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competency 10/11 > neuro: schizophrenia > Flashcards

neuro: schizophrenia Flashcards

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1
Q

antipyschotic meds, aka

A

neuroleptics
- Generally tranquilize without impairing consciousness and without causing
paradoxical excitement

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2
Q

indications for antipsychotics

A
  • schizo and related psychoses
  • acute mania
  • short-term adjunctive mgmt of severe anxiety or psychomotor agitation, violent behaviour

other uses:
- antiemetic in palliative care (chlorpromazine, haloperidol, prochlorperazine)
- adjunct treatment for major depression (quetiapine, aripiprazole)
- irritability a/w autism disorder (risperidone)
- motor tics and adjunctive treatment in choreas and Tourette’s syndrome (haloperidol)
- intractable hiccups (haloperidol)

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3
Q

antipyschotics for schizo

A

relieve sx of psychosis such as thought disorder, hallucinations and delusions
- less effective in apathetic withdrawn patients

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4
Q

is long-term treatment necessary after first episode of psychosis?

A

yes, prevent illness from becoming chronic

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5
Q

a person who is maintaining well on antipyschotic may relapse if

A

treatment is withdrawn inappropriately
- relapse is often delayed for several weeks after cessation of treatment
- adipose tissues act as depot resesrvoir after chronic regular usage of antipsychotics: antipsychotics store in fat cells then diffuse back into bloodstream after treatment cessation and until depletion

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6
Q

methods to overcome poor treatment adherance

A
  • IM long-acting injections
  • Community Psychiatric Nurse
  • Patient and Family (Caregiver) Education
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7
Q

central dopamine systems is composed of the following 4 tracts

A
  • mesolimbic tract
  • mesocorticol tract
  • nigrostriatal tract
  • tuberoinfundibular tract
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8
Q

mesolimbic tract

A

common moa for all antipsychotics: blockade of the dopamine receptors in this tract
- overactivity in this region is responsible for the pos sx

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9
Q

mesocorticol tract

A

responsible for higher-order thinking and executive functions
- dopamine blockade or hypofunction in this region results in neg sx

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10
Q

nigrostriatal tract

A

modulates body movement
- dopamine blockade in this region causes EPSE

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11
Q

tuberoinfundibular tract

A

dopamine blockade in this region of the anterior pituitary leads to hyperprolactinemia
- unopposed secretion of prolactin into blood stream: can cause osteoporosis, sexual dysfunction, gynecomastia

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12
Q

d2 antagonism

A

improve +sx
se: EPSE, hyperprolactinemia

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13
Q

5ht1a agonism

A

anxiolytic

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14
Q

5ht2a antagonsim

A

antidepressant effects? improve -sx?

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15
Q

5ht2c antagonism

A

se: weight gain

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16
Q

h1 antagonism

A

se: sedation/weight gain

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17
Q

a1 antagonism

A

orthostasis, sedation

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18
Q

m1 antagonism

A

memory dysfunction, peripheral anticholinergic effects

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19
Q

IKr antagonism

A

qtc interval prolongation: pro-arrhythmic

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20
Q

adequate trial

A

at optimal therapeutic doses, at least 2-6 weeks
- clozapine trial req up to 3months
- additional augmentation trial of up to 8-10weeks req if another antipsychotic is added to clozapine

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21
Q

long-acting injectables

A

IM Risperidone microspheres, IM Paliperidone prolonged release suspension, IM Aripiprazole LAI, IM
Haloperidol decanoate, IM Flupenthixol Decanoate, IM Zuclopenthixol decanoate

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22
Q

consider clozapine in those

A

treatment-resistant ie. failed >= 2 adequate trials of diff antipsychotics, at least 1 should be a SGA

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23
Q

routine _____ monitoring is req for pt on clozapine

A

hematological: FBC monthly - risk of agranulocytosis

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24
Q

precautions to antipsychotic use

Study These Flashcards
A

Cardiovascular disease
􀂇 QTc prolongation (contraindicated)
􀂇 ECG required esp. if physical exam identifies cardiovascular
risk factors, or if there is personal history of cardiovascular
disease, or if patient is being admitted as inpatient.
􀂱 PD: EPSE worsened by antipsychotics
􀂱 Epilepsy & conditions predisposing to seizures
􀂱 Depression
􀂱 Myasthenia gravis
􀂱 Prostatic hypertrophy
􀂱 Angle-closure glaucoma
􀂱 Severe respiratory disease
􀂱 History of jaundice
􀂱 Blood dyscrasias, esp. for Clozapine
􀂱 Elderly with Dementia - increased risks for mortality and stroke

25
which antipsychotics must be taken w food
lurasidone, ziprasidone
26
which SGA better in terms of metabolic profile
ziprasidone, aripiprazole, brexiprazole lurasidone also q good
27
which SGA worst in terms of metabolic profile
clozapine, olanzapine
28
mgmt of side effects: dystonia (muscle spasms eg. oculogyric crisis, torticollis)
risks: - high potency antipsychotics eg. haloperidol - neuroleptic-naive patients - young males onset: within mins (if im/iv) or hrs (if PO) IM anticholinergics eg. benztropine, diphenhydramine
29
mgmt of side effects: pseudo-parkinsonism (tremors, rigidity, bradykinesia, salivation)
risks: - elderly females - those with previous neurological damage eg. head injury or stroke onset: days or weeks decr antipsychotic dose or switch to SGA + anticholinergics PRN eg. benzhexol or benztropine
30
mgmt of side effects: akathisia (restlessness)
risks: high potency antipsychotics > risp > olan > quet/cloz onset: hrs to weeks decr antipsyhotic dose or switch to SGA or clonazepam low dose prn or propranolol 20mg TDS, max 160mg/d - anticholinergics generally unhelpful
31
mgmt of side effects: tardive dyskinesia (orofacial moements eg. lip chewing, tongue protrusion, pelvic thrusting)
risks: FGA>SGA, those who develop acute EPSEs when inisitated on FGA, WORSENS W ANTICHOLINERGIC DRUGS onset: months/years to develop, 50% irreversible discontinue any anticholinergics, decr antipsychotic or switch to SGA (clozapine possibly effective), or reversible inhibitor of vesicular monoamine transporter 2 (VMAT2) valbenazine 40-80mg/d, or clonazepam PRN
32
mgmt of side effects: hyperprolactinemia
risks: FGA, pali>risp> other SGA decr FGA dose, dopaine agonist (eg. amantadine, bromocriptine), or switch to aripiprazole
33
mgmt of side effects: metabolic
risks: olan/cloz (high), cpz/quet/risp (moderate), ari,lura,zip,halo (low) lifestyle modification: diet or exercise, treat dm w metformin, treat hld, switch to lower risk agents
34
mgmt of side effects: cv, orthostatic hypoTN
risks: cpz, cloz > risp, pali, quet > olan, zip, ari, sulpride switch to lower risk agents - get up slowly from sitting or lying position
35
mgmt of side effects: qtc proongation
thio>cpz>zip>halo>ilo?qut?risp?olan high doses, IV halo, hypoK, IHD, female switch to lower risk agent: - >440ms for male - >470ms for female
36
mgmt of side effects: VTE/PE
low potency>SGA>FGA> high potency, air manage emergent DVT
37
mgmt of side effects: sedation
switch to lower risk agent (risp, pali,zip,ari)
38
mgmt of side effects: seizure
switch to high potency agents eg halo
39
mgmt of side effects: neuroleptic malignant syndrome - muscle rigidity, fever, incr ck
IV dantrolene 50mg TDS, oral dopamine agonist eg. amantadine, bromocriptine switch to SGA
40
pt on quet
eye exam every 6 months
41
clozapine impt but rare adr
agranulocytosis: decr absolute neutrophil and WBC count - ANC<1.5x10^9/L - WBC <3x10^9/L weekly counts for the first 6 months then every 2 weeks for next 6 months then weekly - sg: weekly for first 18 weeks then monthly
42
monitoring parameters
BMI, waist circumference, fasting blood sugar/HbA1c, lipid panel, plasma prolactin, bp, EPSE, WBC and ANC, ECG
43
ziprasidone need to monitor
ECG, qt prolongation
44
antipyschotics for breastfeedign
olanzapine, quetiapine - pt on clozapine should continue on the drug and not breastfeed
45
antipyschotics for renal impairment
oral aripiprazole preferred - avoid sulpride and amisulpride
46
antipyschotics for hepatic impairment
sulpride, amisulpride preferred
47
elderly
Avoid drugs with high propensity for a1-adrenergic blockade (orthostatic hypotension eg. cloz) or anticholinergic side effects (constipation, urinary retention, delirium); start low go slow; simplify regime; avoid adverse interactions; avoid long T½ drugs - Precaution: FGAs and SGAs reported to incr mortality and CVAs dementia patients
48
pregnancy
Olanzapine, Clozapine, to watch for gestational diabetes
49
antipsychotics may worsen what disease condition
parkinson's
50
cbz and cloz
agranulocytosis
51
time course of treatment response
Early improvements - 1st week: decr agitation, aggression, hostility - 2-4 weeks: decr paranoia, hallucinations, bizarre behaviors + improved organization in thinking Late improvements - 6-12 weeks: decr delusions, negative Sxs may improve - 3-6 months: cognitive Sxs may improve (with SGAs)
52
FGA and SGA moa
d2 antagonist in mesolimbic dop tract, improve + sx
53
SGA only moa
5ht2a anta may improve mood sx and possibly also - sx
54
SGA: -ines
clozapine, olanzapine, quetiapine: relatively more sedating, more weight gain
55
SGA: -ones or -piprazoles
risperidone, lurasidone, ziprasidone, aripiprazole: relatively less sedating, less weight gain
56
IM rapid acting
IM haloperidone or olanzapine
57
IM long actign
IM haloperidol deconate, 4-weekly dose of 200mg
58

competency 10/11 (31 decks)

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