ic11 schizophrenia Flashcards
(74 cards)
what are the diagnoses associated with psychotic symptoms?
organic disorders:
- CNS: infections, epilepsy, dementia, parkinsons.
- Head: trauma, tumours/malignancy.
- Endocrine: hypo/hyperthyroidism
- Drug or substance abuse related
- Iatrogenic causes
- metabolic disorders/physiological disturbances affected nervous system.
affective disorders:
- mania, psychotic depression, postpartum depression
drugs associated with drug-induced psychosis (examples)
alcohol
barbiturates (eg phenobarbital)
benzodiazepines
beta blockers (eg propanolol)
corticosteroids
cns stimulants (amphetamines)
dopamine agonists (levodopa, for PD)
what is the dsm5 criteria for diagnosis of schizophrenia?
at least 2 of the following for at least 1 month
- disorganised speech
- catatonic behaviour (two extremes)
- hallucinations
- negative symptoms (affective flattening, avolition)
- delusions
symptoms for more than 6 months
social or occupational dysfunction
rule out medical disorders or substance abuse.
what are the labs and monitoring prior to diagnosis and treatment
almost all labs to rule out any general medical conditions or substance induced psychosis.
FBC
TFT
LFT
kidney function U/E/Cr
FBG
Lipids
ECG
urine toxicology
non phx interventions for schizophrenia
Psychosocial rehab: to help with adaptive behaviour/function
Support, counselling (incl vocational sheltered)
CBT: individual and group (eg family members)
ECT: electroconvulsive therapy
rTMS: repetitive transcranial magnetic stimulation
when is ECT used in schizophrenia?
for treatment resistant schizophrenia
when is rTMS used in schizophrenia?
may be used to help with auditory hallucinations.
mechanism of dopamine antagonism and the additional adverse effects of antipsychotics?
1) mesolimbic tract
- positive symptoms
ADR
2) mesocortical tract
- cause negative symptoms (region of higher order thinking and executive functions)
3) nigrostriatal tract
- EPSE
4) tuberofundibular tract
- hyperprolactinemia (anterior pituitary blockade)
receptor affinities and associated clinical implications (therapeutic and side effects)
D2
- antagonism: improve positive symptoms
- side effects: EPSE, hyperprolactinemia
5HT2A
- antagonism: possibly antidepressant effects, improve negative symptoms(?)
5HT2C
- antagonism side effects: weight gain
H1
- antagonism side effects: sedation, weight gain
alpha 1
- antagonism side effects: orthostatic hypotension
M1
- antagonism side effects: memory dysfunction, peripheral anticholinergic effect (constipation, dry mouth…)
what is the treatment algorithm for schizophrenia
1) FGA or SGA except clozapine
if inadequate or intolerable SE
2) FGA or SGA except clozapine
if inadequate or intolerable SE
3) Clozapine
4) Combination therapy:
- clozapine + FGA/SGA/ECT
- FGA + FGA
- FGA + SGA
- FGA/SGA + ECT
should have adequate response, no intolerable side effects, and compliant
how long should treatment be initiated for schizophrenia before swapping to another agent?
atleast 2-6 weeks at OPTIMAL therapeutic doses
(except clozapine up to 3 months for mono therapy; 8-10 wks for combination)
treatment considerations if patient is non-compliant?
consider long acting injectable antipsychotics
- iM risperidone microspheres, paliperidone, aripiprazole, haloperidol decanoate, flupenthixol decanoate, zuclopenthixol decanoate.
what tx can be considered for acute agitation (where patient is cooperative)?
consider
1) oral lorazepam 1-2mg
2) oral antipsychotic
- halo 2-5mg tab/sol with pre tx ecg
- risp orodispersible tab/sol 1-2mg
- quetiapine IR tab 50-100mg
- olanzapine orodispersible tab 5-10mg
what tx can be considered for acute agitation (where patient is uncooperative)?
1) fast acting
IM lorazepam 1-2mg
2) antipsychotic
- IM olanzapine, aripiprazole, haloperidol, promethazine
what tx can be considered for catatonia (abnormal movement/behaviour, withdrawal)
po/im lorazepam
or ECT
what tx can be considered for depressive sx or negative sx
depression: antidepressant
negative symptoms: mild/moderate efficacy antidepressant
which oral antipsychotics have poor Tmax >3h (less rapidly absorbed and or slower onset)
aripiprazole
brexpiprzole
olanzapine
which oral antipsychotics have shorter t1/2 (will require divided dosing)
chlorpromazine
sulpiride
amisulpride
clozapine
quetiapine
ziprasidone
which antipsychotics can be given with food to increase BA
lurasidone
ziprasidone
what are the EPSE side effects and their characteristics?
fast onset (hours to weeks)
1) dystonia: muscle spasms (mins to hours)
2) akathisia: restlessness
3) pseudo-parkinsonism: dyskinesia, tremors, rigidity, salivation..
late onset
4) tardive dyskinesia: orofacial movements, tongue protrusions (IRREVERSIBLE)
what are the risks and management of dystonia caused by antipsychotics?
associated with high potency antipsychotics
lower dose or switch to SGA
manage with IM anticholinergics: benzatropine, diphenhydramine
what are the risks and management of pseudo-parkinsonism caused by antipsychotics?
higher likelihood in elderly females and previous neurological damage (stroke, head injury)
lower dose or switch to SGA
manage with benztropine or trihexyphenidyl (benzhexol)
what are the risks and management of akathasia caused by antipsychotics?
associated with high potency antipsychotics
FGA> risp > olan >quetiapine, clozapine
Lower dose or switch to SGA
anticholinergics are not effective
consider
clonazepam PRN or
propanol 20mg TDS (max 160mg/day)
what are the risks and management of tardive dyskinesia caused by antipsychotics?
FGA > SGA
WORSENS WITH ANTICHOLINERGICS
DISCONTINUE any anticholinergics
lower dose or switch to SGA
consider:
- reversible vesicular monoamine transporter 2 (VMAT2): valbenazine 40-80mg/day
- clonazepam PRN
