Schizophrenia Part 3

Describe the side effects of antipsychotic medications.

Antipsychotic medications can cause side effects due to their action on receptors throughout the body, not just in the mesolimbic part of the brain. Typical antipsychotics are known to cause Extra Pyramidal Side Effects (EPSEs), while atypical antipsychotics may also cause EPSEs at high doses, with weight gain and metabolic syndrome being significant concerns.

Explain Extra Pyramidal Symptoms (EPSEs).

Extra Pyramidal Symptoms (EPSEs) are symptoms that patients experience due to dopamine blockade in the basal ganglia, often resulting from the use of antipsychotic medications.

How do atypical antipsychotics differ from typical antipsychotics regarding side effects?

Atypical antipsychotics can cause Extra Pyramidal Side Effects (EPSEs) at high doses, but their main side effects are weight gain and metabolic syndrome, whereas typical antipsychotics primarily cause EPSEs.

Define metabolic syndrome in the context of antipsychotic medication use.

Metabolic syndrome refers to a cluster of conditions, including increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels, which can be exacerbated by the weight gain associated with antipsychotic medications.

Do antipsychotic medications increase the risk of diabetes and cardiovascular disease?

Yes, patients with schizophrenia are already at a higher risk of diabetes and cardiovascular disease, and the use of antipsychotic medications that cause weight gain can further increase this risk.

What is the significance of dopamine blockade in the treatment of schizophrenia?

Dopamine blockade is significant in the treatment of schizophrenia as it helps to alleviate psychotic symptoms, but it can also lead to side effects such as Extra Pyramidal Symptoms due to its effects on the basal ganglia.

How can the side effects of antipsychotic medications impact patient health?

The side effects of antipsychotic medications, particularly weight gain and metabolic syndrome, can negatively impact patient health by increasing the risk of diabetes and cardiovascular diseases.

Describe the pharmacological effects of antipsychotics.

Antipsychotics primarily work by blocking dopamine receptors in the brain, which helps to alleviate symptoms of psychosis.

Explain what dystonia is in the context of antipsychotic treatment.

Dystonia is a sustained repetitive movement or abnormal posture that can occur as a side effect of antipsychotic medications.

Identify common types of dystonic reactions associated with antipsychotics.

Common dystonic reactions include torticollis, oculo gyrocrisis, and cogwheel rigidity.

Define torticollis and its implications for patients.

Torticollis is a twisting of the neck that forces the patient to look to one side, which can prohibit swallowing and requires urgent management.

Describe oculo gyrocrisis and its urgency in treatment.

Oculo gyrocrisis involves the eyes rolling into the back of the eye socket, showing only the whites of the eyes, and requires urgent treatment due to its acute onset.

Explain cogwheel rigidity and how patients may describe it.

Cogwheel rigidity is characterized by stiffness in the arm, where movement feels like a slow, stiff, round motion, similar to a cog.

What causes dystonic reactions in patients taking antipsychotics?

Dystonic reactions are caused by cholinergic excess due to the blockade of dopamine receptors.

How can dystonic reactions be treated in patients on antipsychotics?

Dystonic reactions can be treated with the administration of anticholinergics, such as procyclidine, administered intramuscularly.

Considerations for treating dystonia in patients on antipsychotics include what?

Consideration may include using another antipsychotic agent if necessary.

Describe akathisia and its symptoms.

Akathisia is characterized by an inner restless feeling where patients cannot sit still, often rocking from one foot to another, needing to move around, and appearing agitated.

How does akathisia differ from psychosis-related symptoms?

Akathisia is described as an 'inner restlessness' and should not be confused with responding to voices due to psychosis.

When does akathisia typically begin after drug administration?

Akathisia usually begins shortly after drug administration, often within a couple of days.

What are the treatment options for akathisia?

Treatment options for akathisia include reducing the dose of the medication or changing antipsychotics. Anticholinergics should not be given.

Define pseudo parkinsonism and its symptoms.

Pseudo parkinsonism refers to symptoms resembling Parkinson's disease, which include stooped posture and bradykinesia, or slow movements.

Explain the significance of recognizing akathisia in patients.

Recognizing akathisia is important for appropriate management, as it can significantly affect a patient's comfort and adherence to treatment.

What should be avoided in the treatment of akathisia?

In the treatment of akathisia, it is important to avoid giving anticholinergics.

List the symptoms associated with pseudo parkinsonism.

Symptoms of pseudo parkinsonism include stooped posture and bradykinesia, which is characterized by slow movements.

Describe the symptoms associated with pseudo parkinsonism.

Symptoms include resting tremor, shuffling gait, and a mask-like face.

Explain the cause of pseudo parkinsonism.

Pseudo parkinsonism is caused by an imbalance in acetylcholine, affecting the brain's basal ganglia which have a high concentration of dopamine receptors.

How does normal movement control function in relation to dopamine and acetylcholine?

Normal movement control relies on a balance between dopamine and acetylcholine activity in the basal ganglia.

What are the treatment options for pseudo parkinsonism?

Treatment options include dose reduction, changing to another drug, and administering anticholinergic medications as a short-term measure.

Define tardive dyskinesia and its symptoms.

Tardive dyskinesia is characterized by involuntary movements such as lip smacking and tongue darting, often resembling the behavior of characters like the Joker in Batman.

Explain the underlying cause of tardive dyskinesia.

Tardive dyskinesia is due to super sensitivity of D2 receptor blockade, which occurs many years after prolonged use of typical antipsychotics.

What treatment options are available for tardive dyskinesia?

Treatment options include switching from typical to atypical antipsychotics, considering Clozapine, and using Tetrabenazine, which is licensed for treating tardive dyskinesia.

How does Tetrabenazine work in the treatment of tardive dyskinesia?

Tetrabenazine prevents the transport of dopamine and other monoamines into synaptic vesicles, leading to a depletion of these neurotransmitters in the synaptic cleft.

What is a significant side effect of Tetrabenazine?

A major side effect of Tetrabenazine is depression, which limits its common use.

Describe the Glasgow Antipsychotic Side Effect Scale.

It is a self-report rating scale used to assess extra pyramidal side effects in patients.

Explain the importance of observation in recognizing side effects.

Observation allows healthcare providers to notice side effects that patients may not verbally report, such as their behavior while waiting to speak.

Define metabolic syndrome.

Metabolic syndrome is a condition characterized by a cluster of conditions including high waist circumference, raised triglycerides, reduced HDL, raised blood pressure, and raised fasting plasma glucose.

How is waist circumference used to diagnose metabolic syndrome in men and women?

In women, a waist circumference greater than 35 inches and in men, greater than 40 inches is required for diagnosis.

List two criteria that can indicate metabolic syndrome aside from waist circumference.

1. Raised triglycerides (≥ 1.7mmol/l) 2. Reduced high-density lipoprotein (≤ 1.03mmol/l in males and ≤ 1.29mmol/l in females).

What blood pressure readings are considered indicative of metabolic syndrome?

Systolic blood pressure ≥ 130mmHg and diastolic blood pressure ≥ 85mmHg.

How is fasting plasma glucose related to metabolic syndrome diagnosis?

A fasting plasma glucose level of ≥ 5.6mmol/l is one of the criteria, but HBa1c levels are often used in practice due to difficulties in fasting patients.

Do most trusts develop their own version of the Glasgow Antipsychotic Side Effect Scale?

Yes, many trusts create their own versions of the scale for use in practice.

Describe the NICE guidance on monitoring patients prescribed antipsychotics.

The NICE guidance recommends monitoring waist measurement, weight, fasting blood glucose or HbA1c, lipids, and performing an ECG if required by product specifications. Blood pressure should also be checked at the initiation of treatment.

Explain the potential side effect of antipsychotics related to prolactin levels.

Antipsychotics can cause hyperprolactinemia, which may present as breast milk production in women or gynecomastia in men. Patients should be sensitively asked about their sexual history to identify these side effects.

Define Neuroleptic Malignant Syndrome and its association with antipsychotics.

Neuroleptic Malignant Syndrome is a rare but serious condition that can occur in patients prescribed antipsychotics, either after years of treatment or at the start. It is characterized by rigid muscles, high fever, rapid breathing, and sudden onset.

How should Neuroleptic Malignant Syndrome be treated?

Treatment for Neuroleptic Malignant Syndrome involves stopping the antipsychotic medication, offering muscle relaxants, and considering a re-challenge after 14 days.

Do antipsychotics have any cardiovascular monitoring requirements according to NICE guidance?

Yes, NICE guidance suggests monitoring blood pressure at the initiation of antipsychotic treatment as part of good practice.

What symptoms might indicate hyperprolactinemia in patients taking antipsychotics?

Symptoms of hyperprolactinemia in patients taking antipsychotics may include breast milk production in women and gynecomastia in men.

Explain the importance of monitoring metabolic parameters in patients on antipsychotics.

Monitoring metabolic parameters such as weight, waist measurement, fasting blood glucose or HbA1c, and lipids is crucial to manage the risk of metabolic side effects associated with antipsychotic medications.

Describe the impact of cigarette smoke on liver enzymes.

Cigarette smoke contains over 3000 chemicals that can induce liver enzymes, particularly CYP1A2, leading to faster breakdown of certain medications.

Explain how smoking affects clozapine levels in the body.

Smoking can reduce the amount of clozapine in the body by more than a third (33%), requiring a higher dose for the same effect.

What happens to clozapine levels when a person stops smoking?

When a person stops smoking, clozapine levels can almost double (up to 75%), potentially leading to increased side effects.

How often should blood tests be conducted after stopping smoking while on clozapine?

Blood tests should be conducted every week or so to monitor clozapine levels after stopping smoking.

Define the relationship between smoking cessation and clozapine dosage.

If a person stops smoking, they may need a lower dose of clozapine, often requiring a reduction by half.

Explain the importance of informing healthcare providers when stopping smoking while on clozapine.

It's crucial to inform healthcare providers when stopping smoking to adjust clozapine dosage and monitor for potential side effects.

Describe the effect of vaping on clozapine levels compared to smoking.

Starting to vape may also lead to a reduction in harmful chemicals, similar to stopping smoking, which can affect clozapine levels.

What are the potential risks associated with increased clozapine levels after quitting smoking?

Increased clozapine levels can lead to more side effects and have been associated with some reported deaths.

How does clozapine affect the gut?

Clozapine affects the gut in three ways, although the specific effects are not detailed in the provided content.

What is enzyme induction in the context of smoking and medication?

Enzyme induction refers to the process by which certain chemicals in cigarette smoke increase the activity of liver enzymes, affecting drug metabolism.

Describe the anticholinergic effect of clozapine.

Clozapine blocks acetylcholine, a natural chemical that causes gut muscles to contract, leading to excessive relaxation of the intestines and potentially stopping movement.

Explain the antiserotonergic effect of clozapine.

Clozapine blocks serotonin receptors in the digestive tract, which helps coordinate normal bowel pacing, thus further slowing down the passage of stool.

How does clozapine affect transit time in the colon?

Clozapine can extend the normal transit time of the colon from about 24 hours to 100 hours or more, causing stool to dry out and harden in the body.

What important safety information is associated with clozapine regarding intestinal issues?

Clozapine is associated with risks of intestinal obstruction, fecal impaction, and paralytic ileus, and patients should seek medical advice if constipation develops.

Define the monitoring recommendations for clozapine blood concentrations.

The MHRA recommends monitoring blood concentrations of clozapine for toxicity in situations such as smoking cessation, interactions with other medicines, serious infections, suspected reduced metabolism, or suspected toxicity.

Do patients need to be cautious when taking clozapine?

Yes, patients and their carers should be advised to seek immediate medical advice if constipation develops while taking clozapine.

Explain the potential consequences of slowed transit time due to clozapine.

Slowed transit time can lead to stool hardening and drying out, which may result in severe constipation and related complications.

What should be monitored in patients taking clozapine?

Blood concentrations of clozapine should be monitored for toxicity, especially in specific clinical situations that may affect metabolism or increase levels.

Describe the importance of clozapine blood concentration monitoring.

Clozapine blood concentration monitoring is essential to manage the risk of agranulocytosis, a potentially serious side effect associated with the medication.

Explain the role of blood tests in managing clozapine treatment.

Blood tests are required alongside clozapine blood concentration monitoring to ensure patient safety and to detect any adverse effects early.

Define agranulocytosis in the context of clozapine use.

Agranulocytosis is a severe drop in white blood cell count that can occur as a side effect of clozapine, increasing the risk of infections.

How can healthcare professionals encourage medicines optimisation in schizophrenia?

Healthcare professionals can encourage medicines optimisation in schizophrenia by providing education, support, and resources to patients and their families.

List some resources available for individuals with schizophrenia and their families.

Resources include the MIND website, Rethink Mental Illness support pages, and downloadable booklets about symptoms and treatment.

What is the purpose of the post-workshop quiz mentioned in the presentation?

The post-workshop quiz is designed to reinforce learning and assess understanding of the material covered in the workshop.

Identify a key reference for schizophrenia management guidelines.

The National Institute for Health and Care Excellence (NICE) Clinical guideline CG178 provides guidelines for the prevention and management of psychosis and schizophrenia in adults.

Do cigarette smoking interactions with medications need to be considered in schizophrenia treatment?

Yes, clinically significant drug interactions with cigarette smoking should be considered when managing medications for schizophrenia.

Summarize the content of the NHS Choices overview on schizophrenia.

The NHS Choices overview on schizophrenia provides information about the condition, its symptoms, treatment options, and living with the illness.