Dr. Aebi's Schizophrenia and Bipolar Disorder Flashcards
(120 cards)
1
Q
TAP
A
typical antipsychotic
2
Q
FGA
A
first generation antipsychotic
3
Q
What are the treatment goals of schizophrenia treatment?
A
- Decrease symptoms
- increase quality of life (minimize adverse effects from treatment)
- encourage adherence
- decrease hospitalizations/health care $
4
Q
Out of the FGAs, what reduces positive symptoms the best?
A
All FGAs reduce positive symptoms at equivalent doses.
5
Q
How the FGAs handle negative symptoms?
A
Do not reduce negative symptoms well.
6
Q
What are the general positives and negatives to FGA treatment?
A
EPS is a higher risk, as well as anticholinergic SEs
Lower risk for metabolic syndrome/weight gain
7
Q
How do SGAs handle positive and negative symptoms of schizophrenia?
A
Handles positive symptoms well (but not as good as FGAs) and has moderate efficacy at reducing negative symptoms.
8
Q
What are the benefits in using SGAs over FGAs?
A
- Possible effect on increasing cognition (hits serotonin receptors: 5HT7 Lurasidone)
- Less EPS because of 5HT2 antagonism in nigrostriatal dopamine pathway
9
Q
What is the disadvantage in using SGAs over FGAs?
A
Higher risk for weight gain/metabolic syndrome
10
Q
What are some negative symptoms in schizophrenia?
A
Depression, apathy, anhedonia
11
Q
How is D2 affinity related to potency in FGAs?
A
The higher the D2 affinity, the more potent the drug is.
12
Q
What is the range for effectiveness in affinity of the drug for dopamine receptor?
A
60% to see effectiveness. higher than 80% you start seeing AEs
13
Q
How are FGAs dosed?
A
Dosed based on chlorpromazine equivalents
14
Q
What is the normal range of CPZ equivalents?
A
300-1000mg CPZ equivalents
15
Q
In the FGAs, what do the drugs with low mg strength also have?
A
Higher potency, higher D2 affinity, high EPS, low sedation, and low anticholinergic effects.
16
Q
In FGAs, what do the drugs with the high mg strength also have?
A
lower potency, lower EPS risk, lower D2 affinity, higher sedation, higher anticholinergic SEs.
17
Q
What drugs have lower mg strength?
A
Haloperidol, Fluphenazine, trifluoroperazone
18
Q
What drugs have high mg strength?
A
Thioridazine, chlorpromazine
19
Q
What drug is used for tourette’s?
A
pimozide and delusional parasitosis
20
Q
Out of the SGAs, which has the lowest risk of EPS?
A
clozapine and quetiapine. Also, olanzasine, ziprasidone, and asenapine have low risk.
21
Q
Which has the highest sedation of the SGAs?
A
also clozapine and quetiapine
22
Q
Which has the highest hypotension risks? The lowest hypotension risks?
A
Clozapine has the highest hypotension risk, lurasidone and ziprasidone the least.
23
Q
Which has the most weight gain SE’s of the SGAs? The least?
A
most: clozapine and olanzapine
least: aripiprazole, asenapine, risperidone, and ziprasidone
24
Q
Which SGA has the lowest sedation?
A
Aripiprazole, lurasidone, paliperidone, risperidone, ziprasidone
25
Which SGAs have QT prolongation problems?
paliperidone, olanzapine, quetiapine, risperidone, ziprasidone
26
Which SGA's do not have many QT problems?
asenapine, lurasidone
27
Which SGAs increase prolactin levels the most?
olanzapine, paliperidone, risperidone, lurasidone, and ziprasidone
28
What is the best way to reduce side effects?
Start low, titrate slowly
29
What are the main long-term side effects to watch out for?
Metabolic syndrome
QT prolongation
Prolactin increase
EPS
30
When do EPS show up in FGAs? SGAs?
FGAs: 6-12 months
SGAs: 1.5-2 years
31
When do you use clozapine?
After failing 2 previous antipsychotics
32
Treatment guidelines: What is recommended with first episode psychosis?
SGA: risperidone, quetiapine, aripiprazole
33
Treatment guidelines: What is recommended with acute severe psychosis? (positive symptoms)
Haldol: FGA - good for positive symptoms
Olanzapine: SGA - strong M, H1 receptors for sedation
34
Treatment guidelines: What meds do you choose for lifelong maintenance if you are younger? Why?
SGA (less EPS, less sedation)
35
Treatment guidelines: What meds do you choose for lifelong maintenance if you are middle-aged?
SGA or FGA (more weight gain, diabetes in SGA)
36
Treatment guidelines: treatment resistant? What drug?
FGA or clozapine
37
Treatment guidelines: Pregnancy?
clozapine or lurasidone: category B
38
What are the special considerations with Lurasidone and ziprasidone?
Must be taken with a full meal (350-500 calories)
39
What are the special considerations with cardiac concerns? What should you avoid?
Ziprasidone
40
What is the most common EPS symptom with SGAs?
Akathisia
41
What happens if you reach risperidone doses of higher than 6mg?
Increased EPS risk
42
What is akathisia?
A movement disorder characterized by the need to be in constant motion.
43
What follow-up do you need if you are taking clozapine?
Weekly lab draws
REMs
Baseline WBC/ANC levels must be met prior to administration.
44
What is neutropenia?
An abnormally low number of neutrophils. <1500uL (whites) or <1200 (middle east)
45
What has a risk of neutropenia?
Clozapine has a high risk of this and agranulocytosis, as well as all FGAs and SGAs. Usually seen 4 weeks to 4 months of use.
46
What is considered leukopenia?
WBC < 4000/uL
47
How long does it take to classify someone as a non-responder?
4-6 weeks
| 12 weeks for clozapine
48
How long does it take to see the full effects of antipsychotics?
12 weeks
| up to 6 months for clozapine
49
When would you switch meds sooner?
If there was acute relapse danger
50
How often should you check HbAlc and blood glucose on SGAs?
Quarterly
51
How is clozapine metabolized?
Using CYP 1A2, 3A4 ( and 2D6)
52
What non-drug habits can interfere with CYP 1A2?
cigarette smoking is a strong 1A2 inducer. So is caffeine
53
What is the main benefit of injectable APs?
They can improve adherence to medications
54
What is the main adverse effect of AP injectables?
If there is an adverse effect, you cannot retrieve the drug out of the body.
55
What is preferred, oral or injectable?
Oral first.
56
What is the preferred route in AP injectables?
Gluteal usually over deltoid
57
long-acting medication: what two decanoate medications are there?
Fluphenazine and haloperidol
58
What meds are Maintenna and Aristada?
Abilify
59
What is the longest dosing interval?
6 weeks at 882mg for ability Aristada
60
What medication is Consta?
Risperidone Consta
61
What medication is Sustenna?
Paliperidone
62
What tablets are used to test if paliperidone Sustenna is is tolerated?
risperidone
63
What medical conditions may precipitate mania?
```
Stroke
Traumatic Brain Injury
Epilepsy
HIV/AIDS
Lupus
B12 deficiency
Cushing's
Sleep deprivation
Light exposure
Extreme Stress
Wilson's Disease
```
64
Drugs which may precipitate mania in a bipolar patient
```
alcohol
bronchodilators
caffeine
cocaine
stimulants
steroids
TCAs
hallucinogens
Dopamine agonist
Pseudo ephedrine
Interferon
```
65
What is bipolar I?
Manic and depressive episodes, classic bipolar.
66
What is bipolar II?
Less severe manic episodes than I, same depressive episodes.
67
What is cyclothymia?
chronic but milder form of bipolar disorder, characterized by episodes of hypomania and depression that last for at least two years.
68
What are mixed episodes?
Where mania and depression occur simultaneously. may feel hopeless and depressed yet energetic and wanting to participate in risky behaviors.
69
When are destructive times for patients?
Either in mania or depressive phase.
70
What is rapid-cycling?
Bipolar individuals experience four or more episodes of mania, depression, or both within one year.
71
What is classified as a manic phase?
At least 7 days of abnormally or persistently elevated or irritable mood. May alternate back and forth between the two.
72
What symptoms may be part of a manic episode?
```
Inflated self-esteem
Decreased need for sleep
Intensified speech
Rapid ideas
Distractibility
Increased goal-pursuit
Involvement in pursuits of pleasure with high risks of consequences
```
73
What is a hypomanic episode?
A less intense manic episode.
Only required to be present for 4 days
impacts function
Observable by others
74
What is valproate indicated for?
Mania or mixed
75
What is carbamazepine indicated for?
Mania and mixed
76
What is lamotrigine indicated for?
maintenance and depression
77
What is lithium indicated for?
Mania and maintenance
78
What is aripiprazole indicated for?
Mania, mixed, and maintenance
79
What is quetiapine indicated for?
Mania and depression
80
What is risperidone indicated for?
Mania and mixed
81
What is olanzapine indicated for?
mania, mixed, maintenance
82
What is olanzapine and fluoxetine indicated for?
depression
83
what is ziprasidone indicated for?
mania and mixed
84
What is step 1 for bipolar disorder?
Li, VPA, or SGA
| Li or VPA + SGA
85
What is step 2 for bipolar disorder?
Switch to another 1st line agent
| Combination of any two: Li, VPA, or SGA
86
What is step 3 for bipolar disorder?
Combination of any two: Li, VPA, SGA (not 2 SGAs or Cloak) CBZ, FGA, OXC
87
What is the best treatment for hypomania/mania or psychotic mania?
Lithium, vaproate, aripirazole, quetiapine, risperidone or ziprasidone
88
What is the best treatment for dysphoric or mixed episodes?
Divaproex, risperidone, aripiprazole or ziprasidone
89
Secondary options for mania?
- carbamazepine (many drug interactions)
| - olanzapine (metabolic syndrome risk)
90
What would be the most sedating if one wanted to quickly slow down a manic person threatening to cause harm?
Valproate
91
Which has the best overall evidence for acute euphoric mania?
quetiapine
92
If someone had a past history of cardiac myopathy or QT prolongation, which one(s) would you stay away from?
Stay away from quetiapine, risperidone, ziprasidone
93
What has the best evidence for treating Bipolar II or severe bipolar I and depression?
- If on lithium, add lamotrigine or quetiapine, then olanzapine with fluoxetine
- If not on lithium, then add lamotrigine or QTP + antimanic
- If not on lithium and has not had a recent or severe manic episode, may try lamotrigine by itself
- May add on olanzasine or olanzasine + fluoxetine
94
What drug interaction do you want to watch out for?
valproic acid plus lamotrigine
95
What is wrong with antidepressants in mono therapy for bipolar disorder?
Not recommended in BPD I, and could cause a mania switch. Possibly appropriate in BPD II with mood stabilizer on board (lithium or lamotrigine), but evidence of improved stability is lacking.
- SSRI, SNRI, MAOI (phenelzine) suggested. No TCAs
96
Later stages of bipolar disorder, or resistance treatment:
- oxcarbazepine: watch for hyponatremia (na+)
- Clozapine (treatment resistant cases only)
- ECT - highly effective for acute mania
- inhaled loxapine: indicated to treat acute agitation in bipolar I
97
What is lithium indicated for?
Acute mania
| Maintenance in BPD I and II
98
What should serum levels be for lithium?
0.5-1 mEq/L
99
What are prophylactic benefits of lithium useful for?
Episodes of mania rather than depression recurrence
100
How does the suicide rate decrease with lithium use?
5-fold decrease in suicide rate compared with placebo
101
What direct illness-modifying effect does lithium have?
A neuroprotective effect
102
What are the adverse effects of lithium?
```
Cognitive dulling
Tremor
Memory impairments
Weight gain
Polyuria
Hypothyroidism (30% longterm patients) - cause of Breakthrough depression
Leukocytosis: increases WBC
Pregnancy category D - cardiac malformations 1st trimester
```
103
What do NSAIDs and lithium cause?
They cause increase lithium levels
104
What other drugs cause increased lithium levels?
ACE inhibitors, thiazide diuretics
105
What drug causes encephalopathy with lithium?
Haloperidol
106
At what serum level does lithium toxicity occur?
At higher than 1.2, but symptoms can occur within normal range
107
What symptoms occur with lithium toxicity?
GI upset, N&V, diarrhea, tremor, dystonia, hyperreflexia, ataxia, cardiac dysrhythmias, neurotoxicity, nephrotoxicity, dehydration
108
At what lithium levels is dialysis required?
>4 mEq/L
109
If a person is on lithium and is dehydrated, what is the worry?
Lithium toxicity. Either way on the water can cause toxicity.
110
What does taking haldol and lithium together increase the risk of?
Neurological disorders, especially encephalopathy
111
What are some symptoms of encephalopathy?
weakness, fever, tremor, lethargy, fluctuating cognition, delirium, ataxia, rigor in extremities, akinesia.
112
What test would you do to determine neurological impairment?
An EEG
113
What would you do if neurologic impairment was an issue?
Usually stopping the medications will reverse the symptoms.
114
What is the role of a pharmacist in lithium monitoring?
- have patient go in for labs (low therapeutic index)
- counseling: well hydrated, but avoid polydipsia, light snack with dose if cause, do not restrict sodium intake. Do not take NSAIDs, COX2 inhibitors, ACEs, or diuretics w/o telling MD. May experience light hand tremor, may go away.
- Don't stop taking med or interrupt therapy w/o MD
- Notify MD if diarrhea, vomiting, unsteady gait, excessive urination, weak muscle onset, significant tremor, confusion, ataxia, slurred speech
- don't start antidepressant w/o psychiatrist
115
Valproate: IR form, DR form, ER form
IR form: valproic acid TID
DR form: Divalproex BID
ER form: divalproex QD
116
What are the therapeutic ranges of valproate?
50-125 mpg/L
117
What are the side effects of valproate in acute and maintenance patients?
- Increased sedation, nausea, vomiting, dizziness in acutely manic patients
- Weight gain, reduced platelets and WBC, increased ammonia levels and alopecia in maintenance
118
Lamotrigine:
- usefulness
- often used with?
- Should not be used if...
- Warnings:
- bipolar disorder, limited anti-mania efficacy
- often used with lithium
- should not be used if history of severe or recent mania w/o antimanic on board
- start low, go slow. Go slower with valproate.
- SJS skin reaction, aseptic meningitis
119
Olanzasine + fluoxetine:
- Indications?
- AE's?
- Take at what time of day?
- Bipolar I associated depression and treatment resistant depression
- AE's: Hypotension, weight gain
- Dosed at bedtime due to olanzapine sedation
120
How can you treat hyperammonemic encephalopathy?
With lactulose, the gut can be cleared of ammonia before it is absorbed.
