schizophrenia/psychosis

negative signs/sx of schizophrenia

• loss of interest in everyday activities (anhedonia)

• lack of emotion (apathy)

• inability to plan or carry out activities

• poor hygiene

• social withdrawal

• loss of motivation (avolition)

• lack of speech (alogia)

positive signs/sx of schizophrenia

• hallucinations

• delusions

• disorganized speech/behavior

• difficulty paying attention

how do we diagnose schizophrenia?

≥ 2 sx for ≥ 1 month period

• ≥ 1 sx must be the following

  • hallucinations

  • delusions

  • disorganized speech

• disorganized behavior

• negative sx

meds that can cause psychotic sx

• anticholinergics

  • diphenhydramine

  • benztropine

• dextromethorphan

• dopamine or dopamine agonists

• efavirenz

• interferons

• ketamine

• keppra

• FQs

• stimulants

• systemic steroids

recreational drugs that can cause psychotic sx

• cannabis

• cocaine

• LSD

• PCP

• methamphetamine

first line tx for schizophrenia

antipsychotics

which antipsychotics have a higher incidence of extrapyramidal sx?

a. FGAs

b. SGAs

a. FGAs

extrapyramidal side effects

• akathisia

• dystonia

• parkinsonism

• tardive dyskinesia

EPS: how to treat akathisia

benzos

propranolol

EPS: how to treat dystonia

centrally-acting anticholinergics: diphenhydramine, benztropine

EPS: how to treat parkinsonism

anticholinergics

amantadine

EPS: akathisia

restlessness with anxiety and inability to remain still

EPS: dystonia

prolonged contraction of muscles, painful muscle spasms

EPS: parkinsonism

tremors, abnormal gait, bradykinesia

MOA of FGAs

block D2 receptors

some 5-HT2A receptor blockade

FGAs: phenothiazine class

“-azine”

• chlorpromazine

• thioridazine

• perphenazine

• fluphenazine

• trifluoperazine

FGAs: butyrophenones

haloperidol

all FGAs ADRs

• QT prolongation

• hyperprolactinemia

• NMS

low-potency FGAs

chlorpromazine

thioridazine

low-potency FGAs (chlorpromazine, thioridazine) ADRs

• sedation

• anticholinergic

• orthostasis

high-potency FGAs

haloperidol

fluphenazine

high-potency FGAs (haloperidol, fluphenazine) ADRs

• EPS

  • acute dystonia

  • akathisia

  • parkinsonism

  • tardive dyskinesia

hyperprolactinemia

• irregular or absent menstrual periods

• gynecomastia

• galactorrhea

• decr. libido

• ED

• infertility

which FGAs have more sedation and less EPS?

a. low potency

b. high potency

a. low potency

which FGAs have less sedation and more EPS?

a. low potency

b. high potency

b. high potency

MOA of SGAs

block D2 and 5-HT2A receptors

SGAs

aripiprazole (Abilify)

clozapine (Clozaril)

lurasidone (Latuda)

olanzapine (Zyprexa)

paliperidone (Invega)

quetiapine (Seroquel)

risperidone (Risperdal)

ziprasidone (Geodon)

asenapine (Saphris, Secuado)

cariprazine (Vraylar)

brexpiprazole (Rexulti)

iloperidone (Fanapt)

lumateperone (Caplyta)

ANC calculation

WBC * [(% segs + % bands)/100]

when is clozapine indicated?

treatment-resistant schizophrenia

failure of ≥ 2 other antipsychotics

ADRs of clozapine

• neutropenia and agranulocytosis

• myocarditis and cardiomyopathy

• seizures

• metabolic syndrome

• sialorrhea (hypersalivation)

• constipation

what ANC is required prior to initiation of clozapine?

≥ 1,500

at what ANC do we STOP clozapine therapy?

< 1,000

SGAs with highest risk of metabolic syndrome

• clozapine

• olanzapine

SGAs with lowest risk of metabolic syndrome

• aripiprazole

• asenapine

• lurasidone

• ziprasidone

SGAs with highest risk of QT prolongation

• ziprasidone

SGAs with lowest risk of QT prolongation

• aripiprazole

• lurasidone

SGAs with highest risk of EPS

• paliperidone

• risperidone

SGAs with lowest risk of EPS

• clozapine

• quetiapine

SGAs with highest risk of elevated prolactin levels

• paliperidone

• risperidone

SGAs with lowest risk of elevated prolactin levels

• aripiprazole

• clozapine

• lurasidone

• quetiapine

SGAs with highest risk of anticholinergic adverse effects

• clozapine

SGAs with highest risk of sedation

• clozapine

• olanzapine

• quetiapine

SGAs with lowest risk of sedation

• aripiprazole

• paliperidone

what SGA should be placed under the tongue and dissolved, avoiding eating or drinking ≥ 10 minutes after the dose?

asenapine (Saphris)

what SGA should be taken with ≥ 350 kcal?

lurasidone (Latuda)

with what SGA does the pt need to be monitored for 3 hours after injection due to risk of sedation and delirium?

olanzapine LAI (Zyprexa Relprevv)

what SGA should be taken at night, without food or with a light meal (≤ 300 kcal)?

quetiapine XR

what SGA should be taken with food (no calorie requirement)?

ziprasidone (Geodon)

which antipsychotics are available as a short-acting injection?

• fluphenazine

• haloperidol

• olanzapine

• ziprasidone

which antipsychotics are available as a long-acting injection?

• aripiprazole (Aristada, Abilify Maintena, Abilify Asimtufii)

• fluphenazine (fluphenazine decanoate)

• haloperidol (Haldol Decanoate)

• olanzapine (Zyprexa Relprevv)

• paliperidone (Invega Sustenna, Erzofri, Invega Trinza, Invega Hafyera)

• risperidone (Risperdal Consta, Rykindo, Perseris, Uzedy)

how often is Aristada (abilify LAI) given?

1-2 months

how often is Abilify Maintena (aripiprazole LAI) given?

monthly

how often is Abilify Asimtufii (aripiprazole LAI) given?

2 months

how often is fluphenazine decanoate given?

2 weeks

how often is Haldol Decanoate (haloperidol LAI) given?

monthly

how often is Zyprexa Relprevv (olanzapine LAI) given?

2-4 weeks

how often is Invega Sustenna (paliperidone LAI) given?

monthly

how often is Erzofri (paliperidone LAI) given?

monthly

how often is Invega Trinza (paliperidone LAI) given?

3 months

how often is Invega Hafyera (paliperidone LAI) given?

6 months

how often is Risperdal Consta (risperidone LAI) given?

2 weeks

how often is Rykindo (risperidone LAI) given?

2 weeks

how often is Perseris (risperidone LAI) given?

monthly

how often is Uzedy (risperidone LAI) given?

1-2 months

what atypical antipsychotic is approved for psychosis in Parkinson disease?

pimavanserin

tardive dyskinesia irreversible sx

uncontrollable movements in tongue, face, trunk and extremities

how do we treat tardive dyskinesia?

VMAT2 inhibitors

• valbenazine (Ingrezza)

• deutetrabenazine (Austedo)

VMAT2 inhibitors

valbenazine (Ingrezza)

deutetrabenazine (Austedo)

s/sx of neuroleptic malignant syndrome

• hyperthermia

• mental status changes

• muscle rigidity

  • lead-pipe rigidity

• autonomic instability

  • sweating

  • tachycardia

  • labile BP

• elevated CPK

tx of NMS

d/c causative agent

provide supportive care

relax muscles: benzos, dantrolene

aripiprazole formulations

• tablet/capsule

• liquid

• ODT

• long-acting injection

clozapine formulations

• tablet/capsule

• liquid

• ODT

fluphenazine formulations

• tablet/capsule

• liquid

• short-acting injection

• long-acting injection

haloperidol formulation

• tablet/capsule

• liquid

• short-acting injection

• long-acting injection

lurasidone formulations

• tablet/capsule

olanzapine formulations

• tablet/capsule

• ODT

• short-acting injection

• long-acting injection

paliperidone formulations

• tablet/capsule

• long-acting injection

quetiapine formulations

• tablet/capsule

risperidone formulations

• tablet/capsule

• liquid

• ODT

• long-acting injection

ziprasidone formulations

• tablet/capsule

• short-acting injection

long-acting injectable antipsychotics given every 2 weeks

• fluphenazine decanoate

• risperdal consta

• rykindo

long-acting injectable antipsychotics given every 2-4 weeks

zyprexa relprevv

long-acting injectable antipsychotics given monthly

• abilify maintena

• haldol decanoate

• invega sustenna

• erzofri

• perseris

long-acting injectable antipsychotics given every 1-2 months

• aristada

• uzedy

long-acting injectable antipsychotics given every 2 months

• abilify asimtufii

long-acting injectable antipsychotics given every 3 months

• invega trinza

long-acting injectable antipsychotics given every 6 months

• invega hafyera