55. Schizophrenia & Psychosis Flashcards
Benjamin is an older gentleman with advanced Parkinson’s disease. He has lived in a skilled nursing facility for about one year since he became unable to feed himself. Benjamin tried to hit his roommate with a butter knife. He explained to the nurse that the roommate was planning to attack him when he was sleeping in order to take his eyes out and sell them. Which of the following medications are possibly contributing to Benjamin’s psychosis? (Select ALL that apply.)
A. Sinemet
B. Requip
C. Proscar
D. Aggrenox
E. Imuran
A, B. Both levodopa/carbidopa and the dopamine agonists can aggravate psychosis; the dopamine agonists are higher risk.
A patient gave the pharmacist a prescription for Risperdal 1 mg PO TID #90. Which of the following is an appropriate generic substitution for Risperdal?
A. Aripiprazole
B. Olanzapine
C. Risperidone
D. Ziprasidone
E. Quetiapine
C. The generic name of Risperdal is risperidone.
John has failed several trials of antipsychotics. He continues to respond to “voices” that constantly torment him. He has tried to commit suicide several times. John’s other medical conditions include poorly controlled seizures since childhood, phenytoin-induced gingival hyperplasia and thickening of facial features, depression, anxiety, elevated cholesterol and pre-diabetes. Fortunately, since a second-anticonvulsant was added to the phenytoin, he has not had a seizure in the past six months. His WBC is 5,500 cells/mm3. Choose the correct statements: (Select ALL that apply.)
A. If he has poor adherence clozapine comes in an ODT formulation called FazaClo.
B. He is unlikely to be able to tolerate clozapine; the seizures may become uncontrolled.
C. Clozapine can be tried as he has failed several trials of antipsychotics.
D. The white blood cell count permits clozapine therapy.
E. Clozapine is a good choice in a patient with a seizure history.
A, B, C, D. Clozapine (Clozaril) has ~5% risk of seizures. Caution should be used in giving this drug to patients having a history of seizures or other predisposing factors. It is likely that this patient will not be able to tolerate the drug due to seizures. However, due to the history, a trial is reasonable.
Haloperidol comes in the following formulations: (Select ALL that apply.)
A. Oral tablet
B. Fast-acting injection
C. Two-week depot formulation
D. Four-week depot formulation
E. Orally disintegrating tablet
A, B, D. Haloperidol comes in a monthly “decanoate” injection that is a useful option for patients who have adherence issues. Several of the atypicals now come as injections for stat control or for longer-acting benefit.
Jessica is a 72 year-old female with a variety of medical conditions. Two years ago, her family reported that Jessica was displaying paranoid delusions, including the belief that her daughter was trying to kill her by poisoning her food. The physician prescribed risperidone, which has been helpful. At clinic today Jessica is darting her tongue in and out and blinking in an involuntary manner. She is displaying the following adverse effect from the use of an antipsychotic:
A. Dystonic reaction
B. Tardive dyskinesia
C. Akathisia
D. Neuroleptic malignant syndrome
E. Sedation
B. Tardive dyskinesias (TDs) are involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients treated with long-term dopamine-blocking agents. They can occur just from the disease as well. If they occur, the drug should be stopped. TDs can be irreversible.
A patient gave the pharmacist a prescription for Geodon 60 mg PO BID #60. Which of the following is an appropriate generic substitution for Geodon?
A. Olanzapine
B. Risperidone
C. Ziprasidone
D. Quetiapine
E. Aripiprazole
C. The generic name of Geodon is ziprasidone.
Doris is a 72 year-old female caregiver for her husband Edward, who is suffering from dementia. Recently, to Doris’ very sad surprise, Edward struck her while she was helping him eat. She asked the physician for help and he prescribed risperidone 1 mg BID. The pharmacist should inform Doris of the risk of using this medicine (and the mild, if any, benefit). The pharmacist should inform her that there may be a slightly increased risk of serious, possibly fatal, side effects when this medication is used in older adults with dementia primarily due to an increased risk of the following: (Select ALL that apply.)
A. Myocardial infarction
B. Cerebrovascular accident
C. Renal failure
D. Decreased sodium bicarbonate, coma
E. Infection
A, B, E. All of the antipsychotics have a boxed warning for an increased risk of mortality in elderly patients with dementia-related psychosis, primarily due to an increased risk of cardiovascular disease or infections.
Charlene had never used drugs but was “talked into” trying methamphetamine by a friend. Charlene took the drug and began to believe that she had to have sexual relations with the boy next to her in order to prove her dedication to God. Charlene experienced drug-induced psychosis. Other drugs that can cause drug-induced psychosis include: (Select ALLthat apply.)
A. Lysergic acid diethylamide
B. Amphetamines, include methamphetamine
C. OTC NSAIDs, taken in high doses
D. Dextromethorphan
E. Phencyclidine (PCP) / MDPV (bath salts)
A, B, D, E. “Bath salts” are being used commonly and causing much distress in the ED, with psychotic patients.
The FDA mandates that all patients taking the following drug (which is a REMS drug) must be included in the drug’s patient registry database:
A. Clozapine
B. Aripiprazole
C. Quetiapine
D. Ziprasidone
E. Risperidone
A. The purpose of the registry is to prevent re-challenge in patients with a history of drug-induced agranulocytosis and to detect leukopenia or agranulocytosis based on WBC counts and ANC values.
A pharmacist will counsel a patient beginning therapy with Seroquel XR. Which of the following are correct counseling statements? (Select ALL that apply.)
A. This medication has a high risk of causing strange movements in your face, such as eyelid blinking or smacking motions with your mouth.
B. Take at night without food, or with a light meal that is not over 300 kcals (calories).
C. Place the tablet under your tongue and allow it to dissolve completely.
D. This medication can make you feel “wired” and may cause difficulty sleeping.
E. This medication can cause you to put on weight and can increase your blood sugar and cholesterol. It is important to try and get regular exercise, such as walking, and to eat healthy foods.
B, E. Seroquel XR is sedating and has a low risk of movement disorders. It has a high risk for metabolic complications, however.
A patient has failed trials with olanzapine and ziprasidone. The psychiatrist will initiate clozapine therapy. The patient cannot be started on clozapine therapy if the white blood cell count is below:
A. 11,500/mm3
B. 7,500/mm3
C. 4,500/mm3
D. 3,500/mm3
E. 5,500/mm3
D. Clozapine is the most effective agent for refractory schizophrenia (cases that do not respond to other treatments.) It is unfortunate that agranulocytosis (loss of granulocytes, which are required to fight infection) limits the use of this medication, along with a risk of seizures. A normal white blood cell count is 4,000-11,000. Do not initiate clozapine if below 3,500, and stop therapy if it falls to 2,500.
Antipsychotics such as chlorpromazine and haloperidol exert their mechanism of action by blocking this receptor:
A. Norepinephrine
B. Epinephrine
C. Dopamine
D. Serotonin
E. Acetylcholine
C. The antipsychotics are primarily dopamine (D2) blocking agents, which is why they cause movement disorders. With some of the newer agents serotonin receptors are involved as well.
What is the rationale behind the production of several different formulations of orally disintegrating tablets for schizophrenia?
A. The patient will not be able to “cheek” the medicine and spit it in the toilet.
B. Most patients with schizophrenia have dysphagia.
C. Most patients with schizophrenia have mucositis; this formulation lowers the risk.
D. Most patients with schizophrenia will not wish to receive injections.
E. Most patients with schizophrenia have elevated blood glucose.
A.
A 23 year old male was picked up by the police for acting erratically and threatening patrons at a subway stop. He was placed into the acute lock-down ward of the psychiatric hospital and given an injection of haloperidol and lorazepam. He quickly developed a very painful sustained contraction of his neck and trunk. Choose the correct statements concerning this adverse drug reaction: (Select ALL that apply.)
A. He is likely experiencing a dystonic reaction due to lorazepam.
B. He is higher risk and should have received prophylaxis for this reaction.
C. He is experiencing a symptom due to the disease state (schizophrenia).
D. He is likely experiencing a dystonic reaction due to haloperidol.
E. He can be treated with a centrally-acting anticholinergic, such as diphenhydramine.
B, D, E. Treatment for dystonic reactions is with centrally-acting anticholinergics (such as benztropine and diphenhydramine). These are administered by injection for fast relief, or can be given orally for prophylaxis during therapy initiation. The highest risk group to get dystonic reactions is young males, although any sex and age group can experience this adverse event.
Charlene is a 74 year-old female who has a unilateral tremor in her right hand. She may have Parkinson’s disease. The physician needs to choose a second generation antipsychotic for Charlene. Among the following second generation agents, which agents have a high risk for movement disorders and should not be chosen for this patient? (Select ALL that apply.)
A. Paliperidone
B. Risperidone
C. Clozapine
D. Quetiapine
E. Olanzapine
A, B. Risperidone, at higher doses, can cause movement disorders. In this case the patient is elderly and even lower doses may cause a problem. Paliperidone (Invega) is similar in side effects to risperidone and also has high risk.
