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B33CNS > Antipsychotic Medicine - Prescribing and Monitoring (Dr J Lawton) > Flashcards

Antipsychotic Medicine - Prescribing and Monitoring (Dr J Lawton) Flashcards

1
Q

What are some of the components of Mental Health Services across Nottingham?

A 
Primary care - GP, mental health nurses
Specialist MH Services
Early Intervention in Psychosis Teams 
Crisis and Home Treatment Teams
Community MH Teams 
Assertive Outreach Teams (some patients don't engage with primary care)
In-Patient Care - acute, residential
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2
Q

Who may be involved in MDT for Adult Mental Health Services?

A

GP, psychiatrist, nurses, junior docs, pharmacists, healthcare assistants, occupational therapists, psychologists, non-medical prescribers, social workers.

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3
Q

What extra services may be offered to the public aside form the Adult Mental Health services?

A 
MH Services for Older People (65+)
Child and Adolescent MH Services
Intellectual Disability Services 
Forensic Psychiatry 
Drug and Alcohol Services 
Dual Diagnosis Services (i.e. substance misuse and MH)
Perinatal Psychiatry Services 
Offender Health Services
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4
Q

What are the roles of a pharmacist in MH care?

A

Explain medicine, provide information
Support adherence, review treatment plans - simplify regimens and review PRN use
Interactions, polypharmacy, high doses, monitor side effects and also general physical health.
Drug histories, TDM result interpretations
Sign post to services- links to MH services
Promote evidence based treatments
Break the stigma
Support carers
Healthy choices / Health promotion
Smoking cessation (smoking, cP450 1A2 induction and clozapine

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5
Q

What is GASS?

A

Glasgow Anti-Psychotic Side Effect Scale

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6
Q

What is an MHA Second Opinion Consultee?

A

After 3 months being detained and treated under the Mental Health Act; before release, experts are consulted

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7
Q

What is the rate of relapse like in chronic schizophrenia?

A

60-70% with chronic will relapse within 1 year of stopping medication VS
10-30% who remain on treatment

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8
Q

How long should medication be continued for after an acute episode of schizophrenia?

A

1-2 years following recovery
Do not stop medicine abruptly
Monitor for signs/symptoms of relapse for 2 years after stopping medication.

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9
Q

What formulations are used that are modified for anti-psychotic target use?

A

Olazapine, aripiprazole and risperidone are available as oro-dispersible tablets;
Freeze dried wafer
Disperses in saliva
Difficult to conceal

Short acting injections used for tranquilisation

Long acting depot injections - may improve medication adherence

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10
Q

What is Rapid Tranquilisation?

A

Use of medicine to control extreme agitation, aggression or potentially violent behaviour that put the individual or those around them at risk of physical harm.
The aim is to sedate the person to minimise the risk without the person losing consciousness.

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11
Q

What medication is no longer recommended for rapid tranquilisation and why?

A

Clopixol-Acuphase

Peak concentration in plasma after 24h

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12
Q

What are the risks associated with anti-psychotic use in rapid tranquilisation?

A

Excessive sedation
Loss of consciousness
Respiratory depression –> arrest
Cardiovascular complications or collapse

Seizures
Akathisia 
Dystonia
Dyskinesia 
NMS
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13
Q

What are the risks associated with using benzodiazepines in rapid tranquilisation?

A

Excessive sedation
Loss of consciousness
Respiratory depression –> arrest
Cardiovascular collapse

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14
Q

What should be monitored in a patient that has been sedated by rapid tranquilisation?

A

Blood pressure, respiration, pulse, temperature, level of consciousness

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15
Q

Give some examples of monthly depot injections?

A

Paliperidone palmitate Xepilion
Risperidone Consta
Aripiprazole Maintena
Olazapine ZypAdhera

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16
Q

Where are long acting depot injections of anti-psychotics administered?

A

Deltoid or gluteal

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17
Q

What is NMS?

A

Neuroleptic malignant syndrome (NMS) is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.

18
Q

What is Akathisia?

A

Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting.

19
Q

What drugs are oil based depot injections?

A

Normally contain palmitate or decanoate

Old fashioned oil based formulations

20
Q

What is treatment resistant schizophrenia?

A

Failure to respond to two different antipsychotics (one of which is atypical) each prescribed for atleast 6-8 weeks in recommended doses.

21
Q

What ‘other’ reasons could be the cause of treatment resistant schizophrenia?

A

Not taking the medicines

Alcohol or illicit substance use

22
Q

What should be tried in patients that have treatment resistant schizophrenia?

A

Clozapine is the drug of choice and should be introduced at the earliest opportunity.

23
Q

What service encomapases patients taking Clozapine?

A

The UK Registered Clozapine Patient Monitoring Services

24
Q

What is monitored in patients taking Clozapine?

A

Full blood count needed
Weekly bloods needed for first 18 weeks
Fortnightly bloods up to a year
Then monthly bloods

25
Q

What happens when a patients monitoring on Clozapine comes up with a Red Alert Result?

A

Stop clozapine immediately

26
Q

What kind of drugs are contraindicated in patients taking Clozapine?

A

Patients taking other drugs that cause bone marrow suppression

27
Q

What is Clozapine metabolised by?

A

c1A2 and c2D6

28
Q

When is a patient most at risk when taking Clozapine?

A

In the first 18 weeks

29
Q

What are the side effects of Clozapine?

A 
Drowsiness
Hypertension or hypotension and dizziness
Increased HR
Raised body temperature
Hypersalivation 
Constipation (can be severe)
Nausea (domperidone)
Weight gain 
Nocturnal enuresis 
Lowers the seizure threshold (use prophylactic sodium valproate when clozapine given >600mg/day)
Raised blood glucose and lipid levels
Cardiomyopathy / myocarditis
30
Q

What is nocturnal enuresis?

A

Nocturnal enuresis is involuntary urination that happens at night while sleeping, after the age when a person should be able to control his or her bladder.

31
Q

How can Clozapine induced nausea be treated?

A

Domperidone

32
Q

How can the lowering of the seizure threshold be counterbalanced in patients taking >600mg/day Clozapine?

A

Sodium valproate prophylaxis

33
Q

What is necessary if 48hr without a Clozapine dose?

A

Patient must re-titrate the dose due to a loss of tolerance

34
Q

What are the signs of cardiomyopathy / myocarditis?

A

Persistent tachycardia with fever, hypotension or chest pain
Rare but can be fatal

35
Q

What can be done is Clozapine does not work?

A

Assess response over atleast 6 months
Gradually increase the dose
Monitor plasma concentrations of clozapine
Augment with a 2nd anti-psychotic for a trial period.

36
Q

How is the choice made for a specific anti-psychotic?

A

Decision should be made with HCP and service user taking into account the views of the carer if the service user agrees
Provide information and discuss the likely benefits and possible side effects of each drug including; metabolic, extrapyramidal, cardiovascular, hormonal, other

37
Q

What are the side effects considered when discussing anti-psychotics?

A 
Metabolic 
Extrapyramidal
Cardiovascular 
Hormonal 
Others
38
Q

How do we facilitate patient choice?

A

Informed discussion
Decision aids
Choice and medication

39
Q

What baseline investigations are completed before a patient is started on an anti-psychotic?

A 
Physical examination 
Weight, BMI, waist circumference 
Pulse and BP
Fasting glucose and HbA1c
Fasting blood lipids 
Prolactin levels 
ECG if specified CV risk 
Any movement disorders 
Nutritional status, diet and level of physical activity 
Smoking status
40
Q

What are routinely monitored in patients taking anti-psychotic medication?

A 
Response (change in symptoms and behaviour)
Side effects and impact on functioning 
Weight, weekly for first 6 wks, then at 3 months then annually 
Waist circ, annually 
Pulse/ BP at 3 months then annually 
Adherence checks 
Overall physical health 
Shared care with GP
41
Q

What steps outline good prescribing of anti-psychotics?

A

Record indication, benefits/risks and expected response time
Start at lower end of the dose range, slowly titrate upwards keeping within the BNF limits
Consider a therapeutic trial as 4-6 weeks at optimum dose
Justify and record reasons for Rx doses above BNF limits
Record rationale for changes or continuation medication and the reasoning
Avoid polypharmacy except for short periods e.g. when switching antipsychotics

B33CNS (20 decks)

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