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Flashcards in Schizophrenia Treatment Deck (57)
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1
Q

DSM-5 Criteria for Schizophrenia

A
	2 or more of the following persisting for at least 1 month:  At least one of the symptoms must be (1), (2), or (3): 
•	Delusions
•	Hallucinations
•	Disorganized Speech
•	Disorganized or catatonic behavior
•	Negative symptoms
2
Q

Other things to look for when diagnosis Schizo

A

 Level of social and/or occupational functioning has significantly declined
 Continuous signs for at least 6 months. May include prodromal or residual symptoms
 Schizoaffective or mood disorder has been excluded
 Disorder not due to a medical disorder or substance abuse
 If a development disorder is present, there must be symptoms of hallucinations/delusions for at least 1 month

3
Q

Acute Stabilization Treatment

A

Initiate antipsychotic treatment and titrate the dose every few days
If “cheeking” use liquid or orally disintegrating tablets
For severely agitate patients, consider quick actin antipsychotic by IM injection
Chemical restraining is recommended over physical

4
Q

During the first 7 days pf acute stabilization, you should see:

A

decreased agitation, hostility, anxiety, and aggression & sleep and appetite should improve

5
Q

Define cheeking

A

When a patient appears to be taking his medication, but instead places the pill inside of his cheek and spit sit out when no one is looking

6
Q

Stabilization Treatment

A

Takes 6 weeks or longer
 If no improvement is seen within 3-4 weeks or only a partial decrease in positive symptoms is observed within 12 weeks with therapeutic doses then the next treatment algorithm stage should be considered.
 Continue increasing the antipsychotic dose gradually for more symptom control if tolerated.

7
Q

Goal of treatment:

A

Achieve no or minimal positive symptoms

Negative/cognitive symptoms are less likely to remit even with appropriate treatment

8
Q

Maintenance Treatment

A

Continued treatment with antipsychotic therapy is recommended to prevent future relapses
At least 5 years but lifetime for chronically ill

9
Q

For patients experiencing their first psychotic episode –

A

A first or second generation antipsychotic other than clozapine or olanzapine is recommended.
• If the first agent is not effective, then switch to another first or second generation antipsychotic other than clozapine. Olanzapine can be considered as an option at this stage.

10
Q

For patients who have experienced more than 1 psychotic episode but they have been treatment responsive in the past-

A
  • A first or second generation antipsychotic other than clozapine is recommended.
  • If the first agent is not effective, then switch to another first or second generation antipsychotic other than clozapine.
11
Q

For treatment resistant patients

A
  • Clozapine is the recommended antipsychotic for treatment resistant patients.
  • Clozapine can be offered sooner for patients with violent behaviors or suicidality.
12
Q

Define Treatment Resistant

A

Failing 2 or more antipsychotic trials where the antipsychotic were dosed appropriately and given for an appropriate amount of time

13
Q

***Class 1 Antipsychotics

A
Chlorpromazine 
Thioridazine 
Loxapine 
Perphenazine 
Thiothixene 
Haloperidol 
Fluphenazine
14
Q

Chlorpromazine and Thioridazine have

A

low EPS and high metabolic side effects (anti-cholinergic, sedation/weight gain, low BP)

15
Q

Loxapine, perphenazine, thiothixene, haloperidol and fluphenazine all have

A

HIGH EPS but low metabolic side effects

16
Q

2nd Generation Antipsychotics

A
THE “PINES” 
Clozapine
Olanzapine
Quetiapine
Asenapine 
THE “DONES”
Risperidone
Paliperidone
Ziprasidone 
Iloperidone 
Lurasidone
THE D2 PARTIAL AGONISTS
(THE “PIPS”)
Aripiprazole
Brexpiprazole
17
Q

The Pines all show

A

Low EPS

18
Q

Ziprasidone shows

A

Low side effects overall

19
Q

Illoperidone shows

A

Low EPS

20
Q

Risperidone, Paliperidone, Lurasidone show

A

High EPS

21
Q

The PIPs show

A

Low everything but Aripiprazole has akathisia while brexpiprazole does not

22
Q

Weight Monitoring

A

Baseline then every month for 3 months and then every 3 months

23
Q

Waist Circumference Monitoring

A

Baseline and annually

24
Q

Blood pressure and FPG monitoring

A

Baseline then 12 weeks then annually

25
Q

FLP Monitoring

A

Baseline then 12 weeks then every 1-5 years

26
Q

Clozapine Counseling and Monitoring

A

o May take daily dose once daily at bedtime or may divide dose into BID dosing
o Dose must be started low and titrated gradually to avoid orthostatic hypotension. If doses are missed > 3 days then the patient needs to restart the dosing titration
o If patient becomes neutropenic (ANC

27
Q

Define Parkinsonism

A
  • Patient may experience muscle rigidity, tremor, bradykinesia, and postural instability
  • 1-2 weeks after the antipsychotic is started or after a dose increase
28
Q

Treatment of Parkinsonism

A

Anticholinergics (benztropin, diphenhydramine, trihexphenidyl)

29
Q

Define Dystonia

A

Dystonia is tonic muscle contractions. These contractions often occur in the neck and shoulder muscles
• 1-4 days after the antipsychotic is started or after a dose increase.

30
Q

Dystonia Treatment

A

Anticholinergics

31
Q

Akathisia

A

Akathisia is a constant feeling of inner restlessness. The patient may pace back and forth, shift constantly in their seat, seen tapping their feet

32
Q

Treatment of Akathisia

A

It is recommended to reduce the antipsychotic dose or use a different agent. Propranolol may be effective in reducing akathisia in some patients

33
Q

Define Tardive Dyskinesia

A

• Tardive dyskinesia is involuntary movements of the muscles. Usually the facial muscles are affected (sticking out tongue, puckering lips, lip smacking, grimacing) but it can also be observed in the extremities and truncal area in severe cases

34
Q

Treatment of Tardive Dyskinesia

A

Recommended to decrease and/or discontinue the antipsychotic and switch to an agent that has less dopamine antagonism. Symptoms will appear to worsen at first, followed by slow improvement

35
Q

Define AIMS

A

Abnormal Involuntary Movement Scale
 Clinicians should administer the scale at baseline before a new antipsychotic is started and every 3-6 months after
 Observing any abnormal movements

36
Q

Haloperidol

A

First Generation Antipsychotics
1A2
Monitor: EKG
Counsel: May take daily dose once at bedtime or divide into BID

37
Q

Fluphenazine

A

First Generation Antipsychotics
2D6
Monitor: EKG, CBC, BP
Counsel: May take daily dose once at bedtime or divide into BID

38
Q

Perphenazine

A

First Generation Antipsychotics
2D6
Monitor: EKG, CBC, BP
Counsel: BID or TID

39
Q

Loxapine

A

First Generation Antipsychotics
1A2
Monitor: EKG, BP
Counsel: May take daily dose once at bedtime or divide into BID

40
Q

Clozapine

A

Second Generation
1A2
Monitor: HR, BP, Constipation
Counsel: May take daily dose once at bedtime or divide into BID

41
Q

Olanzapine

A

Second generation
1A2
Monitor: CBC and metabolic
Counsel: QHS

42
Q

Risperidone

A

Second generation
2D6
Monitor: BP and metabolic
Counsel: May take daily dose once at bedtime or divide into BID

43
Q

Paliperidone

A

Second generation
No CYP
Monitor: BP and metabolic
Counsel: QHS

44
Q

Quetiapine

A

Second Generation
3A4
Monitor: BP and metabolic
Counsel: ER- QHS, IR- BID to TID

45
Q

Ziprasidone

A

Second Generation
3A4
Monitor: EKG
Counsel: BID, take with 500 calorie meal

46
Q

Aripiprazole

A

Second generation
2D6 and 3A4
Monitor: AIMS only
Counsel: QAM

47
Q

Iloperidone

A

Second generation
3A4 and 2D6
Monitor: BP, EKG, metabolic
Counsel: BID

48
Q

Asenapine

A

Second Generation
1A2
Monitor: EKG and metabolic
Counsel: BID sublingual

49
Q

Lurasidone

A

Second generation
3A4
Monitor: AIMS only
Counsel: QD with evening 500 calorie meal

50
Q

Brexipirazole

A
Second generation
3A4 and 2D6
Monitor: AIMS only
COunsel
QAM
51
Q

Aripiprazole IM

A

Abilify Maintena

400 mg → given once monthly – 14 day overlap

52
Q

Haloperidol IM

A

Haldol D

10-15 X → given once monthly – 1 month overlap

53
Q

Paliperidone IM

A

Invega Sustenna

234 mg → 156 mg → given once monthly – no overlap

54
Q

Olanzapine IM

A

Zyprexa Relprevv

Q2 wks x 4 doses → given once/twice monthly – none listed

55
Q

Risperidone IM

A

Risperdal Consta

given every 2 weeks – 3 week overlap

56
Q

Fluphenazine IM

A

Prolixin D

1.2 X → given weekly for 4-6 wks then every 3-6 weeks- 1 week overlap

57
Q

CATIE/CUtLASS Study

A

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS) showed no difference between second generation and first generation antipsychotics when comparing clinical outcomes such as time to discontinuation and quality of life. Both studies were federally funded.