562 Schizophrenia

Card Set Information

Author:
whiteap
ID:
151354
Filename:
562 Schizophrenia
Updated:
2012-05-03 02:23:39
Tags:
UWSOP Pharmacotherapy Dipiro Schizophrenia
Folders:

Description:
UWSOP Pharm 562 Schizophrenia pharmacotherapy Test Dipiro, lecture Webber
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user whiteap on FreezingBlue Flashcards. What would you like to do?


  1. Diagnosis of Schizophrenia
    Persistent dysfunction lasting longer than 6 mos

    ≥2 symptoms present for at least 1 mos (hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior and negative symptoms

    or 1 symptom of: bizarre delusions, hallucinations of voice keeping a running commentary or ≥2 voices conversing.

    Significantly impaired function (work, interpersonal, self-care)

    Not mania or depression
  2. Positive symptoms of schizophrenia
    • most affected by antipsychotic meds
    • delusions
    • hallucinations
    • disorganized speech (difficult understand)
    • behavior disturbance (disorganized or catatonic
    • illusions
  3. Negative symptoms of schizophrenia
    • represent a loss of dimunition of function
    • alogia (poverty of speech)
    • avolition (general lack of drive)
    • affective flattening (lack of emotional activity)
    • anhedonia
    • social isolation
  4. Cognitive dysfunction of schizophrenia
    • impaired attention
    • working memory
    • executive function
  5. Comorbid Conditions
    • Depression
    • Anxiety
    • Aggression
    • Substance abuse
  6. Initial/Acute therapy goals
    • first 7 days
    • Control psychotic symptoms: agitation, hostility, anxiety and aggression
    • Normalize sleep and eating patterns
    • Promote safety
    • Choose appropriate drug that: treats acute sypmptoms, facilitates assessment, fosters a therapeutic relationship
  7. Stabalization/Medium term therapy goals
    • Weeks 2-3
    • Stabalize: positive, negative, depressive and cognitive symptoms
    • Improve: socialization, self-care habits and mood
    • Provide psychosocial support to optimize compliance: information, education, and understanding
    • Establish appropriate dug and dose for maintenance treatment
  8. Maintenance/ Long-term therapy goals
    • ≥12 mos post remission of first psychotic episode: continuous treatment often necessary, lowest effective dose
    • Continue to improve symptoms: negative and cognitive
    • Improve global functioning: social, financial, occupational, practica, prevent relapse
  9. Name typical antipsychotics
    • First generation antipsychotics "FGA"
    • Chlorpromazine
    • Fluphenazine
    • Haloperidol
    • Loxapine
    • Molindone
    • Perphenazine
    • Thioridazine
    • Thiothixene
    • Trifluoperazine
  10. Name atypical antipsychotics
    • Second Generation Antipsychotics "SGA"
    • Mneumonic: CROP ZAAQ
    • Aripiprazole
    • Asenapine
    • Clozapine
    • Olanzapine
    • Paliperidone
    • Quetiapine
    • Risperidone
    • Ziprasidone
  11. AP injectibles
    • PROF-H
    • FGA
    • *Fluphenazine Decanoate - IM/SC, PO overlap, z track, hypotension
    • *Haloperidol Decanoate - IM, PO overlap, z track, hypotension
    • SGA
    • Olanzapine Pamoate - IM, PO NA, oversedation, slurred speech, delirium, No deltoid.
    • Paliperidone Palmitate - IM, PO NA
    • *Risperidone (Consta) - IM, PO overlap, no z track

    musts recommended SE's
  12. Antipsychotic Mecanishm of Action
    • Blocade of D2 receptors: improves positive symptoms of psychosis
    • Blocade of 5-HT2A receptors: improves negative symptoms of psychosis, lessens EPS
  13. Onset of antipsychotic effects:
    Effect typically separates from placebo in ___________
    Agitated behavior ⇒ _____________
    Thought disorder ⇒ ___________
    • Effect typically separates from placebo in 2-3 weeks
    • Agitated behaviorfew hours to few days
    • Thought disorder 3-6 weeks
  14. Pharmacotherapy trials in schizophrenia
    Stage 1: Treatment, Duration
    • Trial of single SGA: aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone
    • 12 weeks
  15. Pharmacotherapy trials in schizophrenia
    Stage 2: Treatment, Duration
    • Trial of different single SGA not tried in stage 1: aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone
    • 12 weeks
  16. Pharmacotherapy trials in schizophrenia
    Stage 3: Treatment, Duration
    • Clozapine
    • at least 6 months
  17. Pharmacotherapy trials in schizophrenia
    Stage 4: Treatment, Duration
    • Clozapine + FGA, SGA or ECT
    • 12 week trial: if 20% improvement of positive symptoms at week 12 --> continue treatment for an additional 12 weeks

    (inconsistent results in RCT's)
  18. Pharmacotherapy trials in schizophrenia
    Stage 5: Treatment, Duration
    • Single agent FGA or SGA not tried in previous stages
    • 12 week trial: if 20% improvement of positive symptoms at week 12 --> continue treatment for an additional 12 weeks

    clozapine failure (value in clozapine failure not established)
  19. Pharmacotherapy trials in schizophrenia
    Stage 6: Treatment, Duration
    • Combination Therapy:
    • SGA + FGA
    • SGA + SGA
    • SGA or FGA + ECT
    • SGA or FGA + other agent (mood stabilizer)

    12 week trial: if 20% improvement of positive symptoms at week 12 --> continue treatment for an additional 12 weeks

    (case reports, no controlled studies)
  20. Critical Decision Points of Stages 1, 2, 4, 5, & 6.
    • CDP #1 = week 0: symptomatic
    • CDP #2 = week 5: full, partial or no response
    • CDP #3 = week 8: full, partial or no response
    • CDP #4 = week 12: full or partial response
  21. Stages 1, 2, 4, 5 & 6
    CDP #1
    Week? Plan?
    • week 0
    • symptomatic, initial presentation: assess patient, select stage and start medication, adjust dose w/in 1 week
  22. Stages 1, 2, 4, 5 & 6
    CDP #2 and 3
    week? Plan?
    • Week: 5&8
    • Full resoponse: continue current dose as maintenance thx
    • Partial response: continue current dose or increase dose if tolerable
    • No response: Consider the next stage
  23. Stages 1, 2, 4, 5 & 6
    CDP #4
    Week? Plan?
    • Full response: continue current dose as maintenance thx
    • Partial response: titrate doses to upper end of therapeutic range, if ≥20% improvement in positive symptoms --> continue treatment for another 12 weeks, if at upper end and/or <20% improvement --> move to next stage.
  24. Critical Decision Points of Stage 3
    • CDP #1 = week 0: symptomatic
    • CDP #2 = week 16: full, partial or no response
    • CDP #3 = week 28: full, partial or no response
  25. Stage 3
    CDP #1
    week? plan?
    • Week: 0
    • symptomatic
    • Initiate Clozapine: titrate to therapeutic dose in 1 month
  26. Stage 3
    CDP #2
    week? plan?
    • Week: 16
    • Full resoponse: continue current dose as maintenance thx
    • Partial & No response: assess serum concentrations and adjust dose accordingly
  27. Stage 3
    CDP #3
    week? plan?
    • Week: 28
    • Full resoponse: continue current dose as maintenance thx
    • Partial response: assess serum concentrations and adjust dose accordingly, consider next stage
    • No response: consider next stage
  28. Dosing FGA'a
    Most patients respond to _________mg/day of chlorpromazine equivalents. (equivalent to ____mg/day of haloperidol)
    Most patients respond to 400-600 mg/day of chlorpromazine equivalents. (equivalent to 8-12 mg/day of haloperidol)
  29. FGA Dosing - Rule of 2's used in non-agitated patients
    • start with 2 mg haloperidol
    • gradually increase by 2mg every 2 days until improvment or intolerable side effects
    • increasing the dose too rapidly leads to overshooting the effective dose
  30. Acute psychotic agitation treatment procedure
    • rapid tranquilization
    • rapid neuroleptization
    • psychotolysis
    • chemical restraint
  31. Acute psychotic agitation medications
    • Haloperidol and Lorazepam
    • Both: control agitation, safe, minimal postural hypotension, no major DDI's
    • Haloperidol: specific for psychosis, cause EPS
    • Lorazepam: cause possible respritory depression and paradoxical hostility
  32. Changing Antipsychotics
    • 3 ways
    • Abrupt stop old and start new
    • Add new and taper old
    • Add new and delay taper of old
  33. AP DDI's
    • antacids
    • anticholinergics
    • anticonvulsants
    • TCA's
    • SSRI's
    • benzodiazepines
    • H-2 blockers
    • lithium
    • nicotine
  34. What are symptoms of drug induced delirium
    • AKA (toxic confusional state - acute brain syndrome)
    • Fluctuating clouding of consciousness or awareness (not present in drug induced psychosis)
    • Restlessness
    • emotional changes
    • disorientation
    • delusions
    • hallucinations
  35. Antipsychotic Adverse Reactions
    Generalized
    • Acute extrapyramidal side effects "EPS" (Dopamine receptor blockade)- Dystonias, Akathisia, pseudoparkinsonism, Tardive Dyskinesia
    • Anticholinergic (histamine and muscarinic receptor blockade)
    • Sedation (histamine receptor blockade)
    • CV (alpha receptor blockade)
    • Weight gain (histamine and muscarinic receptor blockade)
    • hyperprolactinemia (dopamine receptor blockade)
    • Neuroleptic malignant syndrome (EPS w/fever)
  36. Antipsychotic Adverse Reactions
    Acute Extrapyramidal Side Effects "EPS"
    • Dystonias: torsions, twisting, contractions of muscle groups, muscle spasms, e.g. oculogyric crisis, laryngospasm, torticollis
    • Parkinsonian sypmtoms: stiffness, shuffling, mask-like faces, tremor, akinesia, rigidity
    • Akathisia: motor restlessness
    • Tarditive Dyskinesia: involuntary movements
  37. Antipsychotic Adverse Reactions
    Tardive Dyskinesia
    (description, onset, risk factors, relation with SGA's)
    • syndrome of hyperkinetic involuntary movements characterized by mix of orofacial dyskinesia, tics, chorea and or athetosis
    • slow onset
    • risk factors: advancing age, duration of AP trx, female
    • SGA: lower risk, anti-dyskinetic effects
  38. Antipsychotic Adverse Reactions
    Anticholinergic symptoms
    • urinary retention
    • dry mouth
    • constipation
    • blurred vision
    • tachycardia
    • memory dysfunction
    • delirium
  39. AP AE's associated with histamine blockade.
    Which agents are most likely to cause these symptoms?
    • Sedation - clozapine > lpFGA's > hpFGA's > SGA
    • hypotension (?)
    • weight gain (?) clozapine, olanzapine>>risperidone, quetiapine > FGA's (least likely aripripazole & ziprasidone)
  40. AP AE's associated with alpha receptor blockades
    • postural hypotension
    • light-headaches
    • reflex tachycardia
  41. AP AE's
    Other
    • Cardiovascular effects - QTC PROLONGATION with ziprasadone, thioridazine, mesoridazine
    • photosensitivity
    • hepatotoxicity
    • blood dyscrasias - AGRANULOCYTOSIS with clozapine
    • antipsychotic withdrawl
  42. What SGA's are prone to causing weight gain
    • Clozapine - significant
    • Olanzapine - do not choose as first agent d/t weight gain

    • risperidone
    • Quetiapine
  43. Which AP's have major side effect of EPS
    • Haloperidol
    • Fluphenazine

    • FGA's
    • Risperidone - only SGA, very low risk
  44. Which AP's have major side effects of orthostatic hypotension
    Clozapine

    • Chlorpromazine
    • Prochlorperazine
  45. What are the most common side effects of Haloperidol
    EPS
  46. Which drugs are most likely to cause anticholinergic effects
    • Low potency FGA's (chlorpromazine, thioridazine)
    • Clozapine
    • Olanzapine
  47. Which drugs are most likely to cause EPS
    • Dystonia - High potency FGA's (haloperidol, fluphenazine)
    • Akathisia - FGA's (20-40% of patients)
    • Pseudoparkinsonism - FGA's & HD Risperidone
    • Tardive Dyskinesia - FGA's
  48. Which drugs are most likely to cause sedation
    What is a good counseling point for these medications
    • FGA's
    • Clozapine
    • Olanzapine (zyprexa)
    • Quetiapine (seroquel)
    • Take most or all of the dose at bedtime to improve side effects of sedationa and cognition
  49. What AP's should be watched in the elderly
    • Those that cause anticholinergic effects
    • FGA's
    • clozapine
    • olanzapine
  50. What IM injections can not be given together for controling agitation? Why? (SE's)
    • Lorazepam and Olanzapine
    • risk of hypotension, CNS depression, and respiratory depression.
  51. Why is it important to taper FGA's and clozapine slowly when d/c
    To avoid rebound cholinergic withrawl symptoms
  52. Which AP has shown superiority ove other AP's in RCT's for management of refractory schizophrenia
    Clozapine
  53. What is the difference between augmentation and combination therapies in refractory schizo.
    Augmentation is the addition of a non-AP such as a mood stabalizer or SSRI to an FGA or SGA

    Combination is the use of two FGAs or SGA's simultaneously
  54. What are the most common Mood Stabalizers used in augmentation therapy of refractory schizo
    Lithium, VPA, carbamazepine

    VPA + risperidone showed the fastest improvement of symptoms
  55. When is it appropriate to use an SSRI as an augmentation agent in refractory schizo
    • SSRI + FGA's = improved negative symptoms
    • Clozapine induced OCD
  56. What EPS condition would a young male be most at risk of
    Dystonia
  57. What are the treatment options for dystonia
    • IM/IV anticholinergics or benzodiazepines
    • Benztropine mesylate - antimuscarinic
    • Diphenhydramine - antihistamine
    • diazepam or lorazepam - benzo's
  58. Is prophylactic treatment of dystonia an option? If so, when would you do it and with what?
    • Yes - use anticholinergic medications when pt is:
    • on haloperidol or fluphenazine
    • young man
    • history of dystonia
  59. What are treatment options of Akathisia
    • 1 - reduction of AP dose is best intervention
    • 2 - switch to an SGA (Quetiapine & clozapine = low risk)
    • 3 - B-Blocker: propanolol, nadolol, (non-selective) metoprolol (non-selective at <100mg doses)
    • 4 - Diazepam (efficacy questionable)
  60. What are the four cardinal symptoms of pseudoparkinsonism
    • akinesia
    • tremor
    • rigidity
    • postural abnormalities
  61. What EPS condition are you most at risk for if you are:
    on FGA ( at high dose), increasing age and female
    pseudoparkinsonism
  62. What EPS condition are you most at risk for if you are on Risperidone ≥6mg/day?
    pseudoparkinsonism
  63. What are treatment options for pseudoparkinsonism
    • 1 - Anticholinergics: Benztropine, trihexyphenidyl, diphenhydramine, biperiden
    • 2 - Amantadine - less effect on memory

What would you like to do?

Home > Flashcards > Print Preview