Schizophrenia PollEv Questions

Bob has taken his clozapine for twelve months and has been adherent with getting his blood work done every other week. Going forward, how frequently can he get his blood drawn?

a. Weekly

b. Monthly

c. Biannually

d. Annually

b. Monthly

[Blood is drawn for ANC monitoring with clozapine.]

[Bob does not have benign ethnic neutropenia (BEN). Dr. Jackson will tell us specifically if patients in cases do!]

How often should you monitor waist circumference according to the Diabetes Care Guidelines for monitoring antipsychotics?

a. Baseline

b. Every 8 weeks

c. Quarterly

d. Annually

d. Annually

Patients with severe neutropenia can be rechallenged with clozapine, with caution, if the benefits outweigh the risks: T/F

True

[Clozapine is the only drug shown to have efficacy with treatment resistant schizo! Though it’s not an AP you want to start someone (newly diagnosed with schizo.) out on]

Most long-acting injections (LAIs) recommend using an oral antipsychotic prior to initiation of the LAI. Why is this recommended?

a. It helps the LAI achieve steady state

b. It keeps psychosis under control continuously

c. It is intended to make sure the patient can tolerate the drug

d. It decreases the number of side effects associated with the LAI

c. It is intended to make sure the patient can tolerate the drug

[B/c LAI effects CANNOT be reversed once the LAI is given! Only thing that can be done at that point is to wait out the LAI’s duration of action.]

Which LAI should be given on a monthly basis?

a. Risperidone Consta

b. Invega Trinza

c. Abilify Maintena

d. Fluphenazine decanoate

c. Abilify Maintena — lasts 1 month

[a. Risperidone Consta: lasts 2 weeks

b. Invega Trinza: lasts 3 months

d. Fluphenazine decanoate: lasts 2-3 weeks]

Which antipsychotic has a Risk Evaluation and Mitigation Strategy (REMs)?

a. clozapine oral

b. olanzapine long-acting injection

c. loxapine inhalation

d. asenapine oral

a. clozapine oral: [REM program for severe neutropenia, recently stopped but functionally treatment and monitoring should be done the same]
AND

b. olanzapine long-acting injection: [REM program for risk of post-injection delirium/sedation (PDSS) if injected into vein]

AND

c. loxapine inhalation: [REM program b/c of potential for respiratory arrest due to bronchospasm]

[The last option, asenapine oral, has a warning for serious allergic reactions, but no REM program]

Which LAI does not require oral antipsychotic overlap?

a. olanzapine

b. paliperidone

c. aripiprazole

d. risperidone

a. olanzapine

AND

b. paliperidone

Which dosage forms is loxapine available as?

a. Long-acting injectable

b. Oral

c. Short-acting injections

d. Orally disintegrating tablet

e. Patch

f. Inhaler

g. Sublingual

b. Oral

AND

f. Inhaler

[loxapine is the only AP available via inhalation!!!! (Nasal?????)]

Which of the following counseling would you give a patient on asenapine?

a. Do not chew or swallow

b. Eat with 350 calories

c. Avoid food or drink 10 minutes after taking

d. Eat with 500 calories

a. Do not chew or swallow

AND

c. Avoid food or drink 10 minutes after taking

[Both of these actions will inactivate asenapine! Also, asenapine is the ONLY AP given sublingually!!!! Specifically as an SL tablet! While its other form is a patch!]

Orally disintegrating tablets (ODT) are difficult to cheek or discard: T/F

True

[ODT APs stick to your inner cheek and do not come off. They were made this way bc patients who don’t want to take AP meds (due to believing they’re not “sick”) may try to avoid taking them by cheeking it to hide it, and then throwing it away later.]

[Remember “CRAO” as the APs available in ODT form!]

The Black Box Warning “increased mortality in elderly patients with dementia-related psychosis” is used for which antipsychotic?

a. clozapine only

b. olanzapine only

c. pimavaserin only

d. all antipsychotics

d. all antipsychotics

[And so, APs are not approved for treatment of patients with dementia-related psychosis!!! (Except risperidone as we later learn in dementia, because of it’s unique structure. But the black box warning still applies.)]

Which antipsychotic causes neuroleptic maligant syndrome (NMS)?

a. all antipsychotics

b. haloperidol

c. risperidone

d. clozapine

a. all antipsychotics

Sedation, orthostatic hypotension, and anticholinergic effects occur most frequently with which antipsychotics?

a. Second-generation antipsychotics

b. High potency antipsychotics

c. Low potency antipsychotics

d. Mid potency antipsychotics

c. Low potency antipsychotics

[Namely, chlorpromazine and thioridazine. Otoh they also don’t really cause extrapyramidal symptoms, unlike high-potency FGAs)

You are counseling a 30-year-old female about sexual side effects of risperidone. Which adverse effects do you counsel her about?

a. Erectile dysfunction, retrograde ejaculation, difficulty with orgasm

b. Difficulty with orgasm, decreased libido, retrograde ejaculation

c. Gynecomastia, amenorrhea, galactorrhea

d. Gynecomastia, galactorrhea, erectile dysfunction

c. Gynecomastia, amenorrhea [absence of menstrual period for an extended period], galactorrhea

[Mostly risperidone and paliperidone cause these!!!! (Think back to the bolded red lists on the Schizo Pharmacology document. To a lesser extent, high-potency FGAs do also.]

How much weight can a patient gain from baseline before guidelines recommend changing therapy?

a. 3%

b. 5%

c. 7%

d. 9%

c. 7%

[MUST change therapy (change AP) once this happens!]

Which of the following lipid changes are observed clinically more than other lipid changes?

a. Increased total cholesterol

b. Increased triglycerides

c. Increased LDL

d. Increased HDL

b. Increased triglycerides

[Especially seen with APs that cause metabolic syndrome (weight gain, glucose intolerance, lipid abnormalities), which are: clozapine, olanzapine, quietiapine.]

Choose a treatment for a patient who has transportation as a barrier to care.

a. clozapine

b. risperidone long acting injection (LAI) (Risperdal Consta)

c. fluphenazine long acting injection (Prolixin Decanoate)

d. paliperidone long acting injection (Invega Trinza)

d. paliperidone long acting injection (Invega Trinza)

[It’s administered every 3 months!]

How often should an ANC be checked when a patient starts clozapine (Clozaril)?

a. Daily

b. Weekly

c. Every other week

d. Monthly

e. Annually

b. Weekly

[When first started to 6 months thereafter]

[DAILY checking of ANC is only needed if patient develops moderate neutropenia (ANC <1000) or severe neutropenia (ANC <500)]

If a patient has been compliant with getting ANCs drawn weekly for 6 months, in the future those blood draws can be checked:

a. Daily

b. Weekly

c. Every other week

d. Monthly

e. Annually

c. Every other week

[For next 6 months!!!]

If patients have been taking clozapine without missing an ANC blood draw for one year, how often can they get blood drawn thereafter?

a. Daily

b. Weekly

c. Biweekly

d. Monthly

e. Annually

d. Monthly

What is an advantage of using a decanoate or other antipsychotic injection?

a. Greater efficacy than oral tablets

b. Greater safety than other forms

c. Good for individuals with non-adherence

d. Good for treatment of agitation

c. Good for individuals with non-adherence — b/c longer-acting than other forms!!!

[a. Greater efficacy than oral tablets — NOT TRUE

b. Greater safety than other forms — NOT TRUE

d. Good for treatment of agitation — NOT TRUE, LAIs are NOT good for this bc they take a while to start taking effect; you want something that works quickly to soothe the agitation]

Which of the following rating scales should be used to monitor for tardive dyskinesia?

a. Simpson Angus Scale (SAS)

b. Abnormal Involuntary Movement Scale (AIMs)

c. Dyskinesia Identification System of Condensed User Scale (DISCUS)

d. Barnes Akathisia Rating Scale (BARS)

b. Abnormal Involuntary Movement Scale (AIMs) [~10 minutes to administer]

AND

c. Dyskinesia Identification System of Condensed User Scale (DISCUS) [~25 minutes to administer]

[Score from these provides baseline for comparison to assess if movements from tardive dyskinesia are getting worse.]

[Simpson Angus Scale (SAS) — for EPS monitoring; Barnes Akathisia Rating Scale (BARS) — for akathisia monitoring.]

AJ has a PANSS score of 90. Four weeks after his new antipsychotic was initiated, his PANSS score is 68. AJ has achieved a response on his PANSS: T/F?

True

[“Response” is considered to have happened when PANSS score has had a ≥20% decline]

[90 - (20% x 90) = 72, and so follow-up score of 68 means a greater than 20% decline]

How often should lipids be monitored for patients on antipsychotics?

a. Baseline, 12 weeks, and annually thereafter

b. Baseline, 4 weeks, 8 weeks, 12 weeks, and quarterly

c. Baseline, 12 weeks, and every 5 years thereafter

d. Baseline and annually

c. Baseline, 12 weeks, and every 5 years thereafter

How often should blood pressure be monitored?

a. Baseline, 12 weeks, annually

b. Baseline, 4 weeks, 8 weeks, 12 weeks, quarterly

c. Baseline, 12 weeks, every 5 years

d. Baseline, annually

a. Baseline, 12 weeks, annually

[Same as fasting plasma glucose!!!]

How often should fasting plasma glucose be monitored?

a. Baseline, 12 weeks, annually

b. Baseline, annually

c. Baseline, 12 weeks, every 5 years

d. Baseline, 4 weeks, 8 weeks, 12 weeks, quarterly

a. Baseline, 12 weeks, annually

[Same as blood pressure!!!]

What is the definition of benign ethnic neutropenia?

a. ANC of less than 2000 in individuals of African descent in the absence of other causes

b. ANC of less than 1500 in individuals of African descent in the absence of other causes

c. ANC of less than 1000 in individuals of African descent in the absence of other causes

d. ANC of more than 2000 in individuals of African descent in the absence of other causes

b. ANC of less than 1500 in individuals of African descent in the absence of other causes

Which of the following is considered to be mild neutropenia?

a. ANC less than 1500

b. ANC less than 1000

c. ANC less than 500

d. ANC less than 250

a. ANC less than 1500

Which of the following is considered to be moderate neutropenia?

a. ANC of less than 1500

b. ANC of less than 1000

c. ANC of less than 500

d. ANC of less than 250

b. ANC of less than 1000

Which of the following is associated with severe neutropenia?

a. ANC of less than 1500

b. ANC of less than 1000

c. ANC of less than 500

d. ANC of less than 250

c. ANC of less than 500

What is the minimum baseline ANC that an individual with benign ethnic neutropenia must have to start clozapine?

a. ANC of 5000

b. ANC of 2500

c. ANC of 1000

d. ANC of 500

c. ANC of 1000

[For normal population it is ANC of ≥1500]

AJ is taking thiothixene 40 mg, but is switching to risperidone. What is the chlorpromazine equivalent dose?

a. risperidone 2 mg

b. risperidone 4 mg

c. risperidone 20 mg

d. risperidone 40 mg

c. risperidone 20 mg

[We will be given the table of equivalencies by Dr. Jackson on the test!! Just set up ratio and cross multiply.]

Which antipsychotic is available as a nasal spray?

a. loxapine

b. perphenazine

c. lurasidone

d. asenapine

a. loxapine

[The ONLY AP to be available as a nasal spray!!!]

Which antipsychotics come as short-acting injections?

a. risperidone, aripiprazole, haloperidol

b. haloperidol, olanzapine, ziprasidone

c. fluphenazine, paliperidone, aripiprazole

d. olanzapine, paliperidone, risperidone

b. haloperidol, olanzapine, ziprasidone

[Administered IM mostly, except haloperidol which is IM and IV]

[“HOZ”]

[Short-acting injections are to treat agitation!!!]

Which antipsychotics come as orally disintegrating tablets (ODTs)?

a. brexpiprazole, asenapine, lurasidone

b. paliperidone, haloperidol, fluphenazine

c. clozapine, risperidone, aripiprazole

d. asenapine, iloperidone, paliperidone

c. clozapine, risperidone, aripiprazole

[These +olanzapine (as Zyprexa Zydis)]

[“CRAO”]

Which antipsychotic must be taken with food to be absorbed?

a. ziprasidone

b. clozapine

c. risperidone

d. brexpiprazole

a. ziprasidone

[Must take with ~500 calories, so a high-fat meal or ice cream]

Which antipsychotic should be taken with 350 calories to be absorbed?

a. ziprasidone

b. brexpiprazole

c. asenapine

d. lurasidone

d. lurasidone

[Also causes the least amount of weight gain out of the APs]

[a. ziprasidone — needs to be taken with ~500 calories, so a high-fat meal or ice cream

c. asenapine — specifically should NOT eat or drink in the 10-minutes before and 10-minute after range of taking; that will render it ineffective]

[Food/drink not important with brexpiprazole]

What kind of extrapyramidal side effects causes the neck to twist to the side?

a. akathisia

b. acute dystonia

c. pseudoparkinsonism

d. tardive dyskinesia

b. acute dystonia

Which extrapyramidal side effect causes stiffness and tremor?

a. akathisia

b. pseudoparkinsonism

c. acute dystonia

d. tardive dyskinesia

b. pseudoparkinsonism — causes stiffness, tremor, +cogwheel rigidity, sialorrhea (excessive drooling), slow movement, mask-like face

Which extrapyramidal effect is associated with pacing?

a. akathisia

b. pseudoparkinsonism

c. acute dystonia

d. tardive dyskinesia

a. akathisia

[Treat akathisia with propranolol!!!]

Which of the antipsychotics cause the most weight gain?

a. clozapine, olanzapine, quetiapine

b. risperidone, brexpiprazole, aripiprazole

c. lurasidone, iloperidone, asenapine

d. paliperidone, ziprasidone, aripiprazole

a. clozapine, olanzapine, quetiapine

[These also cause the most glucose intolerance and the most abnormal lipid levels on top of the most weight gain… basically they cause the most metabolic syndrome syndrome, but in various orders as you know from the red-text lists.]

Which antipsychotic causes the least amount of weight gain?

a. risperidone

b. lurasidone

c. iloperidone

d. cariprazine

b. lurasidone

Which antipsychotic causes the least sedation?

a. haloperidol

b. thioridazine

c. quetiapine

d. cariprazine

a. haloperidol

[A high-potency FGA, should cause EPS and, eventually, tardive dyskinesia!!!!]

Which antipsychotics cause the most sedation?

a. aripiprazole, asenapine, brexpiprazole

b. lurasidone, iloperidone, paliperidone

c. quetiapine, olanzapine, clozapine

d. haloperidol, fluphenazine, trifluoperazine

c. quetiapine, olanzapine, clozapine

[Reference the red-text lists!!!]

What serotonin receptor causes sedation?

a. 5-HT1A

b. 5-HT2A

c. 5-HT4

d. 5-HT7

d. 5-HT7

Which antipsychotics cause orthostatic hypotension?

a. aripiprazole, asenapine, ziprasidone

b. quetiapine, thioridazine, clozapine

c. lurasidone, iloperidone, risperidone

d. paliperidone

b. quetiapine, thioridazine, clozapine

[These may sometimes function like low-potency FGAs!]

[*Quetiapine being here is a little off from the red-text lists but whatever….. it mostly tracks]

You just gave a Risperidone Consta long-acting injection. What should you do with the syringe after you give the shot?

a. Put the syringe and needle in your pocket

b. Put the syringe and needle in your soda can

c. Put the syringe and needle in the closest trash can

d. Put the syringe and needle in a sharps box

d. Put the syringe and needle in a sharps box

A new drug came to market in March 2023 and it significant blocks D2 in the basal ganglia. What adverse effect would you expect?

a. Anticholinergic efects

b. Orthostatic hypotension

c. Parkinsonian symptoms

d. QTc interval prolongation

c. Parkinsonian symptoms

[Bc basal ganglia is located in the nigrostriatal pathway, the “Parkinsonian pathway”]

Which of the following medications is a partial agonist at dopamine-2 receptors?

a. olanzapine, quetiapine, risperidone

b. cariprazine, aripiprazole, brexpiprazole

c. chlorpromazine, perphenazine, lurasidone

d. paliperidone, loxapine, thiothixene

b. cariprazole, aripiprazole, brexpiprazole

[lumateperone (part of the “-prazines and -prazoles”) also has partial D2 agonist activity!!]

—> [CAB-L (“-prazoles”)]

[a. olanzapine, quetiapine, risperidone — ??

c. chlorpromazine, perphenazine, lurasidone — chlorpromazine is a low-potency FGA and perphenazine is a mid-potency FGA; both are pure D2 antagonists!]

d. paliperidone, loxapine, thiothixene — loxapine is a mid-potency FGA and thiothixene is a high-potency FGA; both are pure D2 antagonists!]

How would you counsel a patient on ziprasidone?

a. Take in the morning one hour before meals

b. Do not take with food or drink

c. Take at night with a light snack

d. Take with 500 calories twice daily

d. Take with 500 calories twice daily

[You need a lot of calories simultaneously for ziprasidone to work, so take with high-fat meals or ice-cream.]

[Remember: asenapine is the OPPOSITE — NO food or drink when taking at least 10 minutes before and after taking it]

How frequently should an AIMS scale be completed in a first-generation antipsychotic (FGA)?

a. At baseline and every week for 6 months

b. At baseline and every 6 months

c. At baseline and every 12 months

d. At baseline, 6 months, then annually thereafter

b. At baseline and every 6 months

How frequently should an AIMS scale be completed in a second-generation antipsychotic (SGA)?

a. Baseline and weekly thereafter

b. Baseline and every 6 months

c. Baseline and 6 months, then annually

d. Baseline and once every 12 months

d. Baseline and once every 12 months

[AIMS scale evaluates tardive dyskinesia!!!]

Which antipsychotic is metabolized by CYP1A2?

a. thioridazine

b. olanzapine

c. clozapine

d. lurasidone

a. thioridazine

AND

b. olanzapine

AND

c. clozapine

[—> “COT(h)”]

[CYP1A2 metabolism significant bc smoking induces CYP1A2!!!]

[Look in AP DDIs section of Schizo Pharmacology doc!]

[Lurasidone is metabolized by CYP3A4]

Cigarette smoking induces which CYP enzyme?

a. CYP1A2

b. CUP2D6

c. CYP2C19

d. CYP3A4

a. CYP1A2

[Remember that the cigarette smoke is what causes the induction! Also, it doesn’t affect any of the other CYP enzymes listed.]

Which antipsychotics cause akathisia?

a. haloperidol

b. risperidone

c. aripiprazole

d. cariprazine

ALL!!!!!

a. haloperidol — causes most

b. risperidone

c. aripiprazole — causes second-most

d. cariprazine

[Note that all “-prazines and -prazoles” can cause akathisia.]

[Haloperidol and risperidone + all -prazines and -prazoles: “HR + all -prazines/-prazoles”]

Which antipsychotics cause the greatest risk of metabolic syndrome?

a. clozapine, olanzapine, quetiapine

b. aripiprazole, paileridone, asenapine

c. risperidone, ziprasidone, lurasidone

d. brexpiprazole, cariprazine, iloperidone

a. clozapine, olanzapine, quetiapine

[Reference the red-text lists!! They all cause the most metabolic syndrome (weight gain, glucose intolerance, and lipid abnormalities), but not all in the exact same order.]

Which antipsychotics cause the least risk of metabolic syndrome?

a. clozapine, olanzapine, quetiapine

b. aripiprazole, lurasidone, ziprasidone

c. risperidone, paliperidone, quetiapine

d. paliperidone, iloperidone, olanzapine

b. aripiprazole, lurasidone, ziprasidone — “-dones” (besides risperidone) and aripiprazole mostly do not cause metabolic syndrome!!!

[a. clozapine, olanzapine, quetiapine

c. risperidone, paliperidone, quetiapine

d. paliperidone, iloperidone, olanzapine]

[Olanzapine and quetiapine along with clozapine are the most metabolic syndrome-causing APs!]

Pseudoparkinsonism is characterized by which of the following symptoms?

a. Unilateral hand tremor, pacing, stiff neck

b. Grimacing, tongue protrusion, foot dropping

c. Stiffness, bilateral tremor, cogwheel rigidity

d. Inability to sit still, laryngospasm, pacing

c. Stiffness, bilateral tremor, cogwheel rigidity

[Stiffness and cogwheel rigidity are both PD symptoms. For bilateral tremor — actual PD causes unilateral tremor, but drug-induced Parkinsonism causes bilateral tremor]

Response on the BPRS is defined as a decrease of 20% and remission is defined as a score equal or less than 3: T/F?

True

[Response in BPRS = generally 20% reduction in symptoms

Remission in BPRS = score of ≤3 for at least 6 months on each selected item]

• [≥53: markedly ill — 168 is maximum score

• 32-52: moderately ill

• ≤31: mildly ill]