Schizophrenia

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Author:
timothy.pdlt
ID:
212336
Filename:
Schizophrenia
Updated:
2013-04-09 01:34:37
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schizophrenia
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Description:
therapeutics, side-effects, drug interaction
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  1. GoT of schizophrenia Tx
    • treat acute symptoms
    • decrease frequency and severity of psychological episodes
    • restore psychosocial function
    • promote adherence
    • prevent suicide
    • minimize ADRs
    • education
  2. Epidemiology of schizophrenia
    • 1% of Canadians (M=F)
    • S/S begin earlier in males
  3. Prognosis of schizophrenia
    • 10-20% have good outcome
    • 50% have repeated hospitalization
    • 10% commit suicide
    • antipsychotics= 2-4x reduction in relapse
  4. Diagnostic criteria for schizophrenia
    • 1. social or occupational dysfunction
    • 2. s/s >6months
    • 3. not caused by other disease/drugs
    • 4. >2 of the following for 1month: hallucination, delusions, disorganized speech, grossly disorganized/catatonic behavior, negative s/s
  5. Negative S/S (deficit in normal thoughts, emotions, behaviours) of schizophrenia
    • poverty of speech
    • blunted effect
    • social withdrawal
    • avolition (lack of motivation)
    • anhedonia (lack of interest)
  6. Examples of FGA
    • chlorpromazine
    • haloperidol
    • loxapine
    • methotrimeprazine
    • perphenazine
  7. Examples of SGA
    • clozapine
    • risperidone
    • olanzapine
    • quetiapine
    • zipreasidone
    • paliperidone
    • aripiprazole (TGA)
  8. Uses of antipsychotics
    • 1. chronic psychotic disorders
    • a. schizophrenia
    • b. schizoaffective disorders
    • c. delusional disorders
    • 2. acute psychotic episodes
    • 3. affective disorders
    • a. bipolar disorders
    • b. psychotic-depressive disorder
    • 4. agitated states
    • a. delirium
    • b. demetia
    • 5. Tourette's syndrome, refractory anxiety disorders, eating disorders, movement disorders
  9. Psychosocial Tx options for schizophrenia
    • psychoeducation
    • self-management
    • skills training
    • CBT/IPT
    • vocational training
    • supported employment
    • case management
  10. Onset of effects for schizophrenia Tx
    • 4-8weeks: significant reduction in acute s/s
    • >1year: improvement in other s/s and function
  11. General principles of schizophrenia Tx
    • antipsychotics are cornerstones
    • reduce but do not eliminate all core s/s (positive>negative)
    • *lower starting dose if first episode or elderly
    • *much lower dose if prodromal stages or kids (RIS 0.25mg or QTP 25mg)
  12. FGA versus SGA
    • FGA inhibits D2, M2, a1, H1 (causing EPS, anticholinergic s/e, orthostatic hypotension, sedation respectively)
    • SGA inhibits D2, M2, a1, H1 but also 5HT2a (means less EPS)

    • FGA have more EPS and tardive dyskinesia
    • SGA have more weight gain and endocrine changes (esp. OLZ)
  13. Efficacy of antipsychotics
    • equally effective except for CLZ in refractory
    • SGAs have lower d/c rates
    • RIS/OLZ= lower relapse rates
    • CLZ used in refractory schizophrenia (had failed >2 antipsychotics plus 6weeks HDL)
  14. Specific S/S reduction of SGA vs. FGA
    • positive s/s: CLZ>RIS>OLZ (QTP is worse)
    • negative s/s: CLZ>OLZ>RIS
    • depressive s/s: CLZ>RIS>OLZ
  15. Time to discontinua any Tx with SGAs
    OLZ (9months)>RIS, QTP
  16. Relapse rates without schizophrenia Tx
    • 1year= 65%
    • 2years= 90%

    *antipsychotics decrease relapse risk to <30% yearly (RIS= 34% relapse vs. HDL= 60%)
  17. How to start schizophrenia Tx
    • SGA or FGA if previous response= 4-8weeks trial (positive s/s improve but negative s/s and functioning may take months)
    • BDZ for acute agitation and anxiety
  18. Duration of schizophrenia Tx
    • 1-2years: first episode+full remission
    • 2-5years: severe, slower response, remission
    • >5years: >2 episodes
  19. Indications for switching antipsychotics
    • current regimen intolerable
    • partial or no response (<25%)
    • relapse despite adherence
    • comorbid psychological or physical conditions
  20. Risk of EPS
    FGAs>RIS>other SGAs>CLZ/QTP: esp. with rapid dose escalation, patient vulnerability, and target dose

    • s/s= akathisia (unpleasant inner restlessness) must be differentiated from anxiety/agitation
    • *some EPS s/s (except TD) can be treated with benztropine/procyclidine
  21. Acute EPS S/S
    • Parkinsonism: tremor, rigidity, bradykinesia, mask-like face
    • akathisia: restlessness
    • dystonia: torsion of muscle groups
    • Pisa syndrome: leaning to one side
    • Rabbit syndrome: fine tremor of the lower lip
  22. Delayed EPS S/S
    • 1. tardive dyskinesia
    • a. 3-5% annually with moderate FGA doses
    • b. 0.6% annually with SGAs
    • *only reversible in the first month
    • 2. akathisia, dystonia (sustained)
  23. Initial counseling for schizophrenia Tx
    • identify patient's concerns
    • purpose of antipsychotics
    • time of benefit (4-8weeks for positive s/s and >1year for negative s/s and functioning)
    • s/e
    • written information
    • likelihood of benefiting
    • how to take medication
  24. Follow-up counseling for schizophrenia Tx
    • adherence
    • OTC use
    • don't stop just because feeling better
    • taper with d/c
    • avoid illicit substances
  25. Monitoring for schizophrenia Tx
    • 1. efficacy
    • a. target s/s (hallucinations, delusions, hostility, thought patterns)
    • b. improved functioning
    • 2. safety
    • a. sedation
    • b. EPS
    • c. BP/HR/weight/BMI/waist q1month
    • d. FPG/A1c/lipids q4-6months
    • e. ECG
    • f. CBC q2weeks with CLZ
    • g. LFTs q1year
  26. Red flags with schizophrenia Tx
    • late refills
    • weight gain
    • EPS
    • no change in functioning
    • patient presentation (ie. s/s during relapse)
    • antipsychotics during heat waves, excessive physical activity, or illnesses)
  27. Doses of antipsychotics for schizophrenia
  28. S/E of CLZ
    • agranulocytosis
    • seizures
    • sedation
    • orthostatic hypotension
    • tachycardia
    • weight gain
  29. S/E of RIS
    • insomnia
    • anxiety
    • EPS
    • weight gain
    • hyperprolactinemia
    • orthstatic hypotension
  30. S/E of OLZ
    • weight gain
    • DM
    • dyslipidemia
    • sedation
    • antocholinergic s/e
    • orthostatic hypotension
    • EPS
  31. S/E of QTP
    • sedation
    • dizziness
    • weight gain
    • orthostatic hypotension
    • anticholinergic s/e
    • DM
    • dyslipidemia
    • cataracts
  32. S/E of ziprasidone
    • QT prolongation
    • sedation
    • orthostatic hypotension
    • *less weight gain
    • DM
    • hyperglycemia
    • *must be taken with food

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