Schizophrenia- Treatment Regimens Flashcards
Goal of non-pharm treatment for schizo
Set realistic goals and time course for target symptom response, avoidance of relapse, increasing function and integration back into the community
Also avoiding as many side effects as possible
Non-pharm treatment for schizo should be used when?
Add-on therapy to medications
Non-pharm treatment options
Psychosocial rehab
Psychoeducation
Targeted cognitive therapy
Active community treatment (ACT)
Therapeutic alliance
Comprehensive care in a multidisciplinary environment that offers psychological services in addition to psychotropic medication management
What should drive the choice of choosing a schizo medication?
Side effect profiles, drug interactions, adherence, family history, cost
How many schizo meds should a patient ideally be on?
One whenever possible, combinations only for the most treatment-resistant (and even that is kind of iffy because there’s no evidence to support APS polypharmacy)
Schizo treatment considerations: stabilization and maintenance
May take 6-12 weeks to see improvements, but chronically ill patients may take 3-6 months
What should partial responders be evaluated for?
Adherence and other confounding conditions
Length of treatment for first episode of schizo
Continue therapy for an additional 12 months
What is treatment-resistant schizo defined as?
Lack of improvement with at least 2 APs from different classes at an optimal dose for at least 8 weeks
What happens if you need to D/C a schizo med and start another one?
Taper off the old one while slowly titrating up the new one
Augmentation and combination strategies for schizo
Non-APS agents with mood stabilizer, ECT, and/or ziprasidone with clozapine
What happens if a prescriber escalates a schizo med rapidly and above the FDA MDD?
Recommend the use of IM medication for initial rapid relief of symptoms and limit the time over the MDD to 2-4 weeks and evaluate the patient
DOCUMENT EVERYTHING!
What happens if you mix a FGA and SGA?
The SGA’s effects may cancel out
Treatment algorithm: Stage 1
Figure out if the patient is treatment naïve or previously treated, treat them, and check back in 2-4 weeks
Stage 1 of the algorithm: treatment naïve
Give them any AP except clozapine or olanzapine
Stage 1 of the algorithm: previously tried a med
Give then anything except clozapine or the med(s) that didn’t work for them
Treatment algorithm: Stage 2
Happens 2-4 weeks after Stage 1 if nothing in Stage 1 worked
Stage 2: what do you do when a med from Stage 1 doesn’t work?
Give them any other APS not used already except for clozapine (yes, you can use olanzapine) and check back again in 2-4 weeks
Stage 2: exception for clozapine
You can use it if the patient is severely suicidal, has EPS, or a history of violence of substance abuse
Treatment algorithm: Stage 3
2-4 weeks after Stage 2 when those meds don’t work
Stage 3: What to do if Stage 2 medication fails?
Clozapine monotherapy, check back in 2-4 weeks
Treatment algorithm: Stage 4
2-4 weeks after Stage 3 when clozapine monotherapy doesn’t work
Stage 4: what happens if clozapine monotherapy doesn’t work from Stage 3?
Try other APs, augmentation with mood stabilizers, polypharmacy, ECT
What should you always do throughout schizo treatment with a patient?
Assess their adherence!
When can LAIs be used?
Any point during Stages 2-4 if the patient has poor adherence
Before starting a LAI, what should you make sure of regarding adherence?
That the patient’s poor adherence isn’t due to the side effects
Best practice before starting a LAI
PO challenge of the same drug to make sure there’s not an allergy
Newer LAI agents are what: aqueous or oil-based diluents?
Aqueous, they’re physiologically similar to body tissues
Do LAIs take immediate effect?
Most of them don’t
What to do with LAIs and PO meds
Do a PO overlap while starting the LAI, most LAIs will take at least a week or two to work
Schizo treatment of special populations: elderly
Use lowest effective dose, use caution for renal and hepatic impairment
More likely to experience orthostasis and increased fall risk
Schizo treatment of special populations: pregnancy/lactation
Lowest effective dose, higher doses for clozapine and olanzapine may be needed
Recommend to continue current therapy if effective
Schizo treatment of special populations: peds
Kids may be more sensitive to EPS and metabolic effects
Use the lowest effect dose of FDA approved meds and titrate carefully
Monitoring effectiveness of schizo therapy
Must be guided by systematic monitoring of patient symptoms and ongoing surveillance of potential adverse effects- encourage patients to report symptoms!
How do we know if a patient is improving?
If the symptoms we’ve been trying to resolve have been getting better
What side effects should we monitor for at baseline and each visit?
Anticholinergic side effects and overall ACH burden (including constipation)
When should you check for drug interactions?
Whenever a new drug is added to a regimen, when doing med reconciliation (ask about OTC and CAM use), whenever an ADR is suspected
BBW for schizo medications
BBW for dementia-related psychosis (AKA elderly patients with dementia taking APS for behavioral problems, not schizo)
BBW for schizo meds: what if the patient was taking an APS before they were 65?
They should still continue to take it because schizophrenia should be treated!
Caveat to the schizo med BBW
APS are the only agents available to treat patient-specific dementia-related psychosis so you have to use them anyways…DON’T AVOID THEM ALTOGETHER!
How to manage patients on schizo meds with the BBW
Start on a lower dose, monitor them carefully, educate patient on side effects, and make sure the benefits > risks
