55. Schizophrenia & Psychosis Flashcards Preview

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Flashcards in 55. Schizophrenia & Psychosis Deck (37):
1

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.

2

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.

3

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.

4

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. 

5

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.

6

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.

7

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.

8

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.

9

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.

10

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.

11

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.

12

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.

13

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.

14

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.

15

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.

16

Phenylalanine must be avoided in patients with PKU. Which of the following formulations may contain phenylalanine? (Select ALL that apply.)

A. Granules
B. Patches
C. Injectables
D. Chewable formulations
E. ODTs or sublingual formulations

A, D, E. These do not all contain this sweetener, but it is often used in medications the patient can taste.

17

Which of the following prescription drug classes may induce or exacerbate psychotic symptoms? (Select ALL that apply.)

A. Steroids
B. Finasteride or dutasteride
C. Sinemet
D. Mirapex
E. Adderall

A, C, D, E. The stimulants can aggravate psychosis in patients already at risk, but do not seem to cause psychosis independently. Steroids can exacerbate psychotic symptoms, especially in high doses or combined with a lack of sleep.

18

A patient gave the pharmacist a prescription for Zyprexa 5 mg PO QHS #30. Which of the following is an appropriate generic substitution for Zyprexa?

A. Olanzapine
B. Risperidone
C. Ziprasidone
D. Quetiapine
E. Aripiprazole

A. The generic name of Zyprexa is olanzapine.

19

Antipsychotics can cause cardiovascular side effects, including dizziness and orthostasis. Proper counseling points for antipsychotics should include:

A. Use caution when driving, operating machinery, or performing other hazardous activities.
B. Dizziness may be more likely to occur when you rise from a sitting or lying position; rise slowly to prevent dizziness and a possible fall.
C. To reduce the dizziness and lightheadedness that may occur when you first start to take this drug; your doctor may wish you to start taking it at a low dose and then gradually increasing the dose.
D. Avoid consuming alcohol during treatment with this drug. Alcohol may increase drowsiness and dizziness.
E. All of the above.

E.

20

A female patient has been taking haloperidol 1 mg BID. Her family noticed an unusual “smacking” motion made with her lips and unusual eye movements. Choose the correct statements: (Select ALL that apply.)

A. This can be treated with an anticholinergic such as diphenhydramine.
B. The movement disorder can be successfully treated with a skeletal muscle relaxant.
C. If the haloperidol is not discontinued quickly there is a risk that the abnormal movement will become permanent.
D. The haloperidol should be discontinued; she will have to try an alternative antipsychotic.
E. This can be treated by lowering the dose of haloperidol.

C, D. Tardive dyskinesia (TD) can be irreversible; the drug that is causing the problem should be discontinued as soon as a TD develops. On any antipsychotic the patient and/or caregivers should be instructed to contact the doctor about any movements that they cannot control in your face, tongue, or other body parts, as they may be signs of a serious condition called tardive dyskinesia.

21

Ruby is a 17 year-old high school junior who is seen mumbling to herself repeatedly in class. When confronted, it is apparent that Ruby believes she is talking to someone. Choose the response that best describes the symptom of schizophrenia displayed by Ruby:

A. Delusion
B. Hallucination
C. Poor hygiene
D. Lack of emotion
E. Loss of interest in everyday activities

B. Auditory hallucinations (such as hearing voices) are common. Visual hallucinations (such as seeing people who are not there) or other hallucinations can be present but are not common in younger patients. A delusion is a patently false belief, such as thinking someone is out to get you, or that you are being poisoned.

22

Ruby is a 17 year-old high school junior who no longer wishes to socialize with her former friends. Ruby is speaking little and has little desire for social interaction. When asked by her mother if she is interested in seeing her former friends, she states she does not care. Choose the response that best describes these symptoms of schizophrenia displayed by Ruby:

A. Positive symptoms
B. Negative symptoms
C. Auditory symptoms
D. Visual symptoms
E. None of the above

B. Negative symptoms include a flat affect (emotion-less face), alogia (hardly speaking) and avolition (not motivated to do anything). The negative symptoms contribute to social withdrawal and apathy. People with schizophrenia also display disorganized speech and behavior.

23


Select the correct chemical class for Haldol:

A. Phenothiazine
B. Butyrophenone
C. Synthetic pentasaccharide
D. Dopamine and 5HT3-partial agonist
E. NE and 5HT3-blocker

B. The butyrophenones haloperidol (Haldol) and droperidol (Inapsine) are among the agents with the highest QT-risk. They are dopamine-blockers.

24

A patient gave the pharmacist a prescription for Seroquel 25 mg BID #60. Which of the following is an appropriate generic substitution for Seroquel?

A. Olanzapine
B. Risperidone
C. Ziprasidone
D. Quetiapine
E. Aripiprazole

D. The generic name of Seroquel is quetiapine.

25

A pharmacist will counsel a patient on the proper use of the Abilify Discmelt. Choose the correct counseling points: (SelectALL that apply.)

A. This medicine has delayed release; ignore a ghost tablet if it appears in the stool.
B. Upon removing the tablet, dissolve in a small amount of water and swallow; wash the crumbs down with a little more fluid.
C. Immediately upon opening the foil blister, remove tablet and place in mouth; do not push the tablet through the foil because it may crumble.
D. You do not need water to take this medicine; use water only if you want to take some.
E. Do not open if your fingers are wet.

C, D, E. Abilify Discmelt, Risperdal M-Tab, and Zyprexa Zydis are orally disintegrating tablets. If the hands are not dry the medicine will begin to dissolve when being held.

26

Ruby has been diagnosed with schizophrenia and has been prescribed risperidone. She is sleeping almost all day. Choose the agent on the patient’s formulary that is least sedating:

A. Chlorpromazine
B. Fluphenazine
C. Aripiprazole
D. Clozapine
E. Thioridazine

C. The first generation ("typical") antipsychotics are sedating and the lower potency agents (such as chlorpromazine and thioridazine) have the highest degree of sedation. Of the second generation ("atypical") agents, aripiprazole is note-worthy for not being sedating-in fact, it can contribute to insomnia and is taken once daily in the morning.

27

A pharmacist will counsel a patient beginning therapy with Zyprexa. Which of the following are correct counseling statements? (Select ALL that apply.)

A. This medication is taken in the morning; do not take at night or you will have difficulty sleeping.
B. This medication can cause seizures.
C. The other name for this medication is olanzapine.
D. This medication can make you feel "wired" and worsen psychosis.
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.

C, E. Olanzapine is sedating and is taken QHS. It causes weight gain, elevated blood glucose and lipids and (like the others that cause similar problems) the patient will need all of these monitored, along with the blood pressure.

28

Select the correct chemical class for chlorpromazine:

A. Phenothiazine
B. Butyrophenone
C. Synthetic pentasaccharide
D. Dopamine and 5HT3-partial agonist
E. NE and 5HT3-blocker

A. The phenothiazines are strong dopamine (DA) blockers. When used for other conditions, such as nausea, movement disorders are possible side effects, and sedation is expected.

29

A pharmacist will counsel a patient beginning therapy with Saphris. Which of the following are correct counseling statements? (Select ALL that apply.)

A. Do not eat or drink for at least an hour after taking this medicine.
B. The medicine will make your tongue numb.
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. If you have any uncontrollable movements of your mouth, tongue, cheeks, jaw, or your arms or legs, please contact the doctor right away.

B, C, E. Do not eat or drink for ten minutes after taking this medicine. Saphris is sedating. It has about a 5% risk of EPS.

30

A physician has a patient who is forgetful and does not take her antipsychotic on a regular basis. The physician wishes to use one of the newer, atypical or "second generation" agents. He has heard that one of them is available in a two week formulation. Which agent comes in a 2-week intramuscular injection?

A. Olanzapine
B. Risperidone
C. Ziprasidone
D. Quetiapine
E. Aripiprazole

B. Risperdal Consta is given every two weeks.

31

Angelica has been taking an atypical antipsychotic as an adjunctive agent to treat resistant depression. After beginning the antipsychotic she began to feel that she had a feeling of restlessness and an urge to move. She stated that she feels that she cannot keep her legs still. Angelica 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

C. Akathisia is a big problem among the many children that are receiving antipsychotics currently, especially with the more activating agents. It is unfortunate.

32

Rosie is a female patient with schizophrenia, depression, elevated cholesterol, pre-diabetes and hypothyroidism. The physician is considering a trial with olanzapine. Choose the correct statements: (Select ALL that apply.)

A. Olanzapine can increase her blood pressure and blood glucose.
B. Olanzapine requires white blood cell monitoring and cannot be initiated with leukopenia.
C. Olanzapine is sedating and is generally taken at bedtime.
D. Olanzapine can cause hypothyroidism or hyperthyroidism.
E. Olanzapine can increase her weight and cholesterol.

A, C, E. Some of the second-generation antipsychotics, including (most notably) olanzapine, quetiapine and clozapine, can increase weight, elevate lipids, increase blood pressure and cause or worsen hyperglycemia.

33

A 28 year-old female patient experienced high levels of prolactin (hyperprolactinemia) from the use of the atypical agent risperidone. She experienced decreased, irregular periods. She found this very bothersome and discontinued the drug. Which of the following agents would put her at repeated risk for the same adverse reaction?

A. Paliperidone
B. Aripiprazole
C. Clozapine
D. Quetiapine
E. Asenapine

A. Paliperidone is the active metabolite of risperidone. It is formulated in an OROS delivery, and is able to be dosed once daily. It has a similarly high risk of movement disorders, hyperprolactinemia and QT prolongations as risperidone. Elevated prolactin levels decreases period frequency in women and can cause infertility. Galactorrhea may be present. In men it can cause sexual dysfunction, and visual problems. With very high levels, gynecomastia can occur.

34

A pharmacist has instructed a patient's caregiver to draw up the medication in the pipette she has supplied and administered directly down the patient's feeding tube. Which medication is the pharmacist dispensing?

A. Risperidone
B. Ziprasidone
C. Quetiapine
D. Olanzapine
E. Chlorpromazine

A. Alternatively, the solution can be mixed with water, coffee, orange juice or low-fat milk. It cannot be mixed with cola or tea.

35

A patient is going to begin the Invega Sustenna. Choose the correct statements concerning this medication:

A. Invega Sustenna is a once-monthly formulation of risperidone.
B. Invega Sustenna is a once-monthly formulation of olanzapine.
C. Invega Sustenna is a once-monthly formulation of paliperidone.
D. Invega Sustenna is a once-monthly formulation of clozapine.
E. Invega Sustenna is a once-monthly formulation of thioridazine.

C. Nonadherence with therapy is the #1 problem with drug therapy in patients with schizophrenia. The long-acting formulations are important because they help improve adherence.

36

A patient gave the pharmacist a prescription for Abilify 10 mg PO daily #30. Which of the following is an appropriate generic substitution for Abilify?

A. Olanzapine
B. Risperidone
C. Ziprasidone
D. Quetiapine
E. Aripiprazole

E. The generic name of Abilify is aripiprazole.

37

Ruby has been diagnosed with schizophrenia and has been prescribed risperidone. Her heart rate becomes tachycardic and the physician wishes to use an agent with the lowest cardiovascular disease risk. Choose the agent on the patient's formulary that is not considered to be among the higher risk options:

A. Thioridazine
B. Paliperidone
C. Ziprasidone
D. Haloperidol
E. Lurasidone

E. Thioridazine (Mellaril) and ziprasidone (Geodon) should be two of the antipsychotics that stick in your mind as "high QT risk." Most have some QT risk.

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