Schizophrenia/Psychosis Flashcards
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Extrapyramidal side effects: include ___________
Dystonias:
Akathisia:
Parkinsonism:
Tardive dyskinesias (TD):
Dyskinesias:
Dystonias:
painful muscle contractions
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Akathisia:
restlessness, inability to remain still.
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Parkinsonism:
Tardive dyskinesias (TD):
repetitive, involuntary movements (such as, grimacing and eye blinking)
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Dyskinesias:
abnormal movements
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Schizophrenia is ___________
- a chronic, severe mental illness and disabling thought disorder that occurs in ~1% of all societies regardless of class, color, religion or culture.
- it has the highest rate of suicide of the psych conditions
- a person loses much of the ability to think clearly, manage emotions, make decisions and relate to others
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Disorganized thinking/behavior: inability to focus attention and communicate organized thoughts.
Delusions: a belief about something real that is not true, such as imaging that your family (which is real) wishes to hurt you (delusion)
Hallucinations: sensing something that is not present, such as imaginary voices.
Diagnosis of Schizophrenia:
- is NOT based on lab tests/results but on _____1______, which includes both ____2___ and ______3_____.
1) behavior
2) negative signs & symptoms
3) positive signs & symptoms
The ___________________ sets the diagnostic criteria for psychiatric conditions.
DSM-5
Schizophrenia’s pathophysiology is _________1_____ and includes altered brain structure and chemistry, primarily involving ______2______, ____3_____and ____4___
With Schizophrenia, we see increased levels of __________ which causes the ___________ symptoms
1) multifactorial
2) dopamine
3) serotonin
4) glutamine
dopamine
positive
Increased dopamine levels, and can have changes in
glutamate levels
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Hallucinations: Sensing something that is not present, such as imaginary voices
Delusions: a belief about something real that is not true, such as imagining that your family (which is real) wishes to hurt you (delusion)
- “take something that is actually there and misinterpret what it actually represents.”
Disorganized thinking/behavior: inability to focus attention and communicate organized thoughts.
Difficulty paying attention
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Lack of speech (alogia)
Loss of motivation (avolition)
Social withdrawal
Lack of emotion (apathy)
Poor hygiene
Loss of interest in everyday activities (anhedonia)
Inability to plan or carry out activities.
antipsychotics can effectively treat ______________.
antipsychotics primarily block ___________________.
positive signs & symptoms
dopamine receptors. (Newer antipsychotics also block serotonin)
The negative symptoms (lack of motivation, cognitive and functional impairment) are more difficult to treat.
Decreasing dopamine activity helps control ______1____, but negatively affects dopamine pathways involved in _____2_______
1) psychosis
2) focus, attention and movement
Parkinson medications increase _____1____ in the brain, which relieves the ___2___ symptoms.
Having increased ______3____ can trigger hallucinations or delusions.
1) dopamine
2) motor
3) dopamine
Medications/Recreational drugs that can cause Psychotic symptoms:
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Anticholinergics (centrally-acting, high doses)
Dextromethorphan
Dopamine or dopamine agonists - (Requip, Mirapex, Sinemet)
Interferons
Stimulants, especially if already at risk (includes amphetamines)
Systemic steroids (typically with a lack of sleep - ICU psychosis)
*Illicit/recreational substances
Bath Salts
Cannabis
Cocaine
Meth
PCP - phencyclidine
LSD - Lysergic acid diethylamide
Currently ____________________ are used first line due to a lower incidence of extrapyramidal symptoms.
(SGA) second generation antipsychotics
(FGA) First Generation Antipsychotics have a high incidence of extrapyramidal symptoms, including painful:
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dystonias (muscle contractions)
dyskinesias (abnormal movements)
tardive dyskinesias (repetitive, involuntary movements, such as grimacing and eye blinking)
akathisia (restlessness, inability to remain still)
______________can be irreversible; the drug causing ____ should be discontinued.
tardive dyskinesia (TD)
TD
Adherence to antipsychotics is _________, primarily due to lack of insight (inability of the patient to recognize the illness).
Formulations are used to increase adherence and help when dysphagia (difficulty swallowing) is present.
poor
Which antipsychotics come as a long-acting injection? and what are there frequencies?
what is the benefit with this dosing form?
Haldol Decanoate (every 4 weeks)
Risperdal Consta (every 2 weeks)
Invega Sustenna (every 4 weeks), Invega Trinza (every 3 months)
Abilify Maintena (every 4 weeks), others
eliminate the need for daily oral tablets or capsules.
which antipsychotics are available as an ODT?
what is the benefit with this dosing form?
- Abilify Discmelt
- Clozapine Fazaclo
- Risperdal M-tab
- Zyprexa Zydis
- Saphris (sublingual)
are useful with dysphagia (difficulty swallowing) and prevents cheeking (when tablets are hidden inside the cheek and spit out later)
ODTs dissolve quickly in the mouth, also cause less nausea
Which antipsychotics come as an oral solution/suspension?
what is the benefit with this dosing form?
are useful for children and people with a feeding tube
which antipsychotics come as an acute FAST-Acting IM injection?
what is the benefit with this dosing form?
- Haloperidol
- Fluphenazine
- Zyprexa
- Geodon
provide “stat” relief to calm down an agitated, psychotic patient for their own safety and the safety of others.
olanzapine AND _____________ SHOULD NOT be given together (in an injection) due to risk of excess sedation and breathing difficulty.
benzodiazepines
IM antipsychotics are often mixed with other drugs (in cocktails) such as benzodiazepines for anxiolytic/sedative effects, and __________ to reduce ______
anticholinergics
dystonias
Haldol cocktail contains:
haloperidol
lorazepam
diphenhydramine
Boxed Warning for Antipsychotics:
— 1
All Antipsychotics also carry a warning for _____2_____
1) Are NOT indicated for Agitation control in elderly patients with dementia-related psychosis! There is an increased risk of mortality when used for this purpose, mostly due to cardiovascular conditions (heart failure, sudden death) and infection.
2) falls
Several antipsychotics also carry a warning for an increased risk of ________ in patients with dementia
stroke
First Generation Antipsychotics (FGAs): work mainly by ______1_____.
Many of the (FGA) are in the _____1_______ class; they can be easily recognized because their names end in “azine”.
1) blocking dopamine-2 receptors (D2-receptors) with minimum serotonin (5-HT2A) receptor blockade.
“dopamine antagonists”
2) phenothiazine
Highest QT prolongation:
Higher risk TdP with Low potassium and magnesium.
Thioridazine (highest QT risk) > Haloperidol > Ziprasidone (lower risk than Haldol)
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Chlorpromazine LOW potency
Thioridazine LOW potency
Loxapine (Adasuve) MID potency
Perphenazine MID potency
Haloperidol (Haldol) HIGH potency
Fluphenazine HIGH potency
Thiothixene HIGH potency
Trifluoperazine HIGH potency
First Generation Antipsychotics (FGA):
High Potency FGAs, such as haloperidol, are associated with a HIGH RISK OF EPS EFFECTS, a moderate risk of sedation and a lower risk of orthostatic hypotension, tachycardia, and anticholinergic effects compared to low-potency FGAs.
First Generation Antipsychotics (FGA):
In contrast,
Low potency FGAs are associated with a LOWER RISK OF EPS EFFECTS, a high degree of sedation and a HIGH risk of cardiovascular effects (orthostatic hypotension, tachycardia) and anticholinergic effects.
When we talk about EPS, this includes 3 things:
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1) dyskinesia’s = abnormal movements
2) dystonic
- anyone can have dystonic reactions when taking antipsychotics
- younger adults at higher risk, usually antipsychotic is given with a centrally acting anticholinergic like benztropine or Benadryl to prophylaxis dystonic reactions
3) tardive dyskinesia’s
- big deal with FGAs and risperidone and paliperidone SGA
- anyone can get TD when taking antipsychotics, risk is higher in elderly
- common symptom in TD: buckle lip smacking, weird movements with tongue
- discontinue offending agent, the longer the patient has TD symptoms the more likely it can become irreversible
