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53 Finals > IC11 Schizophrenia > Flashcards

IC11 Schizophrenia Flashcards

(60 cards)

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1
Q

Dx a/w psychotic sx

A
  • Organic disorders: iatrogenic causes/ drug induced, alcohol/substance misuse
  • Affective disorders: mania, depression, post-partum psychosis
  • Schizophrenia
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2
Q

Drugs that can cause psychosis

A

alcohol, benzodiazepine, barbiturates, antidepressants, corticosteroids, CNS stimulants (amphetamines), beta blockers (propanolol), dopamine agonist (levodopa, bromocriptine)

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3
Q

criteria for schizophrenia

A
  • ≥2 sx for 1mth
    1. delusions
    2. hallucinations
    3. disorganised speech
    4. grossly disorganised, catatonic behaviour
    5. negative sx
  • impaired daily function
  • duration: ≥6mths
  • exclude medical disorder/ substance use
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4
Q

Non-pharm

A

supportive counselling, social skill therapy, vocational training (employment, rehab), CBT, family support, ECT, psychosocial rehab

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5
Q

Acute stabilisation tx goals

A

minimise threat to self and others, minimise acute symptoms, decrease agitation, improve slp

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6
Q

Stabilisation tx goals

A

prevent relapse, promote medical adherence (usually lifelong), optimise dose

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7
Q

Stable/maintenance tx goals

A

improve functioning and QOL

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8
Q

Indication for antipsychotics

A

schizophrenia, adjunct with antidepressants for MDD, bipolar disorders

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9
Q

Purpose of antipsychotic

A

In short term, used to calm disturbed pt but does not induce coma (unlike benzodiazepine and barbiturates)
- relief sx of psychosis
- prevent relapse

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10
Q

When will relapse occur after stopping meds

A

Relapse often delayed for several weeks after cessation

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11
Q

Methods to overcome poor tx adherence

A

IM long acting injection, community psychiatric nurse, pt and family/caregiver education

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12
Q

Effect of blocking dopamine in mesolimbic tract

A

Mesolimbic tract (D2): dopamine blockade → reduction in positive sx in schizophrenia

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13
Q

Effect of blocking dopamine in mesocortical tract

A

dopamine blockade/ hypofunction → increase negative sx

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14
Q

Effect of blocking dopamine in nigrostriatal tract

A

Nigrostriatal tract (D1/D2): dopamine blockade → Extrapyramidal SE (EPSE/ Parkinson’s like movement disorders) — eg resting tremors, cork-wheel rigidity, shuffling gait, hunch back, stiff posture

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15
Q

Effect of blocking dopamine in tuberoinfundibular tract

A

Tuberoinfundibular tract (D2/D3): dopamine blockade → increase prolactin (breast swelling, lactation, gynaecomastia)

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16
Q

D2 antagonism cause…

A

Antagonism: improve +’ve sx, EPSE, hyperprolactinemia

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17
Q

5HT1A agonism cause…

A

Agonism: anxiolytic (calming)

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18
Q

5HT2A antagonism cause…

A

Antagonism: improve -’ve sx

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19
Q

5HT2C antagonism cause…

A

Antagonism: weight gain

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20
Q

H1 antagonism cause…

A

sedation, weight gain

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21
Q

alpha-1 antagonism cause…

A

postural hypotension

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22
Q

M1 antagonism cause

A

blurred vision, dry mouth, constipation

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23
Q

PK: Tmax and T1/2 of antipsychotics

A

Tmax: 1-3hrs
T1/2: long (can do OD) except clozapine, quetiapine (BD dosing)

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24
Q

Eg of FGA

A

chlorpromazine, haloperidol

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25
Eg of SGA
clozapine, olanzapine, quetiapine, risperidone, aripiprazole, brexpiprazole
26
Eg of IM antipsychotics
- rapid acting (haloperidol q4wks, olanzapine q4wks, risperidone q2wks) - paliperidone (q3mths) - long acting (haloperidol decanoate)
27
Tx plan for schizophrenia
- Step 1 and 2: Use single FGA/SGA (except clozapine) for 2-6 weeks - Step 3: Use clozapine
28
Adequate trial duration of antipsychotic before determining ineffective
at least 2-6 weeks at optimal therapeutic doses
29
monitoring for clozapine
must do FBC every WEEK for first 18weeks, then monthly/28 days
30
when can clozapine be used?
failed ≥2 adequate trials of different antipsychotics (at least one must be SGA)
31
Precaution to antipsychotic use
- CVD — CI in QTc prolongation - PD — EPSE worsened by antipsychotics - Prostatic hypertrophy — urinary retention worsened by antimuscarinic/anticholinergic (ARU is a medical emergency) - Angle-closure glaucoma - Severe respiratory disease - Blood dyscrasia — esp for clozapine (agranulocytosis) - Elderly with dementia — increased risk of mortality and stroke
32
Acute agitation (psychiatric emergency) tx if cooperative
- PO lorazepam - PO antipsychotic (if pt has agitation + psychosis → give antipsychotics): haloperidol, olanzapine, quetiapine, risperidone
33
Acute agitation (psychiatric emergency) tx if NOT cooperative
(use fast acting IM injection) - IM lorazepam (benzodiazepine) - IM olanzapine - IM haloperidol - IM promethazine (sedating antihistamine) - IM haloperidol + promethazine/ lorazepam
34
Catatonia (abnormal movements) tx
PO/IM lorazepam (benzodiazepines)
35
FGA SE
EPSE, hyperprolactinemia
36
Clozapine, Olanzapine, Quetiapine SE
no EPSE, more sedating and weight gain/DM/lipid
37
Risperidone SE
less EPSE, less metabolic
38
Aripiprazole, Brexpiprazole SE
no EPSE, no metabolic
39
4 sx of EPSE
- dystonia - pseudo-parkinsonism - akathisia - tardive dyskinesia
40
mx of dystonia
- IM benztropine/ diphenhydramine (anticholinergic - can cause constipation) - decrease dose, switch to SGA
41
mx of pseudo-parkinsonism
- PO anticholinergic PRN (benztropine, benzhexol) - decrease dose, switch to SGA
42
mx of akathisia
- decrease dose, switch to SGA - low dose clonazepam/ lorazepam PRN (NO anticholinergic)
43
mx of tardive dyskinesia
- discontinue any anticholinergic - decrease dose, switch to SGA - tx: valbenazine - clonazepam/ lorazepam PRN
44
mx of hyperprolactinemia
- decrease FGA dose - switch to aripiprazole/ brexpiprazole
45
mx of metabolic SE
- Lifestyle modification: diet, exercise - Treat DM → metformin - Treat hyperlipidemia → statins - switch to aripiprazole, brexpiprazole, cariprazine, lurasidone
46
mx of OH
get up slowly
47
mx of QTc prolongation
monitoring
48
mx of daytime sedation
take meds at evening
49
sx of neuroleptic malignant syndrome (NMS)
fever, increase CK, lead pipe rigidity, sweating, confusion
50
mx of NMS
AnE - IV dantrolene/ PO dopamine agonist (bromocriptine) - switch to SGA
51
causes of NMS
- succinylcholine (neuro-muscular blocker) used in operating theatre - potent IM antipsychotics - sudden withdrawal of levodopa
52
mx of agranulocytosis
AnE, if severe discontinue
53
Monitoring parameters
BMI, fasting blood sugar, lipid panel, blood pressure, EPSE exam, WBC and ANC count (for clozapine)
54
drugs to avoid in elderly
- alpha-1 antagonism (decrease BP, postural hypotension) - anticholinergic/ antimuscarinic (constipation, urinary retention) effects
55
Drug-disease interactions
antipsychotics worsen Parkinson’s Disease
56
Drug-drug interactions
- CNS depressant effects - Drugs with M1, a1, H1 blockade -> additive AE - Dopamine agonists (eg levodopa, bromocriptine) - Antihypertensives -> increase hypotension - Carbamazepine -> agranulocytosis with clozapine
57
Monitoring for effectiveness of therapy
MSE (mental status exam)
58
Monitoring for adverse effects
- Metabolic parameters: fasting plasma glucose, lipids, body weight, BP - EPSE: pseudo-parkinsonism, akathisia, tardive dyskinesia
59
Tx response (early improvement)
- 1st week: decrease agitation - 2-4 weeks: decrease paranoia, hallucinations
60
Tx response (late improvement)
decrease delusions

53 Finals (10 decks)

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