Schizophrenia- Treatment Regimens

Question 1

Goal of non-pharm treatment for schizo

Answer 1

Set realistic goals and time course for target symptom response, avoidance of relapse, increasing function and integration back into the community

Also avoiding as many side effects as possible

Question 2

Non-pharm treatment for schizo should be used when?

Answer 2

Add-on therapy to medications

Question 3

Non-pharm treatment options

Answer 3

Psychosocial rehab
Psychoeducation
Targeted cognitive therapy
Active community treatment (ACT)
Therapeutic alliance
Comprehensive care in a multidisciplinary environment that offers psychological services in addition to psychotropic medication management

Question 4

What should drive the choice of choosing a schizo medication?

Answer 4

Side effect profiles, drug interactions, adherence, family history, cost

Question 5

How many schizo meds should a patient ideally be on?

Answer 5

One whenever possible, combinations only for the most treatment-resistant (and even that is kind of iffy because there’s no evidence to support APS polypharmacy)

Question 6

Schizo treatment considerations: stabilization and maintenance

Answer 6

May take 6-12 weeks to see improvements, but chronically ill patients may take 3-6 months

Question 7

What should partial responders be evaluated for?

Answer 7

Adherence and other confounding conditions

Question 8

Length of treatment for first episode of schizo

Answer 8

Continue therapy for an additional 12 months

Question 9

What is treatment-resistant schizo defined as?

Answer 9

Lack of improvement with at least 2 APs from different classes at an optimal dose for at least 8 weeks

Question 10

What happens if you need to D/C a schizo med and start another one?

Answer 10

Taper off the old one while slowly titrating up the new one

Question 11

Augmentation and combination strategies for schizo

Answer 11

Non-APS agents with mood stabilizer, ECT, and/or ziprasidone with clozapine

Question 12

What happens if a prescriber escalates a schizo med rapidly and above the FDA MDD?

Answer 12

Recommend the use of IM medication for initial rapid relief of symptoms and limit the time over the MDD to 2-4 weeks and evaluate the patient

DOCUMENT EVERYTHING!

Question 13

What happens if you mix a FGA and SGA?

Answer 13

The SGA’s effects may cancel out

Question 14

Treatment algorithm: Stage 1

Answer 14

Figure out if the patient is treatment naïve or previously treated, treat them, and check back in 2-4 weeks

Question 15

Stage 1 of the algorithm: treatment naïve

Answer 15

Give them any AP except clozapine or olanzapine

Question 16

Stage 1 of the algorithm: previously tried a med

Answer 16

Give then anything except clozapine or the med(s) that didn’t work for them

Question 17

Treatment algorithm: Stage 2

Answer 17

Happens 2-4 weeks after Stage 1 if nothing in Stage 1 worked

Question 18

Stage 2: what do you do when a med from Stage 1 doesn’t work?

Answer 18

Give them any other APS not used already except for clozapine (yes, you can use olanzapine) and check back again in 2-4 weeks

Question 19

Stage 2: exception for clozapine

Answer 19

You can use it if the patient is severely suicidal, has EPS, or a history of violence of substance abuse

Question 20

Treatment algorithm: Stage 3

Answer 20

2-4 weeks after Stage 2 when those meds don’t work

Question 21

Stage 3: What to do if Stage 2 medication fails?

Answer 21

Clozapine monotherapy, check back in 2-4 weeks

Question 22

Treatment algorithm: Stage 4

Answer 22

2-4 weeks after Stage 3 when clozapine monotherapy doesn’t work

Question 23

Stage 4: what happens if clozapine monotherapy doesn’t work from Stage 3?

Answer 23

Try other APs, augmentation with mood stabilizers, polypharmacy, ECT

Question 24

What should you always do throughout schizo treatment with a patient?

Answer 24

Assess their adherence!

Question 25

When can LAIs be used?

Answer 25

Any point during Stages 2-4 if the patient has poor adherence

Question 26

Before starting a LAI, what should you make sure of regarding adherence?

Answer 26

That the patient’s poor adherence isn’t due to the side effects

Question 27

Best practice before starting a LAI

Answer 27

PO challenge of the same drug to make sure there’s not an allergy

Question 28

Newer LAI agents are what: aqueous or oil-based diluents?

Answer 28

Aqueous, they’re physiologically similar to body tissues

Question 29

Do LAIs take immediate effect?

Answer 29

Most of them don’t

Question 30

What to do with LAIs and PO meds

Answer 30

Do a PO overlap while starting the LAI, most LAIs will take at least a week or two to work

Question 31

Schizo treatment of special populations: elderly

Answer 31

Use lowest effective dose, use caution for renal and hepatic impairment

More likely to experience orthostasis and increased fall risk

Question 32

Schizo treatment of special populations: pregnancy/lactation

Answer 32

Lowest effective dose, higher doses for clozapine and olanzapine may be needed

Recommend to continue current therapy if effective

Question 33

Schizo treatment of special populations: peds

Answer 33

Kids may be more sensitive to EPS and metabolic effects

Use the lowest effect dose of FDA approved meds and titrate carefully

Question 34

Monitoring effectiveness of schizo therapy

Answer 34

Must be guided by systematic monitoring of patient symptoms and ongoing surveillance of potential adverse effects- encourage patients to report symptoms!

Question 35

How do we know if a patient is improving?

Answer 35

If the symptoms we’ve been trying to resolve have been getting better

Question 36

What side effects should we monitor for at baseline and each visit?

Answer 36

Anticholinergic side effects and overall ACH burden (including constipation)

Question 37

When should you check for drug interactions?

Answer 37

Whenever a new drug is added to a regimen, when doing med reconciliation (ask about OTC and CAM use), whenever an ADR is suspected

Question 38

BBW for schizo medications

Answer 38

BBW for dementia-related psychosis (AKA elderly patients with dementia taking APS for behavioral problems, not schizo)

Question 39

BBW for schizo meds: what if the patient was taking an APS before they were 65?

Answer 39

They should still continue to take it because schizophrenia should be treated!

Question 40

Caveat to the schizo med BBW

Answer 40

APS are the only agents available to treat patient-specific dementia-related psychosis so you have to use them anyways…DON’T AVOID THEM ALTOGETHER!

Question 41

How to manage patients on schizo meds with the BBW

Answer 41

Start on a lower dose, monitor them carefully, educate patient on side effects, and make sure the benefits > risks