Pharm Antipsychotics, Bipolar, Stimulants + Practice Questions

positive

These are all __________ symptoms of schizophrenia:

•Paranoid Delusions

•Auditory Hallucinations

•Enhanced Sensory Awareness

•Disorganized Behavior

negative

These are all __________ symptoms of schizophrenia:

•Diminished Sociability

•Restricted Affect

•Impoverished Speech

•Poor Self Care

> 2, > 6

Schizophrenia is diagnosed by ______ schizophrenia symptoms for ______ month

hallucinations

false sensory experiences, such as seeing something in the absence of an external visual stimulus

delusions

fixed, false beliefs despite evidence to the contrary

flat Affect

Anhedonia

Avolition

Alogia

Apathy/Asociality

List the negative symptoms of schizophrenia:

Hint "AAAAA"

catatonia

a state of unresponsiveness to one's outside environment, usually including muscle rigidity, staring, and inability to communicate

block receptors for dopamine

MOA of first gen antipsychotics for schizophrenia?

positive

First-gen antipsychotics are used especially for ________ symptoms in schizophrenia.

false - positive only

T/F: first gen antipsychotics are used for BOTH positie and negative sx in schizophrenia.

1-2 days

2-4 weeks

several months

How long does it take for first-gen antipsychotics to have initial effects?

how long for substantial improvement?

how long for FULL effects?

haloperidol

What is the high-potency first-gen antipsychotic drug used in schizophrenia?

true

T/F: despite the higher risk of having EPS, Haloperidol is the preferred FGA for initial therapy in schizophrenia because it causes LESS sedation, orthostatic hypotension and anticholinergic effects.

acute

Haloperidol is used for acute or chronic psychosis?

chlorpromazine, thioridazine

List the low potency first gen antipsychotics for schizophrenia?

less, more

When compared to high potency FGA, the low potency FGAs have ________ EPS sx and _________ sedation, hypotension, and anticholinergic effects.

acute dystonia (reversible, hours-days)

akathisia (reversible, days-weeks)

pseudoparkinsonism (reverisble, weeks-moths)

list the timeline for Drug-induced movement disorder (EPS).

extrapyramidal sx

What are the ADE of FGA?

acute dystonia

spasm of the muscles of tongue, face, neck, back

usually starts within hours/days of starting/increasing dose

diphenhydramine

benztropine

How do you tx acute dystonia?

parkinsonism

bradykinesia, mask-like facies, tremor, rigidity, shuffling gait, drooling, cogwheeling, stooped posture, resting tremors (pill-rolling)

benztropine

amantadine

anticholinergics

How do you treat parkinsonism?

akathisia

MC EPS symptom.

"inner restlessness"

compulsive, restless movements, anxiety, agitation, inability to sit still

reduce dosage or switch meds

benzotropine

propanolol

What is the tx for akathisia?

tardive dyskinesia

What adverse effect from taking FGA occurs later on and has less reliable treatment?

d/c offending agent

switch to SGA (slozapine)

What is the tx for tardive dyskinesia?

VMAT2 inhib

Benzodiazepine

What is symptom management for tardive dyskinesia?

Valbenazine (Ingrezza)

Deutetrabenazine (Austedo®)

Tetrabenazine (Xenazine®)

List the VMAT2 inhibitors.

hint "Benazine"

inhibit VMAT2 which decreases reuptake of dopamine into vesicles

What is the MOA of VMAT2 inhibitors?

worsened depression

emergent suicidality

Patients on VMAT2 inhibitors should be monitored for which side effect?

neuropletic malignant syndrome

This adverse side effect of Schizophrenia meds is rare (4% mortality risk) and is more likely to present with high potency FGAs.

"Lead pipe rigidity, sudden high fever, sweating, autonomic instability, dysrhythmias, BP fluctuations"

d/c antipyschotic, antipyretics, hudration, benzos

dantrolene (skeletal muscle relaxant)

bromocriptine (dopamine agonist)

What is the tx of neuropletic malignant syndrome>?

2 weeks

After treating neuropletic malignant syndrome, wait _____ weeks before initiation of antipsychotic, and consider SGA.

Anticholinergic effects

orthostatic hypotension

PROLONGED qt

sedation

neuroendocrine effects

seizures

sexual dysfunction

aganulocytosis

List all of the other adverse effects of first gen antipsychotics.

T/F: ALL FGA have a BBW for increase risk of mortality when used to treat dementia-related psychosis in older adult patients.

Aripiprazole

Risperidone

Clozapine

Olanzapine

Quetiapine

List the second gen antispcyhotics.

block receptors for dopamine and serotonin (5-HT)

What is the MOA of second gen antipyschs?

less blockade of dopamine D2 receptors

Why do SGAs cause less EPS than FGAs?

true

T/F: SGAs are preferred over FGAs due to less EPS sx including tardive dyskinesia.

false - help with both pos and neg

T/F: SGAs only help with positive symptoms.

psychosis and bipolar mania

What are SGAs used for?

clozapine, olanzapine

Which SGAs have serious metabolic effects including weight gain, diabetes, and dyslipidemia --> lead to cardiovascular event and premature death.

clozapine

Which SGA is more effects than other agents and is reserved for pts who have not responded to other antipsychotics + has significant side effects and medical risks

REMS program

What is required before prescribing clozapine?

monitoring WBC and ANC

check for agranulocytosis

must be WNL prior to starting

What is included in the REMS program before prescribing clozapine?

weekly for 6 months

2 weeks for additional 6 months

How often do you check WBC and ANC before starting clozapine?

WBC < 3000

WBC < 2000

When should you STOP taking clozapine?

when should you permanently stop?

myocarditis

stop med and never use again!

What is the rate but fatal BBW specific to clozapine?

if occurs, what should you do?

anticholinergic effects

orthostatic hypotension

sedation

neuroendocrine effects

seizures

prolonged QT

What are the ADEs of SGAs?

agranulocytosis

Which ADE of SGAs causes marked leukcytopenia (esp neutrophils), high fever, weakness, necrotizing oral lesions, hypotension and increased infection risk?

measure weight, blood sugar, lipids prior to starting + monitor throughout treatment

How should you monitor the metabolic effects of SGAs?

oral

What is the preferred route of administration of antipsych meds?

intramuscular

Which route of admin is reserved for pts with severe, acute schizophrenia and for long term maintenance?

whichever one worked well in the past

When picking a medication for schizoprenia, which should you choose first?

2

patient must be on manufacturer recommended dose for ____ weeks minimum before declaring failure

clozapine

Which med should be considered in patients with suicidal ideation?

clozapine

If a patient has failed two appropriately dosed antipsychotic meds which med should you try next?

retry monotherapy with med not used before

combo therapy (little evidence)

augment w/ non antipsychotic meds

If clozapine has failed, what should you do next?

haloperiodol

diphenhydramine or benztropine

What is the medication of choice for a patient with severe agitation?

If given IM, what should you also give to reduce EPS risks?

olanzapine

Your patient presents to the ED with severe agitation. They agreed to take an oral medication. What med should you give them?

quetiapine

Which medication should be used for patients with insomnia + schizo because its more sedating?

FGA or aripiprazole

Which med should you give to patients with schizo + at risk for metabolic syndrome?

lowest

Patients > 70 years old with schizo should be given _______ dose

Ziprasidone

Quetiapine

Chlorpromazine

IV haloperidol

A patient with long QT risk should avoid which meds?

weekly (adjust pharm and psychosocial tx)

When should you follow up after an acute episode of schizo?

monthly (if continues in remission)

After 3 months, when should you follow up with your schizo patient after an acute episode?

med benefits

side effects

adherence

What needs to be discussed at every follow up appointment?

relapse

After control of an acute episode, antipsychotic therapy should continue indefinitely because a withdrawal of medication can cause _________.

long acting depot injection

Which med is good for patients with relapse due to nonadherence?

q 2-4 weeks

How often are depot injections given for maintenance?

maintenance

All schizophrenic patients should have __________ therapy to reduce relapse risk.

A newly diagnosed patient with schizophrenia is seen and needing to start treatment. Which of the following antipsychotic agents may have the best chance to improve his apathy and blunted affect?

Olanzapine

1 multiple choice option

A patient is treated with haloperidol for schizophrenia. His psychosis is well managed with haloperidol; however, he is reporting restlessness and the inability to sit still at the dinner table. He also states that his family notices that he frequently paces the hallway. Which of the following is the best describes these symptoms?

Akathisia

3 multiple choice options

A patient with a history of treatment-resistant schizophrenia presents for routine monitoring of absolute neutrophil count, as the medication he was prescribed can cause severe neutropenia or agranulocytosis. Which medication is the patient most likely taking?

Clozapine

3 multiple choice options

A patient with schizophrenia is experiencing the extrapyramidal symptoms (EPS) of dystonic reactions in his arms and shoulders from perphenazine. He is now being considered for a switch to an antipsychotic with a lower risk of EPS. Which of the following agents is the most appropriate choice for this patient?

Quetiapine

3 multiple choice options

bipolar disorder

Recurrent fluctuations in mood:

Abnormally elevated

Abnormally depressed

Periods of normalcy

Pure manic episode (euphoric mania)

Hypomanic episode (hypomania)

Major depressive episode (depression)

Mixed episode

What are the 4 types of mood episodes in bipolar disorder?

bipolar I disorder

manic episode +/- major depressive +/- hypomanic episode

bipolar II disorder

hypomanic episode + major depressive episode

mood stabs

antipsychotics

antidepressants

What 3 medication types are used in bipolar disorder?

lithium

divalproex sodium

carbamazepine

List the 3 mood stabilizers used in bipolar disorder.

SGA (olanzapine, risperidone)

list the antipsychotics used in bipolar disorder.

Bupropion

Venlafaxine

Fluoxetine

Sertaline

List the antidepressants used in bipolar disorder.

lithium

What is the drug of choice for patients with acute mania in bipolar disorder?

5-7 days

2-3 weeks

How long does lithium take for the antimanic effect onset?

How long does it take to reach full benefit?

use care with renal impairment

Lithium is excreted by the kidneys unchanged therefore you should do what?

increases lithium levels

use caution with diuretics

diarrhea/dehydration

If a patient has hyponatremia, how does this effect lithium levels?

How should you avoid this?

what can increase lithium levels to toxicity?

GI sx

tremor

polyuria

renal toxicity

goiter and hypothyroid

teratongenic

What are the adverse effects of lithium at therapeutic levels that are early and subside?

reduce with BB

How can you reduce the adverse effect of tremors in a patient on lithium?

drink 8-12 glasses if fluids daily

reduce with amiloride

How can you reduce the polyuria adverse effect of lithium?

thyroid panel

What do you need to obtain before prescribing a patient lithium because one of the ADE is hypothyroidism?

Hepatotoxicity

Pancreatitis

Teratogenic

What is the BBW for lithium?

narrow

2-3 days

3-6 months

}

Lithium has a ________ therapeutic index. Therefore plasma drug levels must be measured routinely.

Beginning of tx: every ________ days.

Maintenance: every ___________ months.

underlying renal insuff

effective volume depletion

older adult pts

When is the risk of lithium toxicity increased?

hemodialysis

What is the tx for lithium if its elevated > 2.5?

increase, increase

Diuretics _______ risk for lithium toxicity

NSAIDS ______ lithium levels by up to 60%

true

T/F: you can not use NSAIDS with lithium, however you CAN use aspirin

divalproex sodium (valproate)

valproate sodium (depacon)

valproic acid (depakene)

List the antiepileptic drugs that are first line BPD treatment options.

Used for sx control in acute manic episodes and prevention of relapse into mania.

pancreatitis

liver fail

teratogenic

What are the BBW adverse effects of divalproex sodium (valproate)?

CBC w/ diff

drug lvl

fasting BG

lipid panel

LFTs

weight

What do you need to monitor in a bipolar patient on divalproex sodium (valproate)?