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3153 IC9,10,11,12,14 Psychiatric > Managing + Monitoring antipsychotic-induced SEs > Flashcards

Managing + Monitoring antipsychotic-induced SEs Flashcards

1
Q

EPSE - Dystonia
- Description
- Risk
- Management

A

Dystonia: muscle spasm, onset within minutes (IM/IV) or hours (PO)

Risks:

  • High potency antipsychotics (e.g., haloperidol)
  • Neuroleptic-naive patients
  • Young males

Management: to relieve muscle side effects

  • IM anticholinergics PRN (benztropine 2mg, diphenhydramine) to relax the muscle - however, may cause/worsen constipation
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2
Q

EPSE - Pseudo-parkinsonism
- Description
- Risk
- Management

A

Pseudo-parkinsonism: tremors, rigidity, bradykinesia, salivation, bradyphrenia; onset days to weeks

Risks:

  • Elderly females
  • Previous neurological damage (head injury, stroke)

Management: to relieve muscle side effects

  • Reduce antipsychotic dose
  • Switch to lower potency antipsychotic
  • Switch to SGA (e.g., Quetiapine)
  • Anticholinergics PRN (e.g., Benzhexol/Trihexyphenidyl, oral/IM Benztropine 2mg) - however, may cause/worsen constipation
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3
Q

EPSE - Akathisia
- Description
- Risk
- Management

A

Akathisia: restlessness; onset hours to weeks

Risks: High-potency antipsychotics > Risperidone > Olanzapine > Quetiapine/Clozapine

(IC9) Note that akathisia correlates directly with duration on medication

Management:

  • Reduce antipsychotic dose
  • Switch to lower potency antipsychotic
  • Switch to SGA (e.g., Quetiapine)
  • Clonazepam (low dose) PRN
  • Propranolol (NSBB) - caution: bradycardia, hypotension
  • NOT helpful: anticholinergics
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4
Q

EPSE - Tardive dyskinesia
- Description
- Risk
- Management

A

Tardive dyskinesia: involuntary orofacial movements (face, lip, tongue), also writhing of the limbs (hand movements, pelvic thrusting); late-onset 3-6m (‘tardive’)

Risks: FGA > SGA, worsen with anticholinergic drugs

Management:

  • DISCONTINUE any anticholinergics
  • Reduce antipsychotic dose
  • Switch to lower potency antipsychotic
  • Switch to SGA (e.g., Clozapine possibly effective)
  • Valbenazine 40-80mg/day - a reversible inhibitor of vesicular monoamine transporter 2 (VMAT2)
  • Clonazepam PRN
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5
Q

Which EPSE are reversible with discontinuation of the drug, and which are not? (IC9)

A

Reversible: dystonia, pseudo-parkinsonism

Irreversible: tardive dyskinesia (Irreversible if detected late in advanced stages), akathisia

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6
Q

Hyperprolactinemia
- Description
- Risk
- Management

A

Hyperprolactinemia: can cause galactorrhea, amenorrhea, decreased libido, gynaecomastia

Risk: FGAs, Paliperidone > Risperidone > other SGAs

Management:

  • Reduce FGA dose
  • Switch to Aripiprazole
  • Dopamine agonist (e.g., amantadine - used in PD, bromocriptine)
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7
Q

Metabolic
- Description
- Risk
- Management

A

Metabolic: weight gain, emergent diabetes, increase lipids

Risks:

  • High: Clozapine, Olanzapine (CO)
  • Mod: Chlorpromazine, Quetiapine, Risperidone (QRC)
  • Low: Aripiprazole, Brexpiprazole, Cariprazine, Lurasidone, Ziprasidone, Haloperidol (ABC, LZH)

Management:

  • Lifestyle modification: diet, exercise
  • Treat diabetes: e.g., metformin
  • Treat hyperlipidemia: e.g., statins
  • Switch to a low risk agent
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8
Q

Cardiovascular - orthostatic hypotension
- Description
- Risk
- Management

A
  • Risks: Chlorpromazine > Risperidone, Paliperidone, Quetiapine > Olanzapine, Ziprasidone, Aripiprazole, Sulpiride

Management:

  • Get up slowly from sitting or lying position
  • Switch to lower risk agent
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9
Q

Cardiovascular - QTc prolongation
- Description
- Risk
- Management

A

Risks:

  • High doses
  • IV Haloperidol

Management:

  • Switch to lower risk agent (e.g., Quetiapine, Risperidone, Olanzapine)
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10
Q

Cardiovascular - VTE/PE
- Description
- Risk
- Management

A

Risks: low potency FGA

Management:

  • prevent, monitor, treat emergent DVT
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11
Q

CNS - sedation
- Description
- Risk
- Management

A

Risks: Chlorpromazine, Clozapine > Quetiapine > Olanzapine > Risperidone, Paliperidone, Ziprasidone, Aripiprazole

Management:

  • switch to lower risk agent
  • administer in early evening for sedation to wear off by morning
  • may consolidate once nightly dosing where appropriate
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12
Q

CNS - seizure
- Description
- Risk
- Management

A

Risks: Clozapine, Chlorpromazine > other SGAs

*Recall Clozapine, Chlorpromazine, and Quetiapine cannot consolidate as once daily dosing

Management:

  • Switch to high-potency agents (e.g., Haloperidol)
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13
Q

CNS - Neuroleptic malignant syndrome (NMS) A&E

  • Description
A

Neuroleptic malignant syndrome (NMS) aka Malignant hyperthermia

  • Muscle rigidity (leadpipe rigidity)
  • High fever
  • Autonomic dysfunction (incr PR, labile high BP, diaphoresis/sweating)
  • Altered consciousness
  • Incr CK (due to muscle breakdown, can cause rhabdomyolysis)
  • May cause kidney to shut down
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14
Q

CNS - Neuroleptic malignant syndrome (NMS) A&E

  • Risk
  • What are 3 causes of NMS
A

Risks:

  • high-potency antipsychotics (e.g., haloperidol)

Three triggers of NMS:

  1. Succinylcholine (muscle relaxant)
  2. Initiation of an antipsychotic - dopamine receptor antagonist (onset: hours to 3 days, within 30 days)
  3. Sudden discontinuation of Levodopa

Mechanism related to sudden dopamine blockade

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15
Q

CNS - Neuroleptic malignant syndrome (NMS) A&E

  • Management
A

Management:

  • IV Dantrolene - 50mg TDS (diluted in WFI only)
  • Oral dopamine agonist (e.g., amantadine, bromocriptine)
  • Supportive measures
  • Switch to SGA
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16
Q

Hematological A&E

  • Description
  • Risk
  • Management
A

Dcr WBC, agranulocytosis: dcr absolute neutrophil count

Risk: Clozapine (monitor FBC)

Management:

  • Discontinue clozapine if severe: WBC <3x10^9/L or ANC <1.5x10^9/L
17
Q

Monitoring parameter for side effects

  • Weight gain
  • Obesity
  • DM
  • HLD
  • Hyperprolactinemia
  • BP
  • EPSE
  • Agranulocytosis
  • QTc prolongation
A

General requirements:

Every visit: EPSE, fall risk, mental state exam, aggression, suicidality, vitals - BP, PR, temperature

at 12w/3m, then annually: FBG, HbA1c, lipid, BMI, waist circumference

at 6m, then annually: prolactin

Annually: cardio ECG

Drug-specific requirements:

  • Agranulocytosis (Clozapine) - WBC, ANC (weekly for first 18w, then monthly)
  • QTc prolongation (Ziprasidone) - ECG, repeat if there are risks/symptoms of QTc prolongation
18
Q

Special populations

  • Pregnancy
A

Watch for gestational diabetes, esp for Clozapine, Olanzapine

19
Q

Special populations

  • Breastfeeding
A

Suitable in breastfeeding: Olanzapine, Quetiapine

*Pt on Clozapine should continue on the drug and stop breastfeeding

20
Q

Special populations

  • Renal impairment
A

Oral Aripiprazole preferred

AVOID sulpiride, amisulpride (mainly renally excreted)

21
Q

Special populations

  • Hepatic impairment
A

Sulpiride, Amisulpride preferred as they are mainly renally excreted

22
Q

Special populations

  • Elderly
A

Avoid drugs with high propensity for a1-adrenergic blockade (orthostatic hypotension) or anticholinergic side effects (constipation, urinary retention, delirium)

Avoid long t1/2 drugs

Start low go slow

Simplify the regime

Precaution: FGAs and SGAs may increase mortality, CVD events, and stroke in dementia patients

23
Q

Interactions with antipsychotics:

  • Drugs with CNS depressant effects
A

Additive CNS effects

  • E.g., BZD, Clozapine
  • With alcohol, opioids, other psychotropics
24
Q

Interactions with antipsychotics:

  • Drugs with antimuscarinic, antihistaminic, a1-adrenergic blockade, or dopamine blockade
A

Additive adverse effects

25
Q

Interactions with antipsychotics:

  • Dopamine-augmenting agents (e.g., Levodopa, amantadine, bromocriptine)
A

Mutual antagonism with antipsychotics (negate effect of each other)

26
Q

Interactions with antipsychotics:

  • Antihypertensives, Trazodone
A

Increase hypotensive effects (esp with a1 adrenergic antagonists - orthostatic hypotension)

27
Q

Interactions with antipsychotics:

  • Lithium
A

Neurotoxicity

28
Q

Interactions with antipsychotics:

  • CYP1A2 inducers - Rifampicin, Phenobarbitone, Phenytoin, Cigarette smoking
A

Decreases phenothiazines, haloperidol, clozapine, olanzapine, ziprasidone

*If pt quits smoking, may need to decrease dose

29
Q

Interactions with antipsychotics:

  • CYP1A2 inhibitor: Fluvoxamine, Quinolone, Macrolide, Isoniazid, Ketoconazole
A

Increases phenothiazines, haloperidol, clozapine, olanzapine, ziprasidone

30
Q

Inetarctions with antipsychotics:

CYP1A2 substrates: CCHOZ

CYP2D6 substrates: PROB AH

CYP3A4 substrates: RABZQ

A

CYP1A2 substrates:

  • Phenothiazines
  • Clozapine
  • Haloperidol
  • Olanzapine
  • Ziprasidone

CYP2D6 substrates:

  • Phenothiazines
  • Risperidone
  • Haloperidol
  • Aripiprazole / Brexpiprazole
  • Olanzapine

CYP3A4 substrates:

  • Risperidone
  • Aripiprazole / Brexpiprazole
  • Ziprasidone
  • Quetiapine
31
Q

Interactions with antipsychotics:

Carbamazepine

A

Agranulocytosis with Clozapine

32
Q

Evaluation of therapeutic outcomes

A
  1. Monitor for effectiveness of therapy
  • Mental status exam
  • Psychiatric rating scales
  1. Monitor for adverse effects
  • Metabolic parameters: FBG, HbA1c, lipids, BW, BP
  • EPSE: dystonia, pseudo-parkinsonism, akathisia, tardive dyskinesia
  1. Pt self-assessment
33
Q

Timecourse of treatment response

  • Early improvements
  • Late improvements
A

Early improvements

  • 1st week: dcr agitation, aggression, hostility
  • 2-4 weeks: dcr paranoia, hallucinations, bizarre behaviors, improved organization in thinking

Late improvements

  • 6-12 weeks: dcr delusions, negative symptoms may improve
  • 3-6 months: improvement in cognitive symptoms with SGAs

3153 IC9,10,11,12,14 Psychiatric (10 decks)

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