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Schizophrenia and Other Psychotic Disorders Flashcards

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1
Q

What are some positive symptoms?

A
  • Hallucinations
  • Paranoia
  • Delusions
  • Hostility
  • Disorganized speech
  • Ideas of reference
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2
Q

What are some negative symptoms?

A
  • Affect
  • Alogia
  • Avolition
  • Asociality
  • Anhedonia
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3
Q

Mesolimbic path of dopamine hypothesis

A
  • VTA–>
  • nucleus accumbens–>
  • D2 blockade–>
  • decrease in positive symptoms
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4
Q

Mesocortical path of dopamine hypothesis

A
  • VTA–>
  • Prefrontal cortex–>
  • D2 blockade–>
  • Increase in negative symptoms
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5
Q

Nigrostriatal path of dopamine hypothesis

A
  • SN–>
  • Basal ganglia–>
  • D2 blockade–>
  • Increase in EPS
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6
Q

Tuberoinfundibular path in dopamine hypothesis

A
  • Hypothalamus–>
  • Pituitary–>
  • D2 blockade
  • Increase in prolactin
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7
Q

What are some factors to consider when selecting a treatment?

A
  • Side effect profile
  • Past responses to treatment (symptom response and tolerability)
  • Physical health conditions that may be affected by medication side effects
  • Medication formulations
  • Drug-drug interactions
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8
Q

What are the antipsychotic treatment response in hours to days?

A
  • Agitation
  • Aggression
  • Motor activity
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9
Q

What are the antipsychotic treatment response in 2 to 6 weeks?

A
  • Hallucinations
  • Disorganized thinking
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10
Q

What are the antipsychotic treatment response in months or longer?

A
  • Delusions
  • Negative symptoms
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11
Q

What are the side effects of serotonin receptor antagonism?

A
  • Reduces EPS
  • Possibly improve cognition
  • Antidepressant properties
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12
Q

What are the side effects of dopamine-D2 receptor antagonism?

A
  • Therapeutic effect
  • Extrapyramidal symptoms
  • Hyperprolactinemia
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13
Q

What are the side effects of muscarinic-M1 receptor antagonism?

A
  • Anticholinergic effects (dry mouth)
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14
Q

What are some histamine-H1 receptor antagonism?

A
  • Sedation
  • Weight gain
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15
Q

What are the side effects of alpha 1 receptor antagonism?

A
  • Syncope
  • Orthostatic hypotension
  • Reflex tachycardia
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16
Q

What are some clinical pearls of haloperidol?

A

-IM:PO 1:2

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17
Q

What are some clinical pearls of fluphenazine?

A

-IM:PO 1:2
-Oral liquid should be diluted prior to use

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18
Q

What are some clinical pearls of chlorpromazine?

A

-Weight gain
-Sedation
-IM:PO 1:4

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19
Q

What are some clinical pearls of thiothixene?

A
  • Smoking may reduce levels (CYP1A2 induction)
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20
Q

What are some clinical pearls of thioridazine?

A
  • Highest QTc prolongation risk
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21
Q

What are some clinical pearls of trifluoperazine?

A
  • Smoking may reduce levels (CYP1A2)
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22
Q

What are the long-acting formulations of the first generation antipsychotics?

A
  • Haloperidol
  • Fluphenazine
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23
Q

Dystonia

A
  • EPS symptoms
  • Within 24-96 hours of initiation
  • Involuntary muscle contraction resulting in slow repetitive movements or abnormal postures
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24
Q

What is the presentation of dystonia?

A
  • Facial grimacing
  • Involuntary upward eye movement
  • Muscle spasms of the tongue, face, neck, and back (back muscle spasms cause trunk to arch forward)
  • Laryngeal spasms
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25
What are the risk factors of dystonia?
* High potency antipsychotics * High antipsychotic dose * Young men
26
What are the treatments of dystonia?
* Diphenhydramine 25-50 mg IM/IV * Benztropine 1-2 mg IM/IV
27
Akathisia
* EPS symptoms * **Days to weeks** * Inner motor restlessness
28
What are the presentations of akathisia?
* Restlessness * Trouble standing still * Paces the floor * Feet in constant motion * Rocking back and forth
29
What are the risk factors of akathisia?
* fast titration * middle-aged females
30
What are the treatment options of akathisia?
* Propranolol 20-120 mg/day * Anticholinergic agent * Benzodiazepine
31
Pseudoparkinsonism
* EPS symptoms * Days to weeks * Parkinsonian like symptoms
32
What are the presentations of Pseudoparkinsonism?
* Stooped posture * Shuffling gait * Rigidity * Bradykinesia * Tremors at rest * Pill-rolling motion of the hand
33
What are some risk factors of pseudoparkinsonism?
* High potency antipsychotics * High dose * Older age * Females
34
What are some treatment options of pseudoparkinsonism?
* Benztropine 1-6 mg/day or trihexyphenidyl 5-15 mg/day * Diphenhydramine 35-300 mg/day--> amantadine 100-400 mg/day
35
Dyskinesia
* EPS symptoms * **Months to years** * Rapid, repetitive involuntary movements
36
What are some presentations of dyskinesia?
* Protrusion and rolling of the tongue * Sucking and smacking movement of the lips * Chewing motion * Facial dyskinesia * Involuntary movements of the body and extremities
37
What are some risk factors of dyskinesia?
* Older age * Females * Other EPS especially early onset * Chemical abuse * Mood disorders
38
What are some treatment options of dyskinesia?
VMAT inhibitors, switch to clozapine, pyridoxine 400-1200 mg/day
39
What are some long acting injections of the second generation antipsychotics?
* Aripiprazole * Olanzepine * Paliperidone * Risperidone
40
What are some clinical pearls of Quetiapine?
* XL formulation dosed once daily (IR dosed BID to TID) * **XL formulation: < 300 calories** * Sedation (XL formulation may assist)-- take at bedtime
41
What are some clinical pearls of Olanzepine?
* High metabolic risk * **Do not give IM olanzapine within 2-hours of IM lorazepam due to risk of cardiorespiratory depression and excessive sedation** * Smoking (smoke hydrocarbons) induces CYP 1A2 metabolism by ~30%
42
What are some clinical pearls of Risperidone?
* Strong D2 affinity * Renal dose adjustments - CrCl 30-60 mL/min: 75% max dose - CrCl 10-30 mL/min: 50% max dose - CrCl < 10 mL/min: 25% of max dose * **Hyperprolactinemia risk (gynecomastia, galactorrhea, amenorrhea, sexual dysfunction)**
43
What are the clinical pearls of paliperidone?
* Active metabolite of risperidone * Renal dose adjustments - CrCl 50-80 mL/min: 6 mg/day - CrCl 10-50 mL/min: 3 mg/day - CrCl < 10 mL/min: avoid use * Hyperprolactinemia * Increased bioavailability when given with food * Ghost tablet (shell in stool)
44
What are the clinical pearls of aripiprazole?
* Activating at low doses * Low risk of weight gain * Dose adjustments for major CYP3A4/2D6 * May assist in antipsychotic-induced hyperprolactinemia
45
What are the clinical pearls of brexipiprazole?
* Renal dose adjustment: max 3 mg if CrCl < 60 mL/min * Dose adjust in moderate/severe hepatic impairment * Dose adjustments for major CYP3A4/2D6 inhibitors * Treats in **agitation associated with Alzheimer’s dementia**
46
What are the cariprazine?
* Avoid in CrCl < 30 mL/min * Take with 350 calories * Dose adjustments for CrCl < 50 mL/min and hepatic impairment * Low weight gain risk
47
What are the clinical pearls of ziprasidone?
* Take with 500 calories * QT prolongation (particularly with IM formulation) * Low weight gain risk
48
What are the clinical pearls of iloperidone?
Significant orthostasis – titrate by no more than 4 mg/day
49
What are the clinical pearls of Pimavanserin?
* Dosing 34 mg/day * Indication: Parkinson’s Disease
50
What are the clinical pearls of Asenapine?
* SL tablet: no food/drink for 10 minutes after taking * Contraindicated in severe hepatic impairment
51
What are the clinical pearls of Lumateperone?
* Only one dose available (42 mg) * Take with food * Dose adjustment in moderate/severe hepatic impairment (max 21 mg/day)
52
What are criterias for metabolic syndrome: * Waist circumference * BP * Fasting blood glucose * HDL * Triglycerides
* Waist circumference: -M: > 40 inch -F: >35 inch * BP: - > or equal to 130/85 * Fasting blood glucose: - > or equal to 110 mg/dL * HDL - M: < 40 mg/dL - F: < 50 mg/dL * Triglycerides - > or equal to 150 mg/dL
53
What are the black box warnings of clozapine?
* Severe neutropenia (REMS) * Seizure * Myocarditis * Orthostatic hypotension, bradycardia, syncope * Increased mortality in elderly patients with dementia-related psychosis
54
What is the starting dose of clozapine?
12.5 mg once or twice daily
55
How do you monitor clozapine?
* Clozapine level: 350-500 ng/mL * Clozapine:norclozapine ratio * Measured as trough
56
What are some REMS monitoring factors of Clozapine?
* Absolute Neutrophil Count (ANC) ≥ 1500/uL before initiating * ≥ 1000/uL with benign ethnic neutropenia (BEN)/Duffy-null associated neutrophil count * Monitoring schedule: Weekly x 6 months; biweekly x 6 months; monthly
57
Recommendation for mild neutropenia (1000- 1499) in clozapine
* Monitor 3x/week * Resume normal schedule once ANC > 1500/uL
58
Recommendation for moderate neutropenia (500-999) in clozapine
* Interrupt therapy * Daily ANC until > 1000/uL (may resume), then 3x week until ANC ≥ 1500/uL * Return to previous monitoring interval when ANC > 1500/uL
59
Recommendation for severe neutropenia (<500) in clozapine
* Interrupt therapy * Daily ANC until > 1000/uL, then 3x week until ANC ≥ 1500/uL * Do NOT rechallenge unless prescriber determines benefit outweighs the risks * If rechallenged, resume treatment as new patient under ‘normal range’ monitoring once ANC ≥ 1500/uL
60
What are some titration-dependent adverse effects of clozapine?
* Orthostatic * Tachycardia * Sedation * Myocarditis
61
What is the level/dose-dependent adverse effect?
Seizures
62
What is the dose-independent adverse effects?
* Sialorrhea * Constipation * Urinary incontinence * Seizures
63
What is the treatment for sialorrhea?
* Atropine eye drops SL * Ipratropium nasal spray SL * Glycopyrrolate, benztropine, clonidine
64
What is the treatment of constipation?
* Osmotic laxatives (Miralax) * Stimulant laxatives (Senna) * Stool softeners (Colace)
65
What are the symptoms of Neuroleptic Malignant Syndrome (NMS)?
* Fever * Lead-pipe rigidity * Mental status changes * Leukocytosis, elevated creatinine kinase, AST/ALT
66
How do you manage Neuroleptic Malignant Syndrome?
Discontinue antipsychotic (for at least 2 weeks) --> No other psychotropic during 2-week time period (except benzodiazepines) --> Bromocriptine (Cycloset®) and dantrolene (Dantrium®)
67
How do you treat psychotic agitation?
* Haloperidol * Fluphenazine * Chlorpromazine * Olanzapine * Ziprasidone
68
What are the pros of long-acting injectable antipsychotics (LAIA)?
* Fewer medications to take daily * Fewer Cmax related events * Aware of nonadherence * Longer interventions windows * Continuous coverage * Closer follow-up
69
What are the cons of long-acting injectable antipsychotics?
* Limited dose titration * Time, logistics, cost * Fear of needles * Inability to change course * Concerns about side effects
70
Haloperidol
* Schizophrenia * Dose Frequency: every 4 weeks * Oral overlap/load:Decrease ½ daily dose every 3 weeks -NOT required if loaded
71
Fluphenazine Decanoate (Prolixin)
* Psychotic disorder * Dose frequency: Every 2-3 weeks * Dose Overlap/load: decrease 1/2 daily dose every 2 weeks

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