the other major side effects

Question 6

Comment on the side effect profile of chlorpromazine

Answer 6

Very high incidence of sedation, hypotension and prolactin elevation (this makes sense because it is a low potency FGA so is a “slutty” binder)

Moderate incidence of weight gain, parkinsonism, anticholinergic

Low incidence of akathisia

It is still a FGA so the main target it the D2 receptor and therefore has an effect on prolactin elevation.

Question 7

Comment on the side effect profile of Clozapine

Answer 7

Low incidence of akathisia, parkinsonism and prolactin elevation

Very high incidence of sedation, weight gain, anticholinergic side effects, hypotension (also a low potency “slutty binder”)

And remember the other special clozapine side effects of agranulocytosis, ileus, myocarditis.

Question 8

Comment on the side effect profile of Flupenthixol - otherwise known as Fluanxol Depot

Answer 8

It is a injectable typical antipsychotic

HIGH incidence of prolactin elevation

Moderate incidence of weight gain, akathisia, parkinsonism, anticholinergic side effects

Low incidence of sedation and hypotension

Question 9

Comment on the side effect profile of Haloperidol

Answer 9

High incidence of EPSEs such as akathisia and parkinsonism

Moderate incidence of prolactin elevation

Low incidence of sedation, weight gain, anticholinergic side effects and hypotension

This is a prudish drug, not slutty. Will help to remember the side effects.

Question 10

Comment on the side effect profile of Olanzapine

Answer 10

High incidence of weight gain

Moderate incidence of sedation

Low incidence of anticholinergic side effects, hypotension and prolactin elevation

Very low incidence of akathisia and parkinsonism

This one is a slut for histamine, not so slutty for the other major neuroreceptors.

Question 11

Comment on the side effect profile of Quetiapine

Answer 11

Very low incidence of EPSEs such as akathisia and parkinsonism
Very low incidence of prolactin elevation.

Low incidence of anticholinergic side effects.

Moderate incidence of sedation, weight gain and hypotension.

This one really isn’t that interested in the D2 receptor in a slutty sense. But still a good antipsychotic. Low potency. Loves the histamine receptor and alpha 1 receptors.

Question 12

Comment on the side effect profile of Risperidone

Answer 12

High incidence of prolactin elevation

Moderate incidence of weight gain and hypotension

Low incidence of sedation, akathisia, parkinsonism and anticholinergic side effects

High potency SGA.

Question 13

Comment on the side effect profile of Zuclopenthixol (otherwise known as Clopixol)

Comes in the Acetate (Acuphase) and the Deconate (Depot) forms

Answer 13

Very high incidence of prolactin elevation

Moderate incidence of sedation, weight gain, akathisia, parkinsonism, anticholinergic side effects

Low incidence of hypotension

Question 14

Which antipsychotic is the safest in use in epilepsy with the lowest chance of lowering the seizure threshold?

Answer 14

Haloperidol

Question 15

Which antipsychotics should be avoided in people with epilepsy

Answer 15

Low potency FGAs such as chlorpromazine

Depot antipsychotics - more related to complex pharmacokinetics making them more unpredictable rather than a clearly proven contraindication or propensity to lower the seizure threshold

Clozapine - not an absolute contraindication because in treatment resistant SCZ, clozapine is sometimes the only option, but it definitely does lower the seizure threshold so care and close monitoring must be used
Concomitant use of Clozapine and Carbamazepine is contraindicated due to the risk of blood dyscrasias and reduced clozapine levels due to interaction in the metabolism.
Valproate and Lamotrigine are first choices.

Question 16

Which two common antipsychotics are associated with moderate risk of worsening seizures?

Answer 16

Olanzapine and Quetiapine

Both have been associated with seizures in RCTs but more with EEG abnormalities than actual seizures.
For Olanzapine, these changes are seen in some but not all studies so the data is difficult to interpret and it has been reported as both an anticonvulsant and a proconvulsant.

Quetiapine is considered high risk for drug interactions in those living with epilepsy.

Question 17

Which common antipsychotics are associated with low risk of lowering the seizure threshold in people living with epilepsy?

Answer 17

• High potency FGAs - such as haloperidol (fluphenazine and flupentixol are also included but since we only have the injectable forms in state in South Africa which are associated with more unpredictable pharmacokinetics and drug drug interactions, not recommended)
• Risperidone
• Amisulpride/sulpride
• Aripiprazole

Question 18

Comment on the monitoring of Clozapine

Answer 18

Weekly for 18 weeks
Then 2 weekly for 1 year
Then monthly

I don’t think this is the most accurate of what actually happens in practice in South Africa but this is the technically right answer.

Question 19

Which antiepileptic agent is advised as seizure prophylaxis when on Clozapine doses >450mg per day and why

Answer 19

Lamotrigine - weight neutral and does not interfere with Clozapine metabolism.

Question 20

How to uptitrate the dose of Clozapine?

Answer 20

Start at 12.5mg at night
Then day two give 12.5mg twice daily
Then increase by 25mg per day until a therapeutic dose of 300mg is reached (as a divided dose)

Doses of greater than 250mg per day have to be given as divided doses.

Doses of greater than 450mg per day have increased risk of seizures and may need seizure prophylaxis.

Maximum licensed dose is 900mg per day.

Question 21

What are the two “A” APs known for and why might I choose them?

Answer 21

Amisulpride and Aripiprazole are both quite metabolically inactive and are therefore more weight neutral.

Amisulpride is also a good choice for those with prominent negative symptoms.

Question 22

What is the maintenance dose of the Clopixol depot and what is the maximum dose?

Answer 22

Maintenance is 200-300mg monthly
Maximum at 600mg

Question 23

Which of the depots is more suited to negative symptoms?

Answer 23

Fluanxol