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53 Finals > IC11 Schizophrenia > Flashcards

IC11 Schizophrenia Flashcards

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
Q

Eg of SGA

A

clozapine, olanzapine, quetiapine, risperidone, aripiprazole, brexpiprazole

26
Q

Eg of IM antipsychotics

A
  • rapid acting (haloperidol q4wks, olanzapine q4wks, risperidone q2wks)
  • paliperidone (q3mths)
  • long acting (haloperidol decanoate)
27
Q

Tx plan for schizophrenia

A
  • Step 1 and 2: Use single FGA/SGA (except clozapine) for 2-6 weeks
  • Step 3: Use clozapine
28
Q

Adequate trial duration of antipsychotic before determining ineffective

A

at least 2-6 weeks at optimal therapeutic doses

29
Q

monitoring for clozapine

A

must do FBC every WEEK for first 18weeks, then monthly/28 days

30
Q

when can clozapine be used?

A

failed ≥2 adequate trials of different antipsychotics (at least one must be SGA)

31
Q

Precaution to antipsychotic use

A
  • 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
Q

Acute agitation (psychiatric emergency) tx if cooperative

A
  • PO lorazepam
  • PO antipsychotic (if pt has agitation + psychosis → give antipsychotics): haloperidol, olanzapine, quetiapine, risperidone
33
Q

Acute agitation (psychiatric emergency) tx if NOT cooperative

A

(use fast acting IM injection)
- IM lorazepam (benzodiazepine)
- IM olanzapine
- IM haloperidol
- IM promethazine (sedating antihistamine)
- IM haloperidol + promethazine/ lorazepam

34
Q

Catatonia (abnormal movements) tx

A

PO/IM lorazepam (benzodiazepines)

35
Q

FGA SE

A

EPSE, hyperprolactinemia

36
Q

Clozapine, Olanzapine, Quetiapine SE

A

no EPSE, more sedating and weight gain/DM/lipid

37
Q

Risperidone SE

A

less EPSE, less metabolic

38
Q

Aripiprazole, Brexpiprazole SE

A

no EPSE, no metabolic

39
Q

4 sx of EPSE

A
  • dystonia
  • pseudo-parkinsonism
  • akathisia
  • tardive dyskinesia
40
Q

mx of dystonia

A
  • IM benztropine/ diphenhydramine (anticholinergic - can cause constipation)
  • decrease dose, switch to SGA
41
Q

mx of pseudo-parkinsonism

A
  • PO anticholinergic PRN (benztropine, benzhexol)
  • decrease dose, switch to SGA
42
Q

mx of akathisia

A
  • decrease dose, switch to SGA
  • low dose clonazepam/ lorazepam PRN
    (NO anticholinergic)
43
Q

mx of tardive dyskinesia

A
  • discontinue any anticholinergic
  • decrease dose, switch to SGA
  • tx: valbenazine
  • clonazepam/ lorazepam PRN
44
Q

mx of hyperprolactinemia

A
  • decrease FGA dose
  • switch to aripiprazole/ brexpiprazole
45
Q

mx of metabolic SE

A
  • Lifestyle modification: diet, exercise
  • Treat DM → metformin
  • Treat hyperlipidemia → statins
  • switch to aripiprazole, brexpiprazole, cariprazine, lurasidone
46
Q

mx of OH

A

get up slowly

47
Q

mx of QTc prolongation

A

monitoring

48
Q

mx of daytime sedation

A

take meds at evening

49
Q

sx of neuroleptic malignant syndrome (NMS)

A

fever, increase CK, lead pipe rigidity, sweating, confusion

50
Q

mx of NMS

A

AnE
- IV dantrolene/ PO dopamine agonist (bromocriptine)
- switch to SGA

51
Q

causes of NMS

A
  • succinylcholine (neuro-muscular blocker) used in operating theatre
  • potent IM antipsychotics
  • sudden withdrawal of levodopa
52
Q

mx of agranulocytosis

A

AnE, if severe discontinue

53
Q

Monitoring parameters

A

BMI, fasting blood sugar, lipid panel, blood pressure, EPSE exam, WBC and ANC count (for clozapine)

54
Q

drugs to avoid in elderly

A
  • alpha-1 antagonism (decrease BP, postural hypotension)
  • anticholinergic/ antimuscarinic (constipation, urinary retention) effects
55
Q

Drug-disease interactions

A

antipsychotics worsen Parkinson’s Disease

56
Q

Drug-drug interactions

A
  • CNS depressant effects
  • Drugs with M1, a1, H1 blockade -> additive AE
  • Dopamine agonists (eg levodopa, bromocriptine)
  • Antihypertensives -> increase hypotension
  • Carbamazepine -> agranulocytosis with clozapine
57
Q

Monitoring for effectiveness of therapy

A

MSE (mental status exam)

58
Q

Monitoring for adverse effects

A
  • Metabolic parameters: fasting plasma glucose, lipids, body weight, BP
  • EPSE: pseudo-parkinsonism, akathisia, tardive dyskinesia
59
Q

Tx response (early improvement)

A
  • 1st week: decrease agitation
  • 2-4 weeks: decrease paranoia, hallucinations
60
Q

Tx response (late improvement)

A

decrease delusions

53 Finals (10 decks)

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