Schizophrenia/psychosis & bipolar disorder Flashcards
(21 cards)
What are 5 extrapyramidal side effects and what can be used for prevention/treatment?
- dystonias - prolonged contraction of muscles during drug initiation
- ppx or treatment: centrally-acting anticholinergics (diphenhydramine, benztropine) - akathisia - restless with anxiety and inability to remain still
- treatment: benzos or propranolol - parkinsonism - tremors, abnormal gait, and bradykinesia, similar to Parkinson disease
- treatment: anticholinergics or propranolol if tremor is the main symptom - tardive dyskinesias (TD) - abnormal facial movements, primarily in tongue or mouth. Can be irreversible.
- treatment: must stop the drug and replace with a second-gen antipsychotic with low EPS (ex. quetiapine, clozapine) - dyskinesias - abnormal movements
What are some negative and positive s/sx of schizophrenia?
Negative
- lack of emotion (apathy)
- social withdrawal
- loss of motivation (avolition)
- lack of speech (alogia)
Positive
- hallucinations
- delusions
- disorganized thinking/behavior
What is the MOA of first-gen antipsychotics? What is 1 boxed warning? What are 6 warnings?
MOA - block dopamine-2 receptors with minimal serotonin receptor blockage
- low potency: chlorpromazine, thioridazine
- mid potency: loxapine, perphenazine
- high potency: haloperidol, fluphenazine, thiothixene, trifluoperazine
*low potency has inc. sedation and dec. EPS
**high potency has dec. sedation and inc. EPS
Boxed warings:
- increased risk of death in elderly patient with dementia-related psychosis
Warnings:
1. CV effects: QT prolongation (esp with thioridazine, haloperidol, chlorpromazine)
2. anticholinergic side effects
3. CNS depression
4. extrapyramidal symptoms
5. hyperprolactinemia (infertility, ED/decreased libido)
6. neuroleptic malignant syndrome (NMS)
What is the MOA of second-gen antipsychotics? What are the brand names of these: aripiprazole, clozapine, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone)
MOA - block D2 and serotonin receptors
aripiprazole -> Abilify
clozapine -> Clozaril
lurasidone -> Latuda
olanzapine -> Zyprexa
paliperidone -> Invega
quetiapine -> Seroquel
risperidone -> Risperdal
ziprasidone -> Geodon
What dosage forms does aripiprazole come in? What are 2 side effects?
aripiprazole is PO or IM
Side effects:
- akathisia
- activating side effects
Why is clozapine used no sooner than 3rd line? What are 3 boxed warnings? What are the common side effects? What do we need to monitor?
Clozapine is used no sooner than 3rd line because of its sever side effect potential
Boxed warnings:
1. neutropenia/agranulocytosis (REMS)
2. myocarditis and cardiomyopathy
3. seizures
Side effects:
- agranulocytosis
- seizures
- constipation
- metabolic syndrome (inc. weight, BG, lipids)
- hypersalivation
Monitor:
- ANC (must be ≥ 1500/mm^3 to start, stop therapy if < 1000mm^3)
What are 3 side effects of latuda? How is its risk of metabolic syndrome compared to other second-gens?
Side effects:
- somnolence
- EPS (dystonias)
- nausea
*decreased risk of metabolic syndrome compared to other SGAs
What is the boxed warning for Zyprexa Relprevv? What are 2 side effects of olanzapine?
Zyprexa Relprevv (injection) boxed warning:
- pts are monitored for 3 hours post-injection due to sedation and delirium (REMS)
Side effects:
- somnolence
- metabolic syndrome (increased weight, BG, and lipids)
What dosage forms does paliperidone come in? What are 3 side effects?
paliperidone can be PO or IM (Invega Trina is q3mo, Invega Hafyera is q6m)
Side effects:
- increased prolactin
- EPS (esp with higher doses)
- metabolic syndrome (increased weight, BG, lipids)
What are 2 side effects of quetiapine? What level of EPS risk does it have? Should it be taken with or without food?
Side effects:
- somnolence
- metabolic syndrome (inc. weight, BG, lipids)
Low EPS risk, often used for psychosis in Parkinson disease
Take without food or with a light meal
What dosage forms does risperidone come in? What are 3 side effects?
risperidone can be PO, IM, or SC
Side effects:
- increased prolactin
- EPS (esp. at higher doses)
- metabolic syndrome
Should ziprasidone be taken with or without food? What dosage forms does it come in? What is the contraindication?
Take WITH food
Comes in PO or IM dosage forms
Contraindicated in QT prolongation
How long is an adequate trial of an antipsychotic? Which drugs should be avoided if cardiac risk/QT prolongation risk? Which should be avoided if hx of movement disorder (ex. Parkinsons)? Which should be avoided if overweight/metabolic risk?
6 weeks is considered an adequate trial with an adequate dose.
Cardiac risk/QT prolongation: avoid ziprasidone, haloperidol, thioridazine, or chlorpromazine
Hx of movement disorder: avoid drugs with high EPS risk (ex. FGAs, risperidone, paliperidone). Quetiapine is preferred
Overweight/metbolic risk: avoid drugs that worsen this, like olanzapine or quetiapine. There is less metabolic risk with aripiprazole, ziprasidone, lurasidone, and asenapine
What are 2 medications that can be used to treat tardive dyskinesia?
valbenazine
deutetrabenazine
What is neuroleptic malignant syndrome?
Rare but highly lethal syndrome due to dopamine blockade.
Signs:
- hyperthermia
- extreme muscle rigidity
- mental status changes
- tachycardia, tachypnea, BP changes
Treatment:
- stop the antipsychotic and provide supportive care
- control pt’s temp
- relax muscles w/ benzos, dantrolene, or dopamine agonist
- after resolution of symptoms, consider a different antipsychotic
What are the treatment options for bipolar disorder?
The goal is to stabilize the mood without inducing a depressive or manic state.
- Mood stabilizers (lithium, antiepileptic drugs) treat both mania and depression without inducing either state
- Antipsychotics can help stabilize mood when mania occurs with psychosis
- Antidepressants can induce or exacerbate a manic episode when used as monotherapy, so they should only be used in combo with a mood stabilizer
Antiepileptics: lamotrigine (not for acute mania), valproate, carbamazepine
What are the acute treatment options for a manic episode or depressive episode of bipolar disorder?
Manic:
1st line - antipsychotic (olanzapine, risperidone), lithium, or valproate
- can combine antipsychotic with lithium or valproate if severe
Depressive:
1st line - antipsychotic (quetiapine, lurasidone)
- lithium, valproate, or lamotrigine can be added or used as alternatives
What is lithium’s MOA? What is the goal therapeutic range? What is 1 warning? What are the side effects within therapeutic range and what are side effects in toxicity? What 3 things should we monitor? Can lithium be used in pregnancy?
MOA - influences the reuptake of serotonin and/or norepinephrine or by moderating glutamate levels in the brain (glutamade is the primary excitatory neurotransmitter, so high levels could case mania)
Goal therapeutic range: 0.6-1.2 mEq/L trough
Warning: serotonin syndrome
Side effects:
- therapeutic range: GI upset, cognitive effects, cogwheel rigidity, tremor, thirst, weight gain, hypothyroidism
- >1.5 mEq/L: ataxia, coarse hand tremor, vomiting
- > 2.5 mEq/L: CNS depression, arrhythmia, seizure, coma
Monitoring:
1. lithium levels
2. renal fx (renally cleared)
3. thyroid fx
Do not use in pregnancy (or breast feeding)!! associated with cardiac malformations
What can increase lithium levels (2)? What can decrease lithium levels (1)?
Increase levels:
- decreased salt intake/sodium loss (w/ ACE-i or ARB, thiazides)
- NSAIDs
Decrease:
- increased salt intake
What are the conversions of lithium between lithium citrate syrup to lithium ion to lithium carbonate tabs/caps?
5mL lithium citrate syrup = 8 mEq of lithium ion
8 mEq of lithium ion = 300mg lithium carbonate tabs/caps
What is the safest option to treat bipolar disease in pregnancy?
Lamotrigine is the safest option relative to the other mood stabilizers.
Second-gen antipsychotics are safer than valproate, carbamazepine, and lithium. Lurasidone has the most favorable safety profile in pregnancy, but can only be used for bipolar depression.
