Maudsley Prescribing Guidelines 2025 Flashcards

Question

What phenomenon has been observed regarding the efficacy of recently introduced antipsychotics?

Answer 1

Lower estimated efficacy ## Footnote This is due to the substantial increase in placebo response since 1970.

Answer 2

Clozapine ## Footnote Despite not being universally recognized as such due to trial biases.

Answer 3

* Weight gain * Dyslipidaemia

Answer 4

Treatment discontinuation

Answer 5

patient-completed checklist

Answer 6

Guaranteed medication delivery ## Footnote This reduces the risk of relapse and rehospitalisation compared to oral antipsychotics.

Answer 7

Clozapine ## Footnote This recommendation is supported by NICE and other schizophrenia guidelines.

Answer 8

Olanzapine

Answer 9

Amisulpride

Answer 10

Patients do not always spontaneously report adverse effects

Answer 11

To accurately assess their presence and severity

Answer 12

To facilitate more detailed and comprehensive assessment of adverse effects

Answer 13

The lowest possible dose should be used and titrated to the lowest known effective dose. ## Footnote Dose increases should occur only after 1–2 weeks of assessment.

Answer 14

Plasma levels rise for at least 6–12 weeks after initiation. ## Footnote This rise occurs even without a change in dose.

Answer 15

Long-acting injectables (LAIs) should be used as first-line treatment aimed at preventing relapse. ## Footnote They should not be reserved only for those who have already relapsed on oral treatment.

Answer 16

Clozapine should be offered as soon as treatment resistance is apparent. ## Footnote The sooner clozapine is prescribed, the more effective it will be.

Answer 17

The use of a single antipsychotic is recommended for the majority of patients. ## Footnote Antipsychotic polypharmacy should generally be avoided due to increased adverse effects.

Answer 18

Combinations should only be used when response to a single antipsychotic has been inadequate. ## Footnote The effect on target symptoms and adverse effects should be carefully evaluated.

Answer 19

Antipsychotics should not be used as 'when necessary' sedatives. ## Footnote Time-limited prescriptions of benzodiazepines or general sedatives are preferred.

Answer 20

Response should be assessed using recognized rating scales and documented in patients' records.

Answer 21

Close monitoring of physical health including blood pressure, pulse, ECG, plasma glucose, and plasma lipids is required.

Answer 22

Reduce the dose slowly in a hyperbolic regimen to minimize withdrawal symptoms and rebound psychosis.

Answer 23

200 mg per day.

Answer 24

4 mg per day.

Answer 25

7.5 mg per day.

Answer 26

The dose established to be optimal in clinical trials.

Answer 27

2 mg per day.

Answer 28

300 mg IR or 500 mg MR.

Answer 29

Olanzapine has been studied for its long-term neurocognitive effects in first-episode psychosis compared to low-dose haloperidol. ## Footnote Refer to Keefe RS et al. for detailed findings.

Answer 30

Pimavanserin shows efficacy in patients with more pronounced psychotic symptoms associated with Alzheimer's disease. ## Footnote See Ballard C et al. for detailed results.

Answer 31

True ## Footnote This is supported by the findings of Nasrallah HA et al.

Answer 32

The maximum licensed dose of chlorpromazine is 1000mg/day. ## Footnote Refer to the table provided for more maximum doses.

Answer 33

The maximum licensed dose of risperidone is 50mg/2 weeks for the Consta formulation. ## Footnote Check the FDA guidelines for more information.

Answer 34

20mg/day ## Footnote Refer to the European Medicines Agency guidelines.

Answer 35

Approximately 1.5mg of risperidone is equivalent to 100mg of chlorpromazine. ## Footnote This equivalence is based on various studies.

Answer 36

* Clozapine: 900mg/day * Olanzapine: 20mg/day ## Footnote Refer to the tables for complete listings.

Answer 37

* Paliperidone palmitate 1-monthly: 150mg/month * Paliperidone palmitate 3-monthly: 525mg/3 months ## Footnote Refer to the prescribing guidelines for more details.

Answer 38

'High-dose' antipsychotic medication can result from the prescription of either a single antipsychotic medication at a dose above the recommended maximum or two or more antipsychotic medications concurrently that, when expressed as a percentage of their respective maximum recommended doses and added together, results in a cumulative dose of more than 100%.

Answer 39

In clinical practice, antipsychotic polypharmacy and prn antipsychotic medication are strongly associated with high-dose prescribing.

Answer 40

There is no firm evidence that high doses of antipsychotic medication are any more effective than standard doses for schizophrenia.

Answer 41

10% of patients were prescribed a high dose of antipsychotic medication.

Answer 42

Just under 10% were prescribed high-dose antipsychotic medication.

Answer 43

Efficacy appears to be optimal at relatively low doses.

Answer 44

4mg/day risperidone.

Answer 45

300mg/day quetiapine.

Answer 46

10mg olanzapine.

Answer 47

Prescribing a higher dosage to increase dopamine blockade in such patients would seem to be of uncertain value.

Answer 48

There was no evidence of any benefit associated with increased dosage in patients whose schizophrenia proved unresponsive to standard-dose pharmacotherapy.

Answer 49

It found modest benefits in a third of patients with refractory schizophrenia.

Answer 50

* EPS * Weight gain * Sedation * Postural hypotension * Anticholinergic effects * QTc prolongation * Coronary heart disease mortality

Answer 51

The decision to prescribe high dosage in the clinical notes, together with a description of the target symptoms.

Answer 52

Regular ECGs and assessment of target symptoms after 6 weeks and 3 months.

Answer 53

Contraindications such as ECG abnormalities and hepatic impairment.

Answer 54

[exceptional]

Answer 55

Adequate time for response should be allowed after each dosage increment.

Answer 56

Dose equivalence and efficacy of antipsychotic medications in treating schizophrenia ## Footnote The article reviews various studies related to antipsychotic dosing and efficacy.

Answer 57

International consensus study of antipsychotic dosing ## Footnote This study aimed to establish standard dosing guidelines for antipsychotic medications.

Answer 58

False ## Footnote Most studies indicate a lack of strong evidence supporting the efficacy of antipsychotic polypharmacy over monotherapy.

Answer 59

* Younger patient age * Male gender * Increased illness severity * Complexity and chronicity * Poorer functioning * Inpatient status * Diagnosis of schizophrenia ## Footnote These factors suggest that polypharmacy is often used for treatment-resistant schizophrenia.

Answer 60

The most common reason for prescribing them was insufficient response to antipsychotic monotherapy ## Footnote This highlights the challenges in treating schizophrenia effectively with single medications.

Answer 61

Lacked double-blind/high-quality evidence of efficacy ## Footnote This suggests that combining antipsychotics may not provide added benefits.

Answer 62

* Lower likelihood of mortality * Reduced psychiatric hospitalizations * Improved medication adherence ## Footnote Combination therapy may offer advantages in managing schizophrenia despite the lack of clear superiority.

Answer 63

* Increased prevalence and severity of extrapyramidal symptoms (EPS) * Metabolic adverse effects * Sexual dysfunction * Prolonged QTc interval * Increased risk of hip fracture ## Footnote These adverse effects are critical considerations in treatment planning.

Answer 64

Receiving more than one antipsychotic medication concurrently was associated with substantially increased mortality ## Footnote This raises concerns about the safety of polypharmacy in certain patient populations.

Answer 65

They are among the most effective monotherapies for relapse prevention in schizophrenia ## Footnote Their effectiveness may justify their use in combination therapies.

Answer 66

Those prescribed three antipsychotics simultaneously were twice as likely to die as those prescribed only one. ## Footnote This suggests a potential risk associated with polypharmacy.

Answer 67

It should be standard practice to document the rationale for prescribing combined antipsychotics and a clear account of benefits and adverse effects. ## Footnote This is considered prudent from a medicolegal standpoint.

Answer 68

* Increased adverse-effect burden * Higher total dosage * Increased risk of drug-drug interactions * Poorer medication adherence * Difficulty in attributing response to individual medications ## Footnote These disadvantages complicate determining optimal long-term regimens.

Answer 69

It should be considered only after other evidence-based pharmacological treatments, such as clozapine, have been exhausted. ## Footnote This consensus is not consistently followed in clinical practice.

Answer 70

Clozapine augmentation with a second antipsychotic medication to enhance efficacy. ## Footnote This strategy is discussed in the chapter on optimizing clozapine treatment.

Answer 71

* To reduce body weight * To normalize prolactin levels ## Footnote While findings on resolving hyperprolactinaemia are generally positive, they are not entirely consistent.

Answer 72

True. ## Footnote This is noted despite the absence of regulatory trials demonstrating safety.

Answer 73

[safety and efficacy] ## Footnote This consideration is important in the context of treatment decisions.

Answer 74

It is probably best avoided ## Footnote This recommendation is based on evidence relating to efficacy and potential serious adverse effects.

Answer 75

Adverse effects ## Footnote This includes monitoring with an ECG and documenting any beneficial effects on symptoms.

Answer 76

Management of weight gain, metabolic disturbances, and cardiovascular risk associated with psychosis ## Footnote These guidelines were published in J Psychopharmacol in 2016.

Answer 77

Prescribed for 1–2 years ## Footnote There is a consensus on this duration of treatment.

Answer 78

Almost 80% after 1 year medication-free and 98% after 2 years ## Footnote This indicates the importance of continued treatment.

Answer 79

Longer treatment leads to lower hospitalization risk ## Footnote Patients treated for 5 years had half the hospitalization rate of those treated for less than 6 months.

Answer 80

94% ## Footnote This highlights the risks associated with discontinuation.

Answer 81

No advantage in the medium term ## Footnote This conclusion is based on RCT findings.

Answer 82

10% concentrated in the first decade of illness ## Footnote This emphasizes the severity of the condition in early stages.

Answer 83

Oral antipsychotics ## Footnote This is likely due to better adherence and medication delivery.

Answer 84

30% relative and 10% absolute risk lower ## Footnote This indicates the effectiveness of depot formulations.

Answer 85

High non-adherence rates, up to 75% at 2 years ## Footnote This dramatically increases the risk of relapse.

Answer 86

5mg/day risperidone equivalents ## Footnote Doses below this may lead to loss of prophylactic efficacy.

Answer 87

A thorough risk–benefit analysis for each patient.

Answer 88

It should be gradual and closely monitored.

Answer 89

Double that seen after gradual withdrawal.

Answer 90

* Is the patient symptom-free? * Severity of adverse effects * Previous pattern of illness * Previous dosage reduction attempts * Current social circumstances * Social cost of relapse * Ability to monitor symptoms

Answer 91

* Headache * Nausea * Insomnia

Answer 92

A hypothesis suggesting that relapse on withdrawal may be due to super-sensitivity of dopamine receptors.

Answer 93

The possibility that it may worsen or not improve outcomes in some patients.

Answer 94

3-monthly paliperidone

Answer 95

The need to use the lowest possible dose.

Answer 96

Withdrawal reactions and high relapse rates.

Answer 97

To identify early signs of relapse and seek help.

Answer 98

Stressful life events can affect the decision and the likelihood of relapse.

Answer 99

At least 3 weeks.

Answer 100

They may have better outcomes.

Answer 101

Rebound phenomena and withdrawal reactions may account for high relapse rates.

Answer 102

Consideration for life-long treatment.

Answer 103

The absence or diminution of normal behaviours and functions.

Answer 104

* Expressive deficits * Avolition/amotivation

Answer 105

Decreased verbal output, verbal expressiveness, and flattened affect.

Answer 106

A subjective reduction in interests, desires, and goals, along with a behavioral reduction in purposeful acts.

Answer 107

Around 60%.

Answer 108

Up to 20%.

Answer 109

* Primary negative symptoms: enduring deficit state, stable over time * Secondary negative symptoms: result from other factors like positive psychotic symptoms or medication effects

Answer 110

* Chronic substance or alcohol use * High-dose antipsychotic medication * Social deprivation * Lack of stimulation * Hospitalization

Answer 111

Determining the most likely cause of negative symptoms in individual cases.

Answer 112

It can improve negative symptoms, primarily in secondary negative symptoms during acute psychotic episodes.

Answer 113

* Cariprazine * Aripiprazole * Amisulpride

Answer 114

Clozapine.

Answer 115

It may help improve those symptoms.

Answer 116

It may be an effective strategy for reducing affective flattening, alogia, and avolition.

Answer 117

* Fluvoxamine * Citalopram

Answer 118

[morbidity]

Answer 119

* Pregnenolone * Raloxifene (in women) * Levetiracetam * Clonidine * Nanocurcumin * Xanomeline (as Cobenfy) * Berberine * Fingolimod

Answer 120

The findings are mixed but promising.

Answer 121

Some potential as a treatment for negative symptoms, but evidence is limited.

Answer 122

Identify and treat psychotic illness as early as possible for better outcomes.

Answer 123

* Detect and treat EPS (specifically bradykinesia) and depression * Consider the contribution of the environment to negative symptoms

Answer 124

Insufficient evidence to support any specific pharmacological treatment.

Answer 125

[lowest dose that maintains control of positive symptoms]

Answer 126

Minimizing potential for compounding adverse effects through pharmacokinetic or pharmacodynamic drug interactions.

Answer 127

Stop suspect medication ## Footnote Unless the patient is diagnosed with benign ethnic neutropenia (BEN).

Answer 128

Baseline, at 3 months, then yearly ## Footnote This is to detect antipsychotic-induced changes.

Answer 129

Clozapine ## Footnote This is to monitor for potential bone marrow suppression.

Answer 130

To detect antipsychotic-induced changes and monitor physical health ## Footnote Frequent monitoring is advised for early intervention.

Answer 131

Offer lifestyle advice, consider changing antipsychotic medication, dietary, or pharmacological intervention

Answer 132

Clozapine, olanzapine ## Footnote Monitoring is recommended every 3 months for the first year, then yearly.

Answer 133

Baseline, at 4–6 months, then yearly

Answer 134

Offer lifestyle advice, obtain fasting sample or non-fasting and HbA1C, refer to GP or specialist

Answer 135

Haloperidol, pimozide, sertindole ## Footnote ECG is mandatory for these medications.

Answer 136

Baseline and then frequently during dose titration and after dosage changes

Answer 137

Slow rate of titration, consider switching to another antipsychotic if symptomatic postural hypotension

Answer 138

Baseline, at 6 months, then yearly

Answer 139

Amisulpride, sulpiride, risperidone, paliperidone

Answer 140

Stop suspect medication

Answer 141

Baseline, then if neuroleptic malignant syndrome (NMS) is suspected

Answer 142

Hepatic failure

Answer 143

Thyroid function tests

Answer 144

Agree the choice of antipsychotic medication with patient and/or carer

Answer 145

Increase the dose or change the drug

Answer 146

Relapse and readmission rates are vastly reduced by early use

Answer 147

2–3 weeks ## Footnote Most improvement occurs during this period.

Answer 148

Increase the dose or change the drug.

Answer 149

They are vastly reduced.

Answer 150

Early use of clozapine.

Answer 151

Diminished response to clozapine.

Answer 152

Medication choice and effectiveness.

Answer 153

Switch to clozapine.

Answer 154

They may be slightly less efficacious.

Answer 155

Second- or third-line use.

Answer 156

Comparative adverse-effect profile and relative toxicity.

Answer 157

It seems to improve outcomes.

Answer 158

Olanzapine or risperidone.

Answer 159

Adherence to prior therapy using depot/LAI formulation or plasma drug level monitoring.

Answer 160

Non-compliance.

Answer 161

Reasons for poor adherence.

Answer 162

Consider compliance aids.

Answer 163

Associated with acute EPS and hyperprolactinaemia.

Answer 164

Haloperidol has a narrow therapeutic index, while olanzapine has a wide range.

Answer 165

Describes drugs by their pharmacological activity.

Answer 166

Neuroscience-Based Nomenclature ## Footnote NbN is a classification system that describes individual drugs by their pharmacological activity rather than traditional classifications.

Answer 167

It preselects specific pharmacological features while ignoring others ## Footnote This is based on expert opinions about essential features for drug action.

Answer 168

A data-driven approach based on in vitro binding profiles ## Footnote This approach identifies clusters of effects by receptor affinity.

Answer 169

* High affinity for muscarinic receptors * Low antagonism of dopamine D2 receptor * Serotonergic antagonism * Pure dopaminergic antagonism

Answer 170

All receptors are assigned equal importance regardless of their clinical impact ## Footnote This could lead to overlooking receptors that have a significant influence on drug effects.

Answer 171

FGAs are often used as 'when necessary' medications ## Footnote Haloperidol is a common choice, and depot preparations are still prescribed.

Answer 172

* Poor tolerance of SGAs due to metabolic changes * Patient preference for FGAs

Answer 173

* Acute EPS * Hyperprolactinaemia * Tardive dyskinesia (TD)

Answer 174

* Risperidone * Paliperidone * Amisulpride

Answer 175

TD occurs more frequently with FGAs than SGAs ## Footnote However, the risk can vary based on the dose of FGA used.

Answer 176

Partial agonists

Answer 177

Relative potential to cause adverse effects, views of the carer, and service user's preferences ## Footnote Adverse effects include extrapyramidal effects, cardiovascular issues, and metabolic changes.

Answer 178

Thorough assessment of physical health and starting at the lower end of the licensed range ## Footnote Titration should be slow and based on clinical guidelines.

Answer 179

For 1 year or until the patient is stable ## Footnote This monitoring includes various health parameters such as weight, blood pressure, and glucose levels.

Answer 180

Offer clozapine after inadequate response to two different antipsychotic drugs ## Footnote Clozapine is often considered for patients who do not respond to standard treatments.

Answer 181

Deciding whether to increase the dose, switch medications, add adjunctive therapy, or monitor ## Footnote This dilemma often arises when current treatment is suboptimal.

Answer 182

160mg/day. ## Footnote This conclusion came from a network meta-analysis.

Answer 183

No additional benefit was found with 40mg compared to 10mg, but there was a greater adverse-effect burden. ## Footnote Adverse effects included weight gain and raised plasma prolactin levels.

Answer 184

No additional benefit with higher doses, but increased risk of adverse effects. ## Footnote Adverse effects included extrapyramidal symptoms (EPS) and raised plasma prolactin.

Answer 185

8mg/day is the dose above which no additional benefit is seen. ## Footnote This finding aligns with studies on other antipsychotics.

Answer 186

False. ## Footnote The frequency of EPS increases at doses beyond standard or high doses.

Answer 187

Trial of clozapine, switching to another antipsychotic, or adding another antipsychotic. ## Footnote Clozapine is the preferred option if criteria are met.

Answer 188

40%. ## Footnote This audit included around 5,000 patients across 60 NHS trusts.

Answer 189

Averse to mandatory blood testing and adverse effects. ## Footnote Regular appointments are also a factor.

Answer 190

Data on switching are sparse and can be associated with destabilisation and adverse effects. ## Footnote The management of a switch is not entirely clear.

Answer 191

Participants whose illness failed to respond to one SGA were assigned to a different SGA. ## Footnote Switching to olanzapine or risperidone was more effective than quetiapine or ziprasidone.

Answer 192

Amisulpride, risperidone, and olanzapine. ## Footnote Clozapine was also noted for its superior efficacy.

Answer 193

To increase efficacy when monotherapy at standard dosage is insufficient. ## Footnote The majority of patients may receive a second antipsychotic for this reason.

Answer 194

Consider watchful waiting. ## Footnote This approach is a part of managing treatment failure.

Answer 195

Switch to olanzapine or risperidone, then use clozapine if these fail. ## Footnote Supporting evidence for clozapine is very strong.

Answer 196

Use time-limited augmentation strategies ## Footnote Supporting evidence for augmentation strategies is variable.

Answer 197

No, at a population level, it does not appear to increase hospitalization rates ## Footnote This finding is based on evidence from multiple studies.

Answer 198

It can be safely switched back without symptom exacerbation in the majority of patients.

Answer 199

* Engagement in case management * Targeted psychological treatments * Vocational rehabilitation

Answer 200

A return to the original polypharmacy regimen.

Answer 201

It can improve attention and processing speed.

Answer 202

To enhance patient well-being and manage symptoms effectively.

Answer 203

Persecutory delusions or hallucinations (auditory, visual, or tactile).

Answer 204

A clinical practice used when appropriate psychological and behavioral approaches have failed to de-escalate acutely disturbed behavior.

Answer 205

Oral and inhaled second-generation antipsychotics (SGAs).

Answer 206

It is restricted in many countries due to the risk of bronchospasm.

Answer 207

IM preparations of olanzapine, ziprasidone, and aripiprazole.

Answer 208

IM olanzapine is more effective than IM haloperidol.

Answer 209

Haloperidol is effective but poorly tolerated; co-administration of promethazine improves tolerability.

Answer 210

Combination treatment, most commonly haloperidol and lorazepam.

Answer 211

Haloperidol alone.

Answer 212

benzodiazepines

Answer 213

De-escalation, time out, seclusion, increased nursing levels, transfer to a psychiatric intensive care unit.

Answer 214

* De-escalation * Time out * Seclusion * Increased nursing levels * Transfer to psychiatric intensive care unit * Pharmacological management

Answer 215

* To reduce suffering for the patient * To reduce risk of harm to others * To do no harm

Answer 216

Concomitant use of two or more antipsychotics (antipsychotic polypharmacy)

Answer 217

Around 20 hours

Answer 218

12–24 hours

Answer 219

It slows absorption and makes the duration of action dependent on the rate of release from the IM reservoir

Answer 220

Zuclopenthixol was detectable in plasma after 1–2 hours, but peak concentrations were not reached until around 36 hours after dosing

Answer 221

* Dystonia * Rigidity

Answer 222

Only after an acutely psychotic patient has required repeated injections of short-acting antipsychotic drugs

Answer 223

* Levels of consciousness * Physical health

Answer 224

Consider IM treatment

Answer 225

* Temperature * Pulse * Blood pressure * Respiratory rate

Answer 226

Give procyclidine 5–10mg IM or IV

Answer 227

Increased risk of cardiac arrhythmia

Answer 228

Flumazenil ## Footnote Flumazenil is indicated for respiratory depression after lorazepam, midazolam, or diazepam administration.

Answer 229

200 mcg intravenously over 15 seconds ## Footnote If consciousness is not achieved within 60 seconds, a subsequent dose may be given.

Answer 230

Patients with epilepsy on long-term benzodiazepines ## Footnote Caution is also required in hepatic impairment.

Answer 231

1 mg ## Footnote This includes one initial dose and up to eight subsequent doses.

Answer 232

Respiratory rate ## Footnote Monitoring should continue until respiratory rate returns to baseline.

Answer 233

Agitation, anxiety, or seizures ## Footnote These effects may occur particularly in regular benzodiazepine users.

Answer 234

Assume sedation is from some other cause ## Footnote This indicates that further evaluation is necessary.

Answer 235

Immediate referral to specialist medical care ## Footnote The patient should lie flat and the bed should be tilted towards the head.

Answer 236

Creatine kinase ## Footnote There is a risk of Neuroleptic Malignant Syndrome (NMS) and arrhythmias.

Answer 237

False ## Footnote Flumazenil has a much shorter half-life than diazepam.

Answer 238

100 mcg over 15 seconds ## Footnote This can be repeated after 60 seconds if necessary.

Answer 239

Neuroleptic Malignant Syndrome (NMS) ## Footnote It may lead to arrhythmias as well.

Answer 240

60 seconds ## Footnote This is crucial to avoid complications.

Answer 241

Patients receiving 10 doses or fewer a year are at a higher risk of relapse compared to those receiving more frequent doses. ## Footnote Consistent, timely administration of LAIs is crucial for preventing relapse.

Answer 242

LAIs ensure clinical awareness of adherence, allowing timely intervention for potential relapses. ## Footnote They help differentiate between treatment resistance and adherence issues.

Answer 243

* Test doses for FGAs * Previous treatment with oral formulations * Patient history of adverse effects ## Footnote Test doses help assess sensitivity to adverse effects and ensure safe administration.

Answer 244

Begin with the lowest therapeutic dose to ensure safety and efficacy. ## Footnote Low doses may be as effective as higher doses with fewer adverse effects.

Answer 245

Administer at the longest possible licensed interval to avoid discomfort and pain from injections. ## Footnote There is no evidence that shortening dosing intervals improves efficacy.

Answer 246

Adjust doses only after an adequate assessment period, usually at least one month. ## Footnote Peak plasma levels and therapeutic effects may take weeks to months to stabilize.

Answer 247

False ## Footnote While LAIs help monitor adherence, they do not ensure it.

Answer 248

A serious adverse effect that requires caution when administering LAIs. ## Footnote Patients with a history of NMS should avoid LAIs.

Answer 249

To assess the patient's sensitivity to extrapyramidal symptoms (EPS) and the base oil used in the formulation. ## Footnote This helps in preventing severe adverse reactions.

Answer 250

Factors beyond poor adherence, including clinician reluctance and patient acceptance. ## Footnote Some studies suggest that patients are generally willing to accept long-acting treatments.

Answer 251

It helps identify barriers to optimal implementation of LAI treatments. ## Footnote Understanding these factors can improve patient outcomes.

Answer 252

Plasma levels are delayed with LAI antipsychotic medications

Answer 253

Doses may be reduced but should only be increased after careful assessment over at least 1 month

Answer 254

Steady state is achieved after at least 6–8 weeks

Answer 255

No, dose increases during this initial period are illogical and impossible to evaluate properly

Answer 256

Monitoring and recording of therapeutic efficacy, adverse effects, and impact on physical health

Answer 257

It risks a high-dose prescription

Answer 258

The regular prescription of an oral antipsychotic medication in addition to an LAI antipsychotic preparation

Answer 259

The safety and tolerability of such a combination over the longer term

Answer 260

Paliperidone (3-month), aripiprazole, olanzapine, and paliperidone (1-month) had the largest effect sizes for relapse prevention

Answer 261

Aripiprazole, paliperidone, risperidone, and olanzapine

Answer 262

LAI paliperidone

Answer 263

Significant weight gain and post-injection delirium/sedation syndrome

Answer 264

Every 4 weeks

Answer 265

High relative to other LAIs

Answer 266

Every 3 months

Answer 267

Tolerability and response to the oral preparation

Answer 268

500mg every week is licensed whereas 1000mg every 2 weeks is not

Answer 269

Estimating the optimal dose of flupentixol decanoate in the maintenance treatment of schizophrenia ## Footnote Systematic review of the literature

Answer 270

Monthly administration of long-acting injectable risperidone and striatal dopamine D2 receptor occupancy for managing schizophrenia

Answer 271

Plasma levels and estimated dopamine D(2) receptor occupancy of long-acting injectable risperidone during maintenance treatment of schizophrenia

Answer 272

Dose-associated changes in safety and efficacy parameters during a 24-week maintenance trial

Answer 273

Depot neuroleptic injection site reactions

Answer 274

Systematic review of the non-systemic adverse effect profile of long-acting injectable antipsychotics

Answer 275

Safety, tolerability, and pharmacokinetics of the highest available dose of paliperidone palmitate in patients with schizophrenia

Answer 276

Pharmacokinetics, tolerability, and safety of aripiprazole once-monthly in adult schizophrenia

Answer 277

Side-effect monitoring of continuing LAI antipsychotic medication in UK adult mental health services

Answer 278

Concurrent oral antipsychotic drug use among schizophrenia patients initiated on long-acting injectable antipsychotics post-hospital discharge

Answer 279

Managing breakthrough psychosis and symptomatic worsening in patients with schizophrenia on long-acting injectable antipsychotics

Answer 280

Maintenance treatment with long-acting injectable antipsychotics for people with nonaffective psychoses

Answer 281

Long-acting injectable second-generation antipsychotics

Answer 282

Evaluating the evidence for the use of long-acting injectable antipsychotics in schizophrenia

Answer 283

Review of paliperidone palmitate for schizophrenia

Answer 284

Risperidone (depot) for schizophrenia

Answer 285

Olanzapine pamoate: a stick in time?

Answer 286

Post-injection delirium/sedation syndrome in patients treated with olanzapine pamoate

Answer 287

Long-acting risperidone for schizophrenia

Answer 288

Clinical review of a long-acting, injectable formulation of risperidone

Answer 289

1–3 days

Answer 290

4–7 days

Answer 291

3–6 days

Answer 292

Essential for reviewing treatment and progress at least once a year ## Footnote This includes systematic assessment of efficacy, tolerability, and safety of the medication.

Answer 293

Cardiovascular and metabolic adverse effects, and EPS (parkinsonism, akathisia, TD) ## Footnote EPS stands for extrapyramidal symptoms.

Answer 294

Uncertain; the risk does not appear different when comparing LAI and oral formulations of the same antipsychotic ## Footnote TD is a serious movement disorder often associated with long-term use of antipsychotic medications.

Answer 295

Individual circumstances, severity of illness, risk of relapse, treatment response, and social situation ## Footnote This includes factors like symptom-free duration, severity of adverse effects, and previous dosage reduction attempts.

Answer 296

No more than a third of the previous dose ## Footnote Reductions should be monitored closely to avoid relapse.

Answer 297

To 4 weeks ## Footnote This is to ensure stable plasma levels before dose reduction.

Answer 298

False ## Footnote The process may sometimes result in discontinuation, but that is not the primary goal.

Answer 299

Relapse may be delayed compared with oral equivalents ## Footnote This is likely due to longer exposure and prolonged dopamine receptor blockade.

Answer 300

It may be preferable to no treatment, although not as effective as continuous treatment ## Footnote This approach is often considered in cases where continuous treatment is not feasible.

Answer 301

14 days ## Footnote This is to establish tolerability and response before initiating LAI.

Answer 302

One-injection start and two-injection start ## Footnote Each regimen involves different methods for maintaining therapeutic aripiprazole concentrations.

Answer 303

This should inform the determination of the minimum effective dose for that patient ## Footnote Monitoring symptoms helps tailor ongoing treatment.

Answer 304

Continuing standard dose LAI ## Footnote High-dose olanzapine LAI and relatively low-dose oral perphenazine were exceptions.

Answer 305

prolactin-related and metabolic adverse effects ## Footnote This makes it a favorable option for patients.

Answer 306

Approved for maintenance monotherapy in bipolar I disorder in adults ## Footnote In some countries, its use for bipolar is off-label.

Answer 307

To maintain therapeutic aripiprazole concentrations during initiation ## Footnote Without this, plasma levels may not be sufficient for therapeutic effects.

Answer 308

Administer one injection of 400mg aripiprazole LAI and continue treatment with 10–20mg/day oral aripiprazole for 14 consecutive days. ## Footnote This regimen is for maintaining therapeutic aripiprazole concentrations during initiation.

Answer 309

Administer two separate injections of 400mg aripiprazole LAI at different sites, along with one 20mg dose of oral aripiprazole. ## Footnote Oral therapy should not continue after this point.

Answer 310

Peak plasma levels are reached 7 days post-injection. ## Footnote Trough levels occur at 4 weeks.

Answer 311

15–20mg of daily aripiprazole.

Answer 312

A lower dose of 300mg a month can be used.

Answer 313

* Increased weight * Akathisia * Insomnia * Injection site pain.

Answer 314

Give oral aripiprazole for 14 days and one dose of ALAI or give two ALAI injections at different sites plus a single dose of 20mg aripiprazole.

Answer 315

Administer 960mg every 56 days into the gluteal muscle.

Answer 316

Administer one 960mg injection and give 10–20mg oral aripiprazole for 14 consecutive days.

Answer 317

1064mg Aristada for every 2 months.

Answer 318

Akathisia.

Answer 319

Administer 960mg or 720mg plus oral aripiprazole for 14 days.

Answer 320

675mg IM injection.

Answer 321

Always use the two-injection starting regimen.

Answer 322

A very poorly water-soluble salt ester of olanzapine

Answer 323

Intramuscular injection

Answer 324

Within 1 week, most commonly within 2–4 days

Answer 325

Every 4 weeks

Answer 326

A prior oral trial is ideal

Answer 327

Start olanzapine 2 weeks after the last Consta injection

Answer 328

A condition that may occur after olanzapine LAI injection, characterized by confusion, delirium, and somnolence

Answer 329

Less than 0.1% of injections

Answer 330

At least 3 hours

Answer 331

Exposure to a large volume of blood or plasma

Answer 332

Continue close medical supervision and monitoring

Answer 333

[olanzapine overdose]

Answer 334

* Male gender * Higher doses * Previous injection site-related adverse effects

Answer 335

Up to 8 months

Answer 336

Naturalistic data

Answer 337

To assess response and tolerability before starting maintenance

Answer 338

Be vigilant for signs and symptoms of overdose

Answer 339

Paliperidone

Answer 340

The ester prodrug of paliperidone

Answer 341

* Monthly * 3-monthly * 6-monthly

Answer 342

As an aqueous nanosuspension, hydrolysed after IM administration

Answer 343

Results in an average 28% higher peak concentration compared to the gluteal muscle

Answer 344

As early as day 4

Answer 345

* Day 1: 150mg IM (deltoid only) * Day 8 (±4 days): 100mg IM (deltoid only)

Answer 346

50-150mg IM every month (±7 days)

Answer 347

25 to 49 days

Answer 348

* Lower risk of hospitalizations * Fewer emergency department visits

Answer 349

Give the first dose of PP3M in place of the next scheduled dose of PP1M (±7 days)

Answer 350

* Less frequent and painful injections * Less travelling * Fewer moments of experiencing shame

Answer 351

84-95 days

Answer 352

Reduce the dose of the oral antipsychotic over 1-2 weeks following the first injection of paliperidone

Answer 353

Patients on maintenance treatment with 100mg or 150mg of PP1M for 4 months or more

Answer 354

Patients should be on a stable and effective therapeutic dose of PP1M

Answer 355

Shake vigorously the prefilled syringe for at least 15 seconds

Answer 356

Adjustments should be made at 3-monthly intervals

Answer 357

* 75mg monthly for general adult population * 100mg and 150mg are more often prescribed in practice

Answer 358

Gluteal muscle ## Footnote PP6M should not be administered via any other route.

Answer 359

PP1M to PP3M equivalent doses: * 50mg to 175mg * 75mg to 263mg * 100mg to 350mg * 150mg to 525mg

Answer 360

148–159 days or longer

Answer 361

Stable mental state ## Footnote Patients should not require any dose adjustments.

Answer 362

Minimum of 30 seconds

Answer 363

Injection site pain

Answer 364

Give 700mg of PP6M in place of the next scheduled dose of 100mg PP1M

Answer 365

Give 1000mg of PP6M in place of the next scheduled dose of 150mg PP1M

Answer 366

Give 700mg of PP6M in place of the next scheduled dose of 350mg PP3M

Answer 367

Give 1000mg of PP6M in place of the next scheduled dose of 525mg PP3M

Answer 368

A 2-weekly injectable suspension of risperidone ## Footnote Given in the gluteal muscle to patients who have previously responded and tolerated risperidone.

Answer 369

25mg every 2 weeks

Answer 370

The first IM injection of Rykindo should be given 4–5 weeks after the last Consta administration.

Answer 371

50mg every 2 weeks

Answer 372

They are rarely initiated in practice

Answer 373

Around 6 weeks

Answer 374

To ensure therapeutic plasma concentration of the new antipsychotic is established before risperidone concentrations become subtherapeutic

Answer 375

4–5 weeks after the last Consta administration ## Footnote Refer to Table 1.25 for equivalent doses.

Answer 376

Stored in the refrigerator and allowed to sit at room temperature for at least 30 minutes before reconstitution.

Answer 377

Start oral tablets 4–5 weeks after the last RLAI injection.

Answer 378

* 25mg/2 weeks = 2mg/day * 37.5mg/2 weeks = 3mg/day * 50mg/2 weeks = 4mg/day

Answer 379

Initiate the equivalent dose of paliperidone LAI in place of the next scheduled dose of RLAI.

Answer 380

Every 28 days.

Answer 381

Initial peak within 24–48 hours, second peak between days 18 and 25.

Answer 382

* Absence of a loading dose requirement * 28-day administration interval

Answer 383

* Not suitable for patients requiring 2mg or 6mg/day of oral risperidone * Not for patients with creatinine clearance of less than 60mL/minute

Answer 384

SC risperidone LAI available in 90mg and 120mg dosage forms, given every 28 days.

Answer 385

* First peak at 4–6 hours * Second peak at 10–14 days post-dose

Answer 386

* Injection site pain * Weight gain

Answer 387

* 75mg or 100mg IM on Day 1

Answer 388

Stored in the fridge and allowed to sit at room temperature for at least 30 minutes before administration.

Answer 389

Therapeutic concentrations are seen on day one.

Answer 390

* Injection site pain * Injection site nodules * Weight gain * Extrapyramidal side effects (EPSEs)

Answer 391

3mg/day oral risperidone

Answer 392

Assumed to be 100%.

Answer 393

A long-acting injectable formulation of risperidone for schizophrenia treatment. ## Footnote RBP-7000 is administered once monthly and is designed to improve adherence in patients.

Answer 394

20–40mg per week. ## Footnote Higher doses have been used in clinical settings, but 30mg is considered adequately effective.

Answer 395

At least 60 hours. ## Footnote This long half-life allows for once-weekly dosing.

Answer 396

True. ## Footnote It serves as an alternative to long-acting injectable antipsychotics.

Answer 397

* Acute EPS * Increased prolactin * Tardive dyskinesia * QT prolongation ## Footnote Sedation is usually minimal.

Answer 398

20mg. ## Footnote The dose can be increased to a maximum of 40mg after assessment.

Answer 399

It assessed the efficacy of monthly risperidone injections following a switch from daily oral risperidone. ## Footnote This study contributes to understanding the transition between different formulations of risperidone.

Answer 400

20–40mg per week.

Answer 401

ECT augmentation of antipsychotic medication can improve persistent positive symptoms. ## Footnote Evidence suggests it may be beneficial for medication-resistant cases.

Answer 402

It compared ECT with placebo, sham ECT, non-pharmacological interventions, and antipsychotic medication for schizophrenia. ## Footnote Results indicated more significant improvement in patients receiving real ECT.

Answer 403

* Improved adherence * Long-acting formulation * Monthly administration ## Footnote Designed to address issues of non-adherence common with daily oral medications.

Answer 404

2–3 weeks. ## Footnote Monitoring of renal and hepatic function is essential during this period.

Answer 405

* Pimozide * Aripiprazole * Cariprazine ## Footnote These alternatives may also improve adherence in treatment.

Answer 406

Lack of data on long-term effectiveness, cognitive deficits, and quality of life. ## Footnote More research is needed to assess these aspects.

Answer 407

Discontinuation trends for oral penfluridol were similar to depot formulations. ## Footnote Suggests comparable efficacy in treatment adherence.

Answer 408

Electroconvulsive Therapy

Answer 409

* Placebo * Sham ECT * Non-pharmacological interventions * Antipsychotic medication

Answer 410

It is a valid treatment option, especially for rapid improvement and reducing symptoms.

Answer 411

The rate of psychiatric hospitalization decreased in those treated with ECT.

Answer 412

Treatment-Resistant Schizophrenia

Answer 413

Moderate-quality evidence suggested a positive effect on medium-term clinical response.

Answer 414

Dominant negative symptoms

Answer 415

The combination was superior in symptom improvement, response, and remission rates.

Answer 416

Almost two-thirds

Answer 417

40% or greater reduction in the psychotic symptom subscale of the Brief Psychiatric Rating Scale

Answer 418

ECT may be an effective augmentation strategy but requires further research.

Answer 419

* Transient retrograde amnesia * Anterograde amnesia * Drowsiness * Headaches * Nausea

Answer 420

Controlled studies with sham ECT as a control

Answer 421

It was not superior to sham treatment for symptom response.

Answer 422

They are generally mild and transient.

Answer 423

Further well-controlled trials

Answer 424

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) ## Footnote These are also known as polyunsaturated fatty acids (PUFAs)

Answer 425

Involvement in maintaining neuronal membrane structure, modulation of membrane proteins, and production of prostaglandins and leukotrienes

Answer 426

The ratio between omega-6 and omega-3 fatty acids

Answer 427

They may have difficulty converting short-chain fatty acids to long-chain polyunsaturated fatty acids

Answer 428

It may protect against psychosis

Answer 429

EPA had no beneficial effect in established schizophrenia

Answer 430

It showed a reduction in symptom severity with a number needed to treat (NNT) of 4 for a 50% reduction in symptoms

Answer 431

Failed to demonstrate any value for PUFAs over placebo

Answer 432

Found no evidence for the use of PUFAs in the treatment of schizophrenia

Answer 433

Unlikely to be a worthwhile option when added to standard treatment

Answer 434

Not recommended for use in schizophrenia

Answer 435

Mild gastrointestinal symptoms may occur

Answer 436

Treatment greatly reduced emergence of psychotic symptoms compared with placebo

Answer 437

Failed to find evidence of efficacy for reducing transition to psychosis or improving symptoms

Answer 438

A positive correlation between functional improvement and frequency of dietary intake of EPA

Answer 439

No longer recommended for treatment of residual symptoms or prevention of transition to psychosis

Answer 440

3 months' treatment

Answer 441

Licensed for the rapid control of mild to moderate agitation in patients with schizophrenia or bipolar disorder ## Footnote It requires cooperation of the patient and is associated with increased risk of bronchospasms.

Answer 442

9.1mg (10mg), can be repeated after 2 hours ## Footnote Manufactured by Angelini Pharma (UK) and Teva (USA).

Answer 443

Acute disturbance ## Footnote ECG monitoring is recommended due to reported EPSEs.

Answer 444

5mg twice daily, up to a maximum dose of 10mg twice daily ## Footnote Licensed for moderate to severe manic episodes associated with bipolar disorder in the UK.

Answer 445

Oral or intramuscular ## Footnote Alternative routes may be needed due to medical illness or patient preference.

Answer 446

Moderate to severe manic episodes associated with bipolar disorder ## Footnote Can be applied to upper arm, upper back, abdomen, and hip.

Answer 447

Starting dose 3.8mg/24 hr, may increase to 5.7mg/24 hr or 7.6mg/24 hr after 1 week ## Footnote Licensed in the USA.

Answer 448

100mg every 6–8 hr ## Footnote Limited information about this route for the treatment of psychosis.

Answer 449

Hypoxia, respiratory depression, and bradycardia ## Footnote Used off-label for acute disturbance.

Answer 450

Rapid onset of tranquillising effect around 10 minutes ## Footnote Administration requires cooperation, which may not be feasible in medically unwell patients.

Answer 451

35% ## Footnote Compared to only 2% when taken orally.

Answer 452

Close ECG monitoring is advised ## Footnote Doses typically recommended are between 5 and 10mg.

Answer 453

30mg/day ## Footnote Bolus doses from 2.5 to 10mg have been safely administered.

Answer 454

Absorbed through the lining of the cheek ## Footnote Absorption is slower compared to sublingual use.

Answer 455

Acute disturbance ## Footnote ECG monitoring is recommended.

Answer 456

Antipsychotics are probably not effective in delirium ## Footnote Large clinical trials showed no benefit over placebo.

Answer 457

1.25–30mg ## Footnote Used off-label for acute disturbance with limited evidence.

Answer 458

Eating and drinking should be avoided for 10 minutes after administration ## Footnote This is to ensure proper absorption.

Answer 459

Developed for intranasal delivery of various antipsychotics ## Footnote Remains clinically untested.

Answer 460

25mg every 12 hr ## Footnote Suppositories available in some countries.

Answer 461

Sublingually ## Footnote Dexmedetomidine is used sublingually for managing acute agitation in patients.

Answer 462

Through the lining of the cheek ## Footnote Buccal administration results in slower absorption compared to sublingual use.

Answer 463

Treatment of nausea and vomiting associated with migraines ## Footnote Prochlorperazine is rarely used for psychiatric indications.

Answer 464

Minimises fluctuations in plasma drug concentrations ## Footnote Transdermal delivery allows for lower doses and possibly reduced systemic adverse effects.

Answer 465

Asenapine (Secuado) ## Footnote Blonanserin is also available as a transdermal patch in certain Asian countries.

Answer 466

Not licensed ## Footnote Chlorpromazine suppositories are available in the UK but the rectal route is not officially licensed for adults.

Answer 467

Withdrawal symptoms including psychotic symptoms ## Footnote Withdrawal effects can also include non-psychotic symptoms like insomnia and anxiety.

Answer 468

Improvement in social functioning ## Footnote This may occur without worsening relapse or symptom burden in the medium term.

Answer 469

Increased risk of relapse ## Footnote Abruptly stopping antipsychotics can lead to withdrawal-associated relapse.

Answer 470

Increased sensitivity to dopamine after long-term antipsychotic treatment ## Footnote This can lead to a higher risk of relapse when antipsychotics are reduced.

Answer 471

Gradual dose tapering ## Footnote Slower tapering allows for neuroadaptations to resolve, reducing relapse risk.

Answer 472

* Agitation * Insomnia ## Footnote Other symptoms can include anxiety, dizziness, and nausea.

Answer 473

Improvement in cognitive functioning ## Footnote Reducing antipsychotic burden may lead to better cognitive outcomes.

Answer 474

False ## Footnote Antipsychotics are recommended for long-term treatment to reduce symptoms and relapse risk.

Answer 475

More than half ## Footnote These prescriptions are often for insomnia, anxiety, personality disorders, and dementia symptoms.

Answer 476

* Psychotic symptoms * Insomnia * Anxiety ## Footnote Withdrawal symptoms can reflect the blocking of various neurotransmitter receptors.

Answer 477

* Restlessness * Myalgia * Rigidity * Paraesthesia * Agitation * Fear * Hallucinations * Confusion or disorientation * Hypothermia * Sweating * Irritability * Insomnia * Depressed affect * Loss of appetite * Nausea * Tremulousness * Incoordination * Lethargy * Amnesia * Withdrawal dyskinesia * Parkinsonism * Neuroleptic malignant syndrome * Akathisia * Auditory hallucinations * Persecutory delusions * Other psychotic symptoms * Flu-like symptoms * Dizziness * Light-headedness * Tachycardia * Electric shock sensations * Anxiety * Low mood * Nightmares * Diarrhoea * Decreased concentration * Headache * Hypertension * Angina * Palpitations * Risk of myocardial infarction * Presyncope * Sweating

Answer 478

A hyperbolic relationship exists between dose of antipsychotic and D2 receptor occupancy.

Answer 479

Each additional molecule of a drug has incrementally less effect as receptor targets become saturated.

Answer 480

They produce increasingly larger reductions of D2 blockade.

Answer 481

A hyperbolic reduction pattern is advised, approximated by sequential halving of the dose.

Answer 482

They should be informed of the risk of withdrawal symptoms, including insomnia and potential increase in psychotic symptoms.

Answer 483

A reduction as large as 25% might be feasible.

Answer 484

Patients should be monitored for withdrawal symptoms or worsening of psychotic symptoms.

Answer 485

An increase in dose back one or two steps or back to the original dose may be necessary.

Answer 486

Final doses may need to be very small to prevent a large decrease in D2 blockade.

Answer 487

Every-other-day dosing of antipsychotics with half-lives of less than 24 hours.

Answer 488

Reducing depot medication might facilitate gradual tapering because of the longer half-lives of elimination.

Answer 489

Reduce olanzapine by 5–10mg every 1–3 months until reaching 20mg per day.

Answer 490

This process could take 12–48 months.

Answer 491

Movement disorders associated with antipsychotic medication that can be stigmatising and distressing. ## Footnote EPS can include symptoms such as dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia.

Answer 492

Factors include: * Dose of antipsychotic medication * Type of antipsychotic used * Genetic predisposition * Substance misuse * Age and gender ## Footnote EPS are less likely to occur with SGAs compared to FGAs.

Answer 493

Clozapine, olanzapine, quetiapine, aripiprazole. ## Footnote These medications have a lower incidence of EPS compared to FGAs like haloperidol.

Answer 494

The prevalence may exceed 30%. ## Footnote This statistic highlights the common occurrence of EPS in patients, even in those who may not be on antipsychotic medication.

Answer 495

The incidence of EPS is often steeply dose-related for most drugs. ## Footnote This relationship can extend beyond the licensed dose range for some antipsychotics.

Answer 496

* Dystonia * Pseudoparkinsonism * Akathisia * Tardive dyskinesia ## Footnote Each type has distinct symptoms and characteristics.

Answer 497

Uncontrolled muscular spasms, including: * Oculogyric spasm * Torticollis * Difficulty swallowing ## Footnote Acute dystonia can be painful and frightening for patients.

Answer 498

Symptoms include: * Bradykinesia * Tremor * Muscle rigidity ## Footnote Pseudoparkinsonism can be mistaken for depression or negative symptoms of schizophrenia.

Answer 499

A state of inner restlessness with a desire to move, characterized by: * Foot stamping * Constantly pacing ## Footnote Akathisia can be mistaken for psychotic agitation and has been linked to suicidal ideation.

Answer 500

Symptoms develop at different rates: * Dystonia: hours * Pseudoparkinsonism: months * Akathisia: hours to weeks * Tardive dyskinesia: months to years. ## Footnote Understanding these timeframes is crucial for monitoring patients on antipsychotics.

Answer 501

Treatment options include: * Anticholinergic drugs * IM or IV administration * Electroconvulsive therapy (ECT) for severe cases. ## Footnote Response to IV anticholinergic administration is seen within 5 minutes.

Answer 502

Abnormal involuntary movements that develop after long-term antipsychotic treatment. ## Footnote The reversibility of TD after stopping medication is unclear and may depend on age.

Answer 503

More common in young males and those who are antipsychotic-naïve. ## Footnote Dystonic reactions are rare in the elderly.

Answer 504

Parkinsonian symptoms and other motor abnormalities may be associated with cognitive impairment and poor long-term psychosocial functioning. ## Footnote This association emphasizes the importance of monitoring cognitive health in patients with EPS.

Answer 505

Prescribe an anticholinergic. ## Footnote Majority of patients do not require long-term anticholinergic agents; use should be reviewed at least every 3 months.

Answer 506

Reduce the antipsychotic dose or change to an antipsychotic drug with lower propensity for akathisia. ## Footnote Refer to sections on akathisia and relative liability of antipsychotic medications for adverse effects.

Answer 507

* Low-dose propranolol (30–80mg/day) * Clonazepam (low dose) * 5HT2 antagonists such as cyproheptadine, mirtazapine, trazodone, mianserin * Possibly diphenhydramine ## Footnote Note that all of the above medications are unlicensed for this indication.

Answer 508

Stop anticholinergic if prescribed. ## Footnote Anticholinergics are generally unhelpful unless akathisia is part of a general EPS spectrum.

Answer 509

Reduce dose of antipsychotic medication or change to an antipsychotic with lower propensity for TD. ## Footnote Clozapine is most likely to resolve symptoms; Quetiapine may also be useful.

Answer 510

* Valbenazine * Deutetrabenazine * Tetrabenazine * Ginkgo biloba ## Footnote Refer to the review by the American Academy of Neurology for other treatment options.

Answer 511

False. ## Footnote Anticholinergics are generally unhelpful unless akathisia is part of a general EPS spectrum.

Answer 512

To reduce symptoms of akathisia. ## Footnote Dosage is typically 30–80mg/day.

Answer 513

tardive dyskinesia.

Answer 514

Review use of anticholinergic agents. ## Footnote Majority of patients do not require long-term anticholinergic agents.

Answer 515

Clozapine. ## Footnote Quetiapine may also be useful in this regard.

Answer 516

Akathisia is a common adverse effect of most antipsychotic medications characterized by mental unease and dysphoria, with a compulsion to move and motor restlessness.

Answer 517

Sertindole and quetiapine have a minimal risk of inducing akathisia.

Answer 518

Haloperidol and lurasidone are associated with a high risk of inducing akathisia.

Answer 519

The risk of akathisia tends to increase with dose, but the dose-response curves differ between medications.

Answer 520

mental unease and dysphoria.

Answer 521

An association with suicidal ideation has been postulated but remains uncertain.

Answer 522

Avoiding high-dose antipsychotic medication, antipsychotic polypharmacy, and rapid increases in dosage may mitigate the risk.

Answer 523

Mirtazapine, biperiden, and vitamin B6 emerged as the most efficacious treatments.

Answer 524

Vitamin B6 was judged to have the most favorable efficacy and tolerability profile.

Answer 525

Trazodone, mianserin, and propranolol were considered effective alternatives.

Answer 526

The efficacy of each treatment option should be evaluated over at least 1 month.

Answer 527

Midazolam has been successfully used to prevent akathisia associated with IV metoclopramide.

Answer 528

30–80 mg/day.

Answer 529

refractory.

Answer 530

Benzodiazepines may be prescribed for a limited period to manage short-lived effects of antipsychotic medication.

Answer 531

Vitamin B6, pregabalin, diphenhydramine, trazodone, and zolmitriptan.

Answer 532

Akathisia can be difficult to diagnose with certainty and is commonly overlooked or misdiagnosed.

Answer 533

To determine effective treatment options for persistent, antipsychotic-induced akathisia.

Answer 534

The risk of akathisia with partial agonists is greatest with cariprazine and lowest with brexpiprazole.

Answer 535

Withdraw previously ineffective add-on akathisia treatments.

Answer 536

They aim to improve the identification and diagnosis of akathisia in clinical practice.

Answer 537

A movement disorder characterized by a feeling of inner restlessness and an uncontrollable need to be in constant motion.

Answer 538

Akathisia has been linked with treatment-emergent suicidality among patients with first-episode schizophrenia.

Answer 539

Haloperidol and risperidone.

Answer 540

D2 receptor

Answer 541

Withdrawal of any co-prescribed anticholinergic agents.

Answer 542

Dopamine partial agonists, particularly aripiprazole.

Answer 543

Withdraw the antipsychotic and substitute it with a medication with lower liability for TD.

Answer 544

Clozapine, quetiapine, olanzapine, aripiprazole.

Answer 545

* Deutetrabenazine * Valbenazine * Amantadine * Vitamin E * Vitamin B6

Answer 546

12–48mg/day.

Answer 547

Limited; a Cochrane review concluded it did not justify routine use.

Answer 548

They are often unaware by the majority of patients.

Answer 549

Considered agents of first choice due to supporting evidence.

Answer 550

100–300mg/day.

Answer 551

Supported by a Cochrane review and a 2020 meta-analysis.

Answer 552

TD can occur even with low doses.

Answer 553

unsuccessful

Answer 554

TD is associated with greater cognitive impairment.

Answer 555

Withdraw the antipsychotic prescribed.

Answer 556

Greater occupancy is associated with a higher risk of TD.

Answer 557

Could reduce TD symptoms but not justified for routine use as treatment. ## Footnote Evidence does not support routine use despite potential benefits.

Answer 558

240 mg/day. ## Footnote This dosage showed a good effect in reducing TD symptoms.

Answer 559

Up to 400 mg/day. ## Footnote Supported by a Cochrane review and a 2020 meta-analysis.

Answer 560

The only licensed treatment for moderate to severe TD. ## Footnote Can cause depression, drowsiness, parkinsonism, and akathisia.

Answer 561

25–200 mg/day.

Answer 562

VMAT-2 inhibitor licensed for TD in the USA. ## Footnote Supports a favorable benefit-risk ratio.

Answer 563

80 mg once daily.

Answer 564

Efficacy remains inconclusive; may slow deterioration of TD. ## Footnote Dose is in the range of 400–1600 IU/day.

Answer 565

Evidence only for slowing deterioration, not definitive treatment effect.

Answer 566

Supported by a small randomized, placebo-controlled trial with low toxicity risk.

Answer 567

Treatment of choice for localized dyskinesia with success reported in case reports.

Answer 568

Deep Brain Stimulation; may have a role in severe and distressing TD unresponsive to pharmacological treatment.

Answer 569

10 mg/day.

Answer 570

Inconclusive data, but supports the theory that GABAergic mechanisms improve TD.

Answer 571

Up to 3000 mg/day.

Answer 572

10 mg/day; supported by a meta-analysis of four trials.

Answer 573

May be effective; well tolerated at a dose of 200 mg/day.

Answer 574

Asthma, bradycardia, and hypotension.

Answer 575

No specific dose mentioned; considered a plant compound with antioxidant properties.

Answer 576

Bilateral hemispheric high-frequency rTMS may be feasible for TD unresponsive to first-line treatments.

Answer 577

10–30 mg a day.

Maudsley Prescribing Guidelines 2025 Flashcards

(634 cards)