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PR3153 FINALS > IC10 Schizophrenia > Flashcards

IC10 Schizophrenia Flashcards

1
Q

In d/dx, what are some causes of organic (2) and affective disorders (2)

A

organic d/o - iatrogenic causes, psychosis related to alcohol or psychoactive substance misuse

affective d/o - mania, psychotic depression

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2
Q

What is the primary pathophysiology of schizophrenia?

A

Dysregulation of dopaminergic or serotonergic functions

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3
Q

What are the 3 key factors in schizophrenia?

A

Predisposing (genetic factors)
Precipitating (drugs or substance-induced psychosis)
Perpetuating (poor adherence)

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4
Q

What is the DSM-5 criteria for schizophrenia?
(total 6)
(first one: HDDCN)

A
  1. Two or more of the following (5) persisting for at least 1 month → hallucinations, disorganised speech, delusions, grossly disorganised or catatonic behaviour, negative symptoms (eg. affective flattening or avolition)
  2. Social or occupational dysfunction → work, interpersonal relations or self-care being significantly below level prior to onset
  3. Duration → continuous signs of disorder for at least 6 months
  4. EXCLUDE schizoaffective or mood disorders
  5. EXCLUDE disorder due to medical disorder or substance use
  6. If a history of pervasive developmental disorder is present, there must be symptoms of hallucinations or delusions present for at least 1 month
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5
Q

What are the non-pharmacological measures in schizophrenia? (3)

A
  1. CBT (gd for pts who can manage their own feelings)
  2. Neurostimulation (ECT, rTMS)
  3. Psychosocial rehab programmes (improve adaptive functioning)
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6
Q

What are the 3 phases in schizophrenia pharmacotherapy and their therapeutic goals?

A
  1. Acute stabilisation → minimise threat to self and others, minimise acute symptoms
  2. Stabilisation → prevent relapse, promote adherence and optimise dose
  3. Maintenance → improve function and quality of life
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7
Q

What are 3 methods to improve poor adherence?

A
  1. IM long-acting injections
  2. Community psychiatric nurse
  3. Patient and family (caregiver) education
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8
Q

What are antipsychotics used for in the short term?

A

calm down disturbed patients

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9
Q

What are the 4 tracts implicated in antipsychotics MOA?

A

mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular

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10
Q

What is the importance of the mesolimbic tract in antipsychotics’ MOA

A

Blockade of the dopamine receptors in this tract is a common MOA for all antipsychotics as overactivity in this region is responsible for positive symptoms of schizophrenia

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11
Q

What is the importance of the mesocortical tract in antipsychotics’ MOA

A

Dopamine blockage or hypofunction in this region results in negative symptoms

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12
Q

What is the significance of the nigrostriatal tract in antipsychotics’ MOA

A

Dopamine blockage causes extrapyrimidal side effects (EPSE)

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13
Q

What is the significance of the tuberoinfundibular tract in antipsychotics’ MOA

A

Dopamine blockage causes hyperprolactinemia, leading to gynecomastia, sexual dysfunction and lactation

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14
Q

Which receptor antagonism effect of antipsychotics help with negative and positive symptoms respectively?

A

Positive - D2 antagonism
Negative - 5-HT(2A) (postulated)

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15
Q

What side effects does D2 antagonism result in?

A

EPSE, hyperprolactinemia

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16
Q

What drugs should be started on diagnosis, in first and second inadequate response?

A

At dx - FGA/SGA (not clozapine)
1st inadequate - another FGA/SGA (not clozapine)
2nd inadequate - clozapine (or clozapine + FGA/SGA)

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17
Q

When should clozapine be started?

A

compliance to at least 2 adequate trials of the antipsychotic (excluding clozapine) (at least 1 must be SGA) of at least 2-6 weeks at optimal therapeutic doses

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18
Q

When should LA-IM injections be used?

A

Patient preference or uncompliant patients? (usually IM decanoate drugs)

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19
Q

What is the most important precaution in antipsychotic use (contraindication)?

A

Cardiovascular disease → CI in QTc prolongation, ECG required especially if a physical examination identifies CV risk factors or if the patient has a personal history of CV disease

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20
Q

What are other precautions to look out for in antipsychotic use? (6)

PPASEB

A
  1. Parkinson’s disease (EPSE worsened by antipsychotics)
  2. Prostatic hypertrophy
  3. Angle-closure glaucoma
  4. Severe respiratory disease
  5. Elderly with dementia (black box warning)
  6. Blood dyscrasias (especially for cloazpine)
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21
Q

What adjunctive medication can be given for acute aggression?

A

If cooperative: PO lorazepam (or PO haloperidol, risperidone)

If non-cooperative: IM lorazepam (or IM haloperidol, olanzapine, promethazine)

If very uncooperative: IM lorazepam + haloperidol OR IM lorazepam + promethazine

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22
Q

What adjunctive medication can be given for catatonia (cannot relax)?

A

Benzodiazepines (like PO/IM lorazepam)

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23
Q

What adjunctive medication can be given for depression?

A

SSRI

24
Q

What are the half-lives of haloperidol, olanzapine and risperidone?

A

haloperidol: 12-36h
olanzapine: 21-54h
risperidone: 3-20h

25
Q

What is the dosing for haloperidol?

A

5-15mg

26
Q

What is the dosing for olanzapine?

A

5-20mg

27
Q

What is the dosing for risperidone?

A

2-6mg

28
Q

What is the max dose for quetiapine?

A

Max 800mg

29
Q

What is max dose for clozapine?

A

Max 900mg

30
Q

How should LA-IM risperidone be given?

A

every 2 weeks, supplement with PO dose during first 3 weeks

31
Q

How should LA-IM paliperidone be given?

A

every 3 months

32
Q

What are most antipsychotic’s tmax and what are the exceptions?

A

1-3h
exceptions: aripiprazole, brexpiprazole, olanzapine

33
Q

Most antipsychotics have long half-lives and can be dosed OD, what are the exceptions (shorter)?

A

clozapine and chlorpromazine

34
Q

Which two SGAs are more likely to cause weight gain?

A

Clozapine and Olanzapine

35
Q

What are the 4 side effects classified under EPSE?

A

dystonia (painful muscle contractions)
pseudoparkinsonism (tremors, ridigidity, bradykinesia)
akasthasia (restlessness)
tardive dyskinesia (orofacial movements)

36
Q

How should dystonia be managed?

A

IM anticholinergics (benztropine)

37
Q

How should pseudoparkinsonism be managed?

A

Decrease dose/switch to SGA
Give PRN anticholinergics

38
Q

How should akasthasia be managed?

A

Decrease dose/switch to SGA
Give PRN clonazepam

39
Q

How should tardive dyskinesia be managed?

A

Discontinue any anticholinergics
Decrease dose/switch to SGA
Give valbenazine or PRN clonazepam

40
Q

What are sx of hyperprolactinemia and how should it be managed?

A

Amenorrhea, lactation, gynecomastia, especially with FGAs

Decrease the FGA dose or switch to aripiprazole

41
Q

What are metabolic side effects and how should they be managed?

A

weight gain, diabetes, lipids
lifestyle modification, treat w metformin or switch to lower risk agents (aripiprazole and lurasidone)

42
Q

What are cardiovascular side effects and how should they be managed?

A

Orthostatic hypotension
Switch to SGA, get up slowly from rest

43
Q

What are CNS side effects and how should they be managed?

A

Neuroleptic malignant syndrome (NMS) (lead pipe rigidity, fever, increased CK)

Give IV dantrolene or PO dopamine agonist
Switch to SGA

44
Q

What are hematologic side effects and how should they be managed?

A

Decreased WBC, agranulocytosis (esp w clozapine)

Discontinue drug if severe

45
Q

What should be monitored for antipsychotic side effects? (6)

A

BMI, FBG, lipid panel, BP, EPSE exam, WBC/ANC

46
Q

How often should BMI be assessed?

A

every 3 months

47
Q

How often should FBG be assessed?

A

3 months after starting, then annually

48
Q

How often should BP be assessed?

A

3 months after starting, then annually

49
Q

How often should EPSE exam be conducted?

A

FGA q3/6 mths; SGA q12 mths
(depending on high/low risk pts)

50
Q

How often should WBC and ANC be taken for patients on clozapine?

A

Weekly for the first 18 weeks then monthly

51
Q

Which 2 types of drugs should the elderly avoid?

A
  • Avoid drugs with high propensity for α1-adrenergic blockage (risk of orthostatic hypotension)
  • Avoid drugs with high propensity for anticholinergic side effects (constipation, urinary retention, delirium)
52
Q

Which CYP isoforms does fluvoxamine inhibit?

A

1A2 and 2C19

53
Q

Which antipsychotics inhibit CYP2D6 (3)

A

fluoxetine, paroxetine, bupropion

54
Q

Which 5 drugs result in fewer CYP interactions?

A

Mirtazapine (impt)
Escitalopram
Venlafaxine
Desvenlafaxine
Vortioxetine

55
Q

Which drugs have clinically significant interactions with antipsychotics? (6)

A
  1. Drugs w CNS effects
  2. Drugs with blockages at muscarinic, H1, α1 or DA receptors
  3. DA-augmenting agents
  4. Antihypertensives
  5. CYP1A2 inhibitors (fluvoxamine, quinolones, macrolides)
  6. CBZ (risk of agranulocytosis w cloazpine)

PR3153 FINALS (8 decks)

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