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'B33CNS - Pharmacology & Therapeutics > Antipsychotic medicine prescribing & monitoring > Flashcards

Antipsychotic medicine prescribing & monitoring Flashcards

1
Q

What is the structure of Adult Mental Health (19:13) services in Nottingham?

A
  • Primary care (GP, mental health nurses)
  • Specialist MH Services
  • Early Intervention in Psychosis (EIP) Teams
  • Crisis and Home Treatment Teams (CRHT)
  • Community MH Teams
  • Assertive Outreach Teams (patients not engaging w/primary care teams)
  • Section 136 Suites (vulnerable patients in a place of safety, under the Mental Health Act)
  • In-Patient care; acute (formal/informal), residential rehab
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2
Q

What does a MH MDT look like?

A
  • GP
  • Psychiatrist
  • Junior doctors
  • Psychiatric nurses
  • Pharmacists
  • Healthcare assistants
  • OTs
  • Psychologists
  • Non-medical prescribers
  • Social workers
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3
Q

What is the role of the pharmacist in a MH MDT?

A
  • Explain medicines
  • Provide information
  • Support adherence
  • Monitor S/Es; using GASS (Glasgow Anti Psychotic Scale) and LUSNERS
  • Physical health
  • Identify polypharmacy/high-doses
  • Review treatment plans
  • Drug histories
  • Identify drug-interactions
  • TDM result interpretation (e.g. Clozapine)
  • Signposting to services
  • MHA (Mental Health Act) Second Opinion Consultee; can give medications for 3 months w/o formal consent under Mental Health Act
  • Promote evidence-based treatments
  • Simplify regimens
  • Review PRN use
  • Break the stigma
  • Support prescribers
  • Links to MH services
  • Support carers
  • Health promotion
  • Healthy choices
  • Smoking cessation
  • Smoking/CYP450-1A2 induction/Clozapine; heavy smokers metabolise smokers much faster as a result
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4
Q

What is the target receptor to treat psychosis? Give examples.

A 
D2 blockade (positive symptoms):
- Haloperidol
- Risperidone
- Amisulpride
(marked blockade)
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5
Q

What does blocking 5-HT2 do w/antipsychotic therapy? Give examples.

A 
Provides protection against extrapyramidal S/Es:
(Atypicals)
- Risperidone
- Olanzapine
- Quetiapine
- Clozapine
(marked blockage; protection)
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6
Q

What occurs if antipsychotics have M, H1 or Alpha-1 receptors activity?

A
  • M; muscarinic side effects (clozapine, olanzapine)
  • H1; histamine, causes sedation/drowsiness (clozapine, olanzapine, quetiapine)
  • Alpha 1; postural hypotension, dizziness etc. (dose-related; start low, go slow)
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7
Q

What is the PANSS rating scale?

A
  • Positive And Negative Symptom Scale

- For patients to report their symptoms (whilst on antipsychotic treatment)

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8
Q

What is the short-term efficacy of antipsychotics like?

A

Relieves acute (positive) symptoms:

  • Quickly calm, reduces anxiety, helps sleep
  • Delusions, hallucinations, thought disorder improve over weeks

Limited effect on chronic (negative) symptoms:
- Social withdrawal, flattening of mood, poverty of speech, lack of drive/motivation/initiative

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9
Q

What are the guidelines to ensure long-term efficacy of antipsychotics?

A
  • 60-70% w/schizophrenia relapse within one year of stopping medication
  • Only 10-30% relapse if they continue treatment as prescribed
  • Continue medication for at least 1-2 years (following recovery from acute episode)
  • Do not stop medication abruptly (brain adapts; titrate down over at least 1 month)
  • Monitor for signs/symptoms of relapse for 2 years after stopping medication
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10
Q

What different formulations are availible for antipsychotic treatment?

A
  • Olanzapine, aripiprazole and risperidone availible as orodispersible tablets
  • Freeze-dried wafer; disperses in saliva, difficult to conceal (but do not act faster than normal tabs)
  • Short-acting injections; rapid tranquillisation
  • Long-acting ‘depot’ injections (IM in gluteal/deltoid); improve adherence
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11
Q

What is rapid tranquilisation and what is its aim?

A
  • Use of medicine to quickly control extreme agitation, aggression and potentially violent behaviour that put the individual/those around them at risk of physical harm
  • Aim to sedate the person to minimise risk, without the person losing consciousness.
    • Time out
    • Distraction
    • Seclusion
    • Restraint
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12
Q

What medicines are availible for RT?

A
  • Lorazepam (first line; BZD)
  • Haloperidol + Promethazine (NICE recommended; Phenergan, sedative antihistamine)
  • Etc.

> > > Flumazenil is BDZ antagonist (GABA antagonist) to treat excessive drowsiness/respiratory depression

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13
Q

Which RT is no longer recommended any why?

A

Clopixol-Acuphase (Zuclopenthixol; antipsychotic)

  • Slowest acting
  • Takes 24 hours to reach peak plasma conc.
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14
Q

What are the risks of drugs used in RT? Which drugs have a better tolerated S/E profile?

A

Both APs and BZDs share risk of:

  • Excessive sedation
  • Loss of consciousness
  • Respiratory depression/arrest
  • Cardiovascular complications/collapse

BUT, APs also have risk of:
• Seizures
• Akathisia (agitation/restlessness stage)
• Dystonia (involuntary muscle contractions)
• Dyskinesia (abnormal/impaired voluntary movement)
• NMS (neuroleptic malignant syndrome)

Whereas BZDs just additionally have:
• Risk of non-access to flumazenil (BZD antagonist in OD)

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15
Q

How are the risks monitored in RT?

A

Monitor:

  • Levels of consciousness
  • Respiration
  • Blood pressure
  • Pulse
  • Temperature
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16
Q

What are the considerations when using long-acting antipsychotics (depots etc.)?

A
  • Half-life
  • Gluteal vs. deltoid for location of injection
  • Fridge storage
  • Loading dose considerations (PO?)
  • Onset of action (PO in meantime)
  • Time to SS
17
Q

Which LA depot antipsychotics last for longer, and why?

A

Typicals:
- Paliperidone palmitate (Xepilon)
- Decanotate, palmitate (OIL- BASED)
> Last for 3 months

Atypicals:
- Risperidone Consta
- Aripiprazole Maintena
- Olanzapine ZypAdhera
> Given every 2 weeks/monthly; newer atypicals are aqueous based
18
Q

What is the potential danger of using Olanzapine ZypAdhere LA AP?

A

Post-injection syndrome:

  • Drug enters vein instead of muscle
  • Resulting olanzapine overdose in blood
19
Q

What is Treatment-Resistant Schizophrenia? What therapy is then used?

A
  • Failure to respond to two different antipsychotics (one of which is an atypical), each trialled for at least 6-8 weeks in recommended doses
  • Clozapine then becomes drug of choice; introduced at earliest opportunity
20
Q

What are some potential reasons for Treatment-Resistant Schizophrenia?

A
  • Not taking the medicines

- Alcohol/illicit drug use

21
Q

What are the conditions for clozapine use/what tests are involved? How is it metabolised?

A
  • Full blood count (FBC)
  • No blood test = no clozapine:
    • Weekly bloods for first 18 weeks
    • Fortnightly bloods to 1 year
    • Then monthly bloods thereafter
  • RED alert result; stop clozapine immediately (dip in neutrophil/WBC count; agranulocytosis risk)
  • CI w/other drugs that can cause bone marrow suppression
    »> Metabolised by: C1A2 & C2D6
22
Q

What is the risk of neutropenia/agranulocytosis in clozapine use, and when is this likely to occur?

A
  • Neutropenia; 3% risk
  • Agranulocytosis; 0.5% risk (blood dyscrasia etc.)
    »> Usually within first 18 weeks
23
Q

What are the common dose-related S/Es of clozapine and how are they managed?

A

Dose-related S/Es include:

  • Drowsiness
  • Hypertension/hypotension, and dizziness
  • Increased heart rate (> 100 bpm)
  • Raised body temperature
  • Hypersalivation
  • Nocturnal enuresis (urination during sleep)
  • Raised blood glucose
  • Raised blood lipid levels (dyslipidemia)

How to minimise:
Gradual dose-titration essential to minimise dose-related S/E’s:
• 12.5mg nocte on Day 1
• 25mg nocte on Day 2
• 25mg mane + 25 mg nocte Day 3
• Increase by 25-50mg/day every 2-3 days to usual range: 150-400 mg/day
• Max 900mg/day in divided doses

24
Q

What other S/Es of clozapine may present, and how are these ones by actively managed?

A

Constipation
- Usually persists, can be severe (TREAT)

Weight gain (atypicals)
- Dietary, exercise advice

Nausea
- May need antiemetic e.g. domperidone

Lowers seizure threshold:

  • Mainly problematic at doses > 600 mg/day
  • Use prophylactic sodium valproate above 600mg/day

Cardiomyopathy/myocarditis

  • Signs: persistent tachycardia w/fever, hypotension or chest pain
  • Rare but MAYBE FATAL
25
Q

What options are there if 3rd-line treatment w/clozapine is ineffective?

A
  • Assess response over at least 6 months
  • Gradually increase dose
  • Monitor plasma concentrations of clozapine (trough level 350-500mcg/L)
  • Augment w/second antipsychotic for a trial period (e.g. sulpiride, amisulpride)
    »> 1/3 respond well, 1/3 respond moderately, 1/3 are not effective
26
Q

If a patient misses more than 48 hours of clozapine treatment, do they still move up to the next titrated dose?

A

No; patient will have lost tolerance, thus must be re-titrated.

27
Q

According to NICE guidelines, who must be the one to start antipsychotic therapy on a first presentation?

A

GPs should not start antipsychotics on a first presentation in primary care; unless done in consultation with a consultant psychiatrist.

28
Q

How is the decision of which antipsychotic to use made?

A
  • Decision to be made by patient and HCP together, in conjunction w/the carer if the patient agrees
  • Provide information and discuss likely benefits and possible S/Es of each drug, including:
    • Metabolic
    • Extrapyramidal
    • Hormonal
    • Other (unpleasant subjective experiences etc.)
29
Q

What information is out there for patients to make an informed decision regarding their antipsychotic therapy?

A
  • Informed discussion between HCP and patient

- Decision aids; e.g. Choice and Medication website, NHS Choices

30
Q

What baseline investigations should be conducted prior to a patient starting antipsychotic therapy?

A
  • Physical examination
  • Weight, BMI, waist circum.
  • Pulse and BP
  • Fasting blood glucose, HbA1c
  • Fasting blood lipids
  • Prolactin levels
  • ECG if specified in the SPC, or if CV risk factors
  • Movement disorders
  • Nutritional status, diet and level of physical activity
  • Smoking status
  • Alcohol intake
31
Q

What routine monitoring should be undertaken for a patient on long-term antipsychotic therapy?

A
  • Response (changes in symptoms, behaviour)
  • S/Es (inc. EPSE; extrapyramidal side effects), and impact on functioning
  • Weight, weekly for the first 6/52, then at 3/12, then annually
  • Fasting blood glucose, HbA1c and lipids at 3/12 then annually
  • Adherence checks
  • Overall physical health
  • ‘Shared-care’ w/GP
32
Q

What is ‘good prescribing’ WRT to antipsychotics, as defined by NICE?

A
  • Record indication, benefits/risks, expected response time
  • Start at lower end of dose range, slowly titrate upwards keeping within BNF limits
  • Consider therapeutic trial as 4-6 weeks at optimum dose
  • Justify and record reasons for Rx doses above BNF limits
  • Record rationale for continuing/changing/stopping medication, and the effect of such changes
  • Avoid polypharmacy, except for short periods (e.g. when switching antipsychotics)
    »> “Start low, go slow”
33
Q

What are the general pointers re. antipsychotic prescribing and monitoring?

A
  • Support patient choice
  • Ensure understanding
  • Use lowest effective dose (within BNF limits)
  • Start low and go slow
  • Prescribe one AP at a time (exceptions)
  • Review effect on target symptoms
  • Monitor and manage SEs
  • Support adherence
  • Don’t forget physical health

'B33CNS - Pharmacology & Therapeutics (13 decks)

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