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PR3136 > Treatment of Schizophrenia > Flashcards

Treatment of Schizophrenia Flashcards

1
Q

What is Schizophrenia & its symptoms

A
  • Prolonged, persistent form of psychosis
  • “Thought disorder”
  • Disorganised bizarre thoughts, hallucinations, delusions, inappropriate effect, impaired psychosocial functioning

Symptoms:

  • Hallucinations
  • Delusions
  • Disorganised thinking
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2
Q

Etiology of Schizophrenia

A

Possible dysregulation of DA & 5-HT

Predisposing factors:
- Genetics, neurodevelopmental effects

Precipitating factors:

  • Drugs (eg. DA agonists)
  • Psychosis related to alcohol & psychoactive substance misuse

Perpetuating factors:

  • lack of support
  • poor adherence to antipsychotics
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3
Q

General Assessment for Schizophrenia

A
  • History of present illness
  • Psychiatric, substance use, complete medical & medications misuse, family, social, forensic, occupational hx
  • Reassess adherence to meds
  • Phy & neurological exam
  • MSE
  • Labs & other investigations to exclude general med conditions/ substance-induced symptoms
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4
Q

Non pharmacological treatment of Schizophrenia

A
  • Individual CBT (if pt able to go through exercises)
  • Electroconvulsive Therapy (ECT) for treatment-resistant Schizophrenia
  • Repetitive Transcranial Magnetic Stimulation (rTMS) for reducing auditory hallucinations
  • Psychosocial rehabilitation programs to improve pt’s adaptive functioning
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5
Q

Goals for treatment of Schizophrenia

A
  • Minimise threat to self & others
  • Minimise acute symptoms
  • Minimise/prevent relapse
  • Promote med adherence
  • Optimise dose vs adverse effects
  • Improve functioning & QOL
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6
Q

What do Antipsychotics do?

A
  • Tranquilize w/o impairing consciousness/causing paradoxical excitement
  • Short-term: Calm disturbed pts
  • Relieve symptoms of psychosis (thought disorders, hallucinations, delusions, prevent relapse)
  • long-term treatment often necessary (may relapse if treatment is withdrawn inappropriately)
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7
Q

Why is relapse of Psychosis often delayed for a few weeks after cessation?

A
  • Adipose tissue acts as depot reservoirs

- Antipsychotics stored diffuses back into bloodstream until depletion

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8
Q

Methods to overcome poor adherence of Antipsychotics

A
  • IM long-acting inj
  • Patient & caregiver education
  • Community psychiatric nurse
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9
Q

MOA of Antipsychotics (Dopamine pathways)

A

1) Mesolimbic tract
- D2 antagonism in this tract most common MOA
- Overactivity in this region responsible for +ve symptoms

2) Mesocortical tract
- Hypofunction/dopamine blockage in this region results in -ve symptoms

3) Nigrostratial tract
- EPSE (Parkinson-like symptoms)

4) Tuberinfundibular tract
- Hyperprolactinemia

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10
Q

Receptor affinities of Antipsychotics & their implications

A

D2 antagonism: Improve +ve symptoms
-> SE: EPSE, Hyperprolactinemia

5-HT2A antagonism: Improve -ve symptoms

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11
Q

Algorithm for Treatment of Schizophrenia

A

1) Single FGA/SGA (NOT clozapine)
2) (+) Single FGA/SGA

If Treatment-resistant…

3) Clozapine (max:900mg)
* only if failed >=2 adequate trials*
4) Clozapine + Augmenting agent (FGA/SGA/ECT)

Notes:

  • Individualised
  • No intolerable SE
  • Compliant to an adequate trial (At least 2-6 weeks @ optimal therapeutic doses)
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12
Q

Precautions for Antipsychotic Use

A
  • CVS Disease
  • Parkinson’s disease
  • Prostatic hypertrophy
  • Angle-closure glaucoma
  • Severe respiratory disease
  • Blood dyscrasias (esp for Clozapine)
  • Elderly with Dementia (increased risks for mortality)
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13
Q

Which Antipsychotics should be given with food?

A
  • Lurasidone

- Ziprasidone

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14
Q

Adjunctive treatment during Acute Agitation (Psychiatric Emergency)

A

If cooperative:

  • PO lorazepam 1-2mg
  • PO risperidone 1-2mg

If uncooperative (IM short-acting):

  • IM Lorazepam 1-2mg
  • IM Olanzapine (immediate release) 5-10mg
  • -> Must not give lorazepam & olanzapine within 1h of each other
  • IM Haloperidol 2.5-10mg (cheapest) with ECG
  • -> Consider + anticholinergics where appropriate
  • IM Promethazine 25-50mg
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15
Q

Adjunctive treatment during Catatonia
[Abnormality of movement and behaviour, may involve repetitive or purposeless overactivity, or catalepsy, resistance to passive movement, and negativism]

A

Benzodiazepines:

- PO/IM Lorazepam

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16
Q

Adjunctive treatment to manage Depressive /Negative Sx of Chronic Schizophrenia

A

1) Antidepressant
- Some SSRIs has mild-moderate efficacy for managing -ve symptoms
2) SGA

17
Q

IM Long-Acting Antipsychotics

A

FGA:

i) Flupenthixol Decanoate
ii) Haloperidol Decanoate
iii) Zuclopenthixol decanoate

SGA:

i) Risperidone long-acting suspension
- Every 2wks
- To supplement with oral dose during 1st 3wks
ii) Paliperidone prolonged-release suspension
- Ivega trinza: Every 3mth

18
Q

Adverse SE of FGA

A
  • EPSE
  • Acute dystonia, tardive dyskinesia, akathisia

*Increased prolactin secretion

  • Anticholinergic SE (dry mouth, constipation, urinary retention)
  • Hypotension (Alpha-1 antagonism)
  • Sedation, weight gain (H1 antagonism)
19
Q

Adverse SE of SGA

A

Weight gain, Increase FBG, TG

  • Clozapine & Olanzapine especially*
  • Ziprasidone, Aripiprazole & Brexpiprazole has less metabolic SE

Sedation (H1 antagonism)
- Clozapine & Olanzapine*

Anticholinergic
- Clozapine* & Olanzapine

Proconvulsant
- Clozapine & Olanzapine*

20
Q

Monitoring of SE of Antipsychotics

A
  • Clozapine-induced agranulocytosis*
  • -> Hematological monitoring weekly for 1st 18weeks, then monthly
BMI: 3mth
FBG: 3mth then annually
Lipid Panel:
BP: 3mth then annually
EPSE Exam:
21
Q

Management of Antipsychotics SE

A

1) EPSE
- Dystonia: IM anticholinergics (benztropine, diphenhydramine)
- Pseudo-PKS: Decrease dose/Switch to SGA, Anticholinergics PRN (benztropine)
- Akathisia: Decrease dose/Switch to SGA, Clonazepam (low-dose) PRN
- Tardive dyskinesia: Discontinue anticholinergics, Decrease dose/Switch to SGA, Valbenazine 40-80mg/day, Clonazepam PRN

2) Hyperprolactinaemia
- Switch to Aripiprazole

3) Metabolic SE
- Lifestyle modifications, treat diabetes (metformin), switch to lower risk agents (Aripiprazole, Lurasidone)

4) CVS
Orthostatic hypot/s: Get up slowly
VTE/PE: mANAGE EMERGENT dvt

5) CNS
* Neuroepileptic Malignant Syndrome (NMS)*
- Muscle rigidities, fever, autonomic dysfunction (Increase PR, labile BP, diaphoresis), altered consciousness, Increased CK
- Happens with high-potency agents
- > IV Dantrolene 50mg TDS (muscle relaxer), Oral Dopamine Agonist, supportive measures
- Switch to SGA (low-potency)

6) Hematological
Clozapine-induced Agranulocytosis: Discontinue if WBC < 3, ANC < 1.5

22
Q

To take note of when treating Elderly with Antipsychotics

A
  • Avoid drugs with high propensity to cause orthostatic hypot/s or anticholinergic SE
  • Simplify regime
  • Elderly with Dementia (increased risks for mortality) when using FGA & SGAs
23
Q

Clinically significant DDI with Antipsychotics

A

Fluvoxamine: Increases Clozapine
Carbamazepine: Agranulocytosis with Clozapine

24
Q

Time course of treatment response with Antipsychotics

A

1st wk: Decreased agitation
2-4wks: Decreased paranoia, hallucinations
6-12wks: Decreased delusions
3-6mths: Cognitive sxs may improve (with SGAs)

25
Q

Clinical differences between SGA & FGA

A

Efficacy
FGA: +ve sxs
SGA: +ve & mood sxs

Toxicity:
FGA: EPSE
SGA:
- More metabolic SE (except Aripiprazole, Brexipiprazole, Lurasidone, Ziprasidone)
- “-ines” relatively > sedating, > weight gain

26
Q

Acute stabilisation phase of Schizophrenia

A

Goal: Reduce agitation, aggression, hostility, improve sleep

If acutely agitated/aggressive:

1st: De-escalate
2nd: Consider oral antipsychotic +/- benzodiazepine
- Fast-acting IM alternatives (IM Haloperidol 5mg with ECG + IM Lorazepam 2mg)

If EPSE:
Dystonia/ pseudo-PKS SE: Oral/IM benztropine 2mg

27
Q

Stabilisation & Maintenance phase of Schizophrenia

A

Goal: minimise/prevent relapse, maintain baseline functioning

If poor adherence/prefer IM:
- IM long-acting (IM haloperidol Decanoate)

PR3136 (14 decks)

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