Schizophrenia Flashcards
(100 cards)
1
Q
age of onset
A
late teens to early thirties
earlier in men
2
Q
what does positive symptoms mean
A
abnormally PRESENT:
hallucination, paranoia, delusion, hostility, disorganized speech, ideas of reference
3
Q
what does negative symptoms mean
A
abnormally ABSENT
affect, alogia, avolition, asociality, anhedonia
the five As
4
Q
other symptoms of schizophrenia
A
attention and memory deficits, poor hygiene, poor psychosocial function
5
Q
dopamine hypothesis
A
brain of a patient with schizophrenia produces more dopamine than a typical brain
6
Q
mesolimbic pathway effects of D2 blockade
A
decrease in positive symptoms
7
Q
mesocortical pathway effects of D2 blockade
A
increase in negative symptoms
8
Q
nigrostriatal pathway effects of D2 blockade
A
increase in EPS
9
Q
tuberoinfundibular pathway effects of D2 blockade
A
increase in prolactin
10
Q
differential diagnosis: things to rule otu
A
meds (dopa agonists, steroids, overdose, withdrawal, hallucinogens)
medical conditions like thyroid, infectious, epilepsy, wilson’s disease, SLE
11
Q
goals of therapy
A
reduce/eliminate symptoms
promote/maintain recovery
reduce medication adverse effects
improve QOL
12
Q
APA recommendations
A
treat with an antipsychotic and monitor for effectiveness and side effects. no evidence that one antipsychotic is superior to another (except clozapine)
13
Q
when do you qualify for clozapine
A
after 2 failed trials of a FGA or SGA
14
Q
factors to consider when selecting treatment
A
side effect profile, past response, health conditions, med formulations, drug interactions
15
Q
antipsychotic response seen in hours to days
A
agitation, aggression, motor activity
16
Q
antipsychotic response seen in 2-6 weeks
A
hallucinations
disorganized thinking
17
Q
antipsychotic response seen in months or longer
A
delusions
negative symptoms
18
Q
receptor targets
A
D2, M1, H1, alpha1, serotonin
19
Q
effects of D2 receptor antagonism
A
therapeutic
EPS
hyperprolactinemia
20
Q
effects of M1 receptor antagonism
A
anticholinergic
21
Q
effects of H1 receptor antagonism
A
weight gain, sedation
22
Q
effects of alpha1 receptor antagonism
A
syncope, orthostatic hypotension, reflex tachycardia
23
Q
effects of serotonin receptor antagonism
A
reduce EPS, improve cognition, antidepressant
24
Q
what is the optimal occupancy of D2 receptors
A
60-80%
25
general adverse effects of FGAs
extrapyramidal: akathisia, parkinsonism, dystonia, tardive dyskinesia
26
general adverse effects of SGAs
metabolic
27
FGAs
haloperidol
fluphenazine
trifluoperazine
thiothixene
loxapine
perphenazine
thioridazine
chlorpromazine
28
FGAs are characterized by
strong D2 affinity
29
low potency FGAs
chlorpromazine, thioridazine
30
high potency FGAs
haloperidol
fluphenazine
thiothixene
trifluoperazine
loxapine
perphenazine
31
implications of low potency FGAs
need a higher dose to get the D2 blockade
anticholinergic, sedation, orthostasis
32
implications of high potency FGAs
stronger D2 antagonism so stronger EPS
33
haloperidol pearls
IM:PO 1:2
34
fluphenazine pearls
IM:PO 1:2, dilute oral liquid prior to use
35
chlorpromazine pearls
weight gain, sedation (less potent)
IM:PO 1:4
36
thiothixene and trifluoperazine pearls
smoking may reduce levels due to CYP1A2 induction from hydrocarbons in cigarette smoke
37
thioridazine pearls
highest Qt prolongation risk
38
which FGAs have long acting injection forms
haloperidol and fluphenazine
39
describe dystonia
happens within 24-96 hours, involuntary muscle contraction results in slow repetitive movements or abnormal postures
40
dystonia risk factors
high potency antipsychotics, high dose, young men
41
dystonia treatment
diphenhydramine, benztropine
consider dose reduction
42
describe akathisia
happens within days to weeks, inner motor restlessness
43
akathisia risk factors
fast titration, middle aged females
44
akathisia treatment
propranolol, anticholinergic, benzodiazepine, consider dose decrease/medication change
45
describe pseudoparkinsonism
happens within days to weeks, stooped posture, shuffling gait, rigid, tremors, pill rolling hand motion
46
pseudoparkinsonism risk factors
high potency antipsychotics, high dose, older age, females
47
pseudoparkinsonism treatment
benztropine, diphenhydramine, amantadine, consider dose decrease
48
describe dyskinesia
months to years, rapid, repetitive, involuntary movements such as rolling tongue, smacking lips, chewing
49
dyskinesia risk factors
older age, females, other EPS, chemical abuse, mood disorders
50
dyskinesia treatment
VMAT inhibitors
switch to clozapine
pyridoxine
weak: ginko, clonazepam, amantadine
51
SGAs
aripiprazoke, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone
52
which SGAs have long acting injection forms
aripiprazole, olanzapine, paliperidone, risperidone
53
quetiapine pearls
sedation: dose at bedtime
XL formation once daily, <300 calories
54
olanzapine pearls
high metabolic risk
smoking induces CYP1A2 metabolism
do not give IM olanzapine within 2 hours of IM lorazepam (cardiorespiratory depression, excessive sedation)
55
risperidone pearls
strong D2 affinity
renal dose adjustments
hyperprolactinemia risk
56
paliperidone pearls
active metabolite of risperidone
renal dose adjustments
hyperprolactinemia
increased bioavailability with food
ghost tablet (shell of tablet in poop)
57
aripiprazole pearls
activating at low dose
low risk weight gain
dose adjustments for CYP inhibitors/inducers
may assist in antipsychotic-induced hyperprolactinemia
58
brexpiprazole pearls
renal dose adjust, hepatic dose adjust, CYP dose adjust
59
cariprazine pearls
avoid CrCL<30
60
lurasidone pearls
take with 350 calories
renal/hepatic dose adjust
low weight gain risk
61
ziprasidone pearls
take with 500 calories
QT prolongation (especially IM)
low weight gain risk
62
iloperidone pearls
significant orthostasis-- titrate by no more than 4 mg/day
63
pimavanserin pearls
no D2 activity
only used in Parkinson Disease Psychosis
64
asenapine pearls
SL tablet: no food/drink for 10 mins
contraindicated in severe hepatic impairment
65
lumateperone
take with food
dose adjust in hepatic impairment
66
metabolic syndrome criteria
must meet at least 3 criteria:
waist circumference >40 inches male, 35 female
triglycerides >150
HDL <40 male, 50 female
fasting blood glucose >110
BP>130/85
67
SGAs with highest risk of EPS, hyperprolactinemia
risperidone, paliperidone
68
SGAs with highest risk of seizures, anticholinergic
clozapine, olanzapine
69
SGA with highest risk of orthostatic hypotension, sedation, weight gain, increased blood glucose, lipid abnormalities
clozapine
70
5 black box warnings for clozapine
severe neutropenia
seizure
myocarditis
orthostatic hypotension, bradycardia, syncope
increased mortality in elderly patients with dementia related psychosis
71
what is the black box warning on ALL antipsychotics
increased mortality in elderly patients with dementia related psychosis
72
what is REMS monitoring requirement for clozapine
severe neutropenia, agranulocytosis
73
how is clozapine dosed (starting and titration)
start at 12.5 mg once or twice daily
increase by 25-50 mg/day inpatient or per week outpatient
74
what do do if you missed a dose of clozapine for >48 hours
re-initiate with 12.5-25 mg/day
75
what is the risk with missing clozapine doses
hypotension, bradycardia, syncope
associated with the alpha antagonism & building a tolerance to it
76
therapeutic drug monitoring for clozapine: what is the target trough level
350-500 ng/mL
but really we are targeting how they respond, not an exact level
77
what must the ANC count be before initiating clozapine
>1500
78
what is the ANC monitoring schedule for clozapine
weekly x 6 months
biweekly x 6 months
then monthly
79
what is the recommendation for clozapine if ANC 1000-1499 (mild neutropenia)
monitor 3x/week and resume normal schedule once ANC >1500
80
what is the recommendation for clozapine if ANC 500-999 (moderate neutropenia)
interrupt therapy and monitor daily ANC until >1000 (may resume at this point)
then monitor 3x/week until ANC>1500
81
what is the recommendation for clozapine if ANC <500 (severe neutropenia)
interrupt therapy & do not rechallenge unless prescriber determines benefit outweighs risk
daily ANC until >1000 then 3x/week until >1500
82
what are TITRATION-DEPENDENT adverse effects of clozapine
orthostasis
tachycardia
sedation
myocarditis
83
what are DOSE-DEPENDENT adverse effects of clozapine
seizures
84
what are DOSE-INDEPENDENT adverse effects of clozapine
sialorrhea (drooling), constipation, urinary incontinence
85
how can you treat sialorrhea with clozapine?
atropine eye drops SL or ipratropium nasal spray SL
glycopyrrolate, benztropine, clonidine
86
how can you treat constipation with clozapine?
osmotic laxatives (miralax), stimulant laxatives (senna(, stool softeners (colace)
87
how can you treat seizures with clozapine?
seizure prophylaxis when levels reach >1000 mcg/L
88
what is neuroleptic malignant syndrome?
rare life-threatening syndrome that involves fever, lead-pipe rigidity, mental status changes, leukocytosis, elevated creatinine kinase, AST/ALT
89
how is neuroleptic malignant syndrome managed?
-straight to the hospital
-discontinue antipsychotic for at least 2 weeks
-no other psychotropic (except benzos) for 2 weeks
-bromocriptine and dantrolene
90
when to use caution with antipsychotics for QT prolongation
pre-existing abnormalities, other QT prolonging agents, patients with baseline QT ~500
91
monitoring for QT prolongation?
baseline & annual EKG, K+, Mg2+
92
which antipsychotics cause the most QT prolongation
thioridazine, ziprasidone
93
which antipsychotics are used for acute psychotic agitation
haloperidol
fluphenazine
clorpromazine
olanzapine
ziprasidone
risperidone, aripiprazole
94
what agents are used for anxiety-related agitation
benzos like lorazepam*, diazepam
non-benzo hydroxyzine
* note separate IM olanzapine and IM lorazepam by at least 2 hours
95
which agents are used for extrapyramidal symptoms and sedation for acute agitation?
benztropine, diphenhydramine
96
what are the key principles to initiation of LAIAs
establish oral tolerability first
screen for dose adjustments/contraindications to LAIA
identify if loading dose or oral overlap needed
determine maintenance dose & frequency
97
which FGAs are available as injectables
haloperidol decanoate and fluphenazine decanoate
98
which SGAs are available as injectables
aripiprazole
olanzapine
paliperidone
risperidone
99
are there any allergy considerations for LAIAs
fluphenazine decanoate and haloperidol decanoate are suspended in sesame oil-- check for sesame allergy
100
which LAIA has a rems program?
olanzapine pamoate: for post-injection delirium/sedation syndrome, increased mortality in elderly patients with dementia-related psychosis
MUST OBSERVE FOR AT LEAST 3 HOURS AFTER INJECTION, BE ACCOMPANIED UPON LEAVING FACILITY
aka a lot of paperwork
