schizophrenia - dr krysiak

4 hours 👉🏻👈🏻 20 questions...sorry it's so long, i feel like she asks little details sometimes :/

schizophrenia is a ___________

a. mood disorder

b. thought disorder

b.

when does onset of illness typically occur?

adolescence or early adulthood

which pathway is this: positive symptoms (hallucinations), increased dopamine, all antipsychotics have ability to block dopamine here

a. mesolimbic

b. mesocortical

c. nigrostriatal

d. tuberoinfundibular

a.

which pathway is this: negative symptoms (cognitive decline), decreased dopamine, hypofunction —> cognitive effects

a. mesolimbic

b. mesocortical

c. nigrostriatal

d. tuberoinfundibular

b.

which pathway is this: movement, D2 antagonism induces EPS

a. mesolimbic

b. mesocortical

c. nigrostriatal

d. tuberoinfundibular

c.

which pathway is this: dopamine released inhibits prolactin, D2 antagonism could increase prolactin levels (hyperprolactinemia)

a. mesolimbic

b. mesocortical

c. nigrostriatal

d. tuberoinfundibular

d.

what causes EPS systems to occur when antipsychotics are taken (blocking dopamine)?

imbalance of dopamine (deficiency) and acetylcholine (excess) in nigrostriatal pathway

checkpoint

which dopamine pathway is involved with positive symptoms of schizophrenia?

a. mesocortical

b. nigrostriatal

c. mesolimbic

d. tuberoinfundibular

c.

schizophrenia is a chronic disorder of _______ and _______

thought and affect

when are relapse and recurrence rates highest?

two-year period following first hospitalization

are the following positive symptoms, negative symptoms, or cognitive symptoms?

• suspiciousness

• unusual thought content (delusions)

• hallucinations

• conceptual disorganization

positive symptoms

are the following positive symptoms, negative symptoms, or cognitive symptoms?

• affective flattening

• alogia (absence of speech)

• anhedonia (diminished interests)

• avolition (no motivation)

negative symptoms

think about the “A’s”

are the following positive symptoms, negative symptoms, or cognitive symptoms?

• impaired attention

• impaired working memory

• impaired executive function

cognitive symptoms

if someone has had symptoms for < 2 weeks, this is _________

a. brief psychotic episode

b. schizophreniform

c. schizophrenia

d. chronic schizophrenia

a.

if someone has had symptoms for ≥ 2 weeks and < 6 months, this is _________

a. brief psychotic episode

b. schizophreniform

c. schizophrenia

d. chronic schizophrenia

b.

if someone has had symptoms for ≥ 6 months, this is _________

a. brief psychotic episode

b. schizophreniform

c. schizophrenia

d. chronic schizophrenia

c.

if someone has had symptoms for > 2 years, this is _________

a. brief psychotic episode

b. schizophreniform

c. schizophrenia

d. chronic schizophrenia

d.

how is schizophrenia diagnosed?

two or more of the following for at least 1 month:

• delusions*

• hallucinations*

• disorganized speech*

• grossly disorganized or catatonic behavior

• negative symptoms

need to have at least one of the * symptoms

T/F co-occurrence of substance use disorder is very common

TRUE

checkpoint

which of the following is a negative symptom of schizophrenia?

a. hallucinations

b. delusions

c. avolition

d. disorganization

c.

T/F schizophrenia is a curable disease

FALSE — NOT a curable disease: most pts will experience residual symptoms

treatment should be _________ during the first ________ after initial psychotic episode

assertive during the first 5 years

list nonpharm treatment options

• psychosocial rehab programs

  • case management

  • psychoeducation

  • targeted cognitive therapy

  • basic living and social skills

  • work programs

  • supported housing

• assertive community treatment (ACT)

  • teams available 24-hour basis and work in pts home and/or employment

  • help with meds, crisis interventions, and daily living skills

list predictors of treatment response

• prior med response

• substance use —> won’t respond as well

• precipitating factors

• onset of symptoms —> later in life, chances of response are higher

• stable interpersonal relationships/employment

list the first gen antipsychotics

• chlorpromazine (thorazine)

• fluphenazine (prolixin, decanoate)

• haloperidol (haldol, haldol-d)

• thioridazine

• perphenazine

• thiothixene

• trifluperazine

• loxapine

• molindone

all first gen antipsychotics are dopamine receptor antagonists with ___________

high affinity for D2 receptors

what other receptors do FGAs affect? (SATA)

a. alpha

b. histaminergic

c. nicotinic

d. muscarinic

a. b. d.

what are the high potency FGAs? (SATA)

a. haloperidol

b. loxapine

c. fluphenazine

d. thiothixene

e. perphenazine

f. trifluoperazine

g. chlorpromazine

h. thioridazine

a. c. d. f.

what are the mild potency FGAs? (SATA)

a. haloperidol

b. loxapine

c. fluphenazine

d. thiothixene

e. perphenazine

f. trifluoperazine

g. chlorpromazine

h. thioridazine

b. e.

what are the low potency FGAs? (SATA)

a. haloperidol

b. loxapine

c. fluphenazine

d. thiothixene

e. perphenazine

f. trifluoperazine

g. chlorpromazine

h. thioridazine

g. h.

what FGA is an inhaled powder, indicated for acute agitation, and requires a REMS program because of it’s risk of bronchospasm?

a. perphenazine

b. chlorpromazine

c. loxapine

d. haloperidol

c.

what is the antipsychotic effect of SGAs on the mesolimbic pathway?

a. relief of positive symptoms

b. relief of negative symptoms

c. less chance of EPS

d. less hyperprolactinemia

a.

what is the antipsychotic effect of SGAs on the mesocortical pathway?

a. relief of positive symptoms

b. relief of negative symptoms

c. less chance of EPS

d. less hyperprolactinemia

b.

what is the antipsychotic effect of SGAs on the nigrostriatal pathway?

a. relief of positive symptoms

b. relief of negative symptoms

c. less chance of EPS

d. less hyperprolactinemia

c.

what is the antipsychotic effect of SGAs on the tuberoinfundibular pathway?

a. relief of positive symptoms

b. relief of negative symptoms

c. less chance of EPS

d. less hyperprolactinemia

d.

T/F SGAs block the dopamine receptor (decr. positive symptoms) AND the serotonin receptor (decr. negative symptoms)

TRUE

all SGAs except ______ and _____ have greater affinity for serotonin receptors than dopamine receptors

aripiprazole and brexpiprazole

what SGAs also exhibit D2 (dopamine) partial agonism?

• aripiprazole

• brexpiprazole

• cariprazine

two “pips” and a “rip”

checkpoint

which of the following FGAs is a low potency agent with high risk of weight gain?

a. haloperidol

b. perphenazine

c. chlorpromazine

d. olanzapine

c.

checkpoint

in addition to dopamine blockade, second generation antipsychotics as a class have a mechanism of:

a. dopamine agonism

b. serotonin antagonism

c. alpha blockade

d. histaminergic blockade

b.

what is a major side effect of aripiprazole (abilify)?

akathisia

what SGA only comes as a sublingual tablet or patch?

how should the SL tablet be administered?

asenapine (saphris, secuedo)

no food or drink for 10 minutes after dose

list ADRs of asenapine (saphris, secuedo)

somnolence

EPS

QT prolongation

what SGAs are only available orally?

brexpiprazole (rexulti)

cariprazine (vraylar)

clozapine (clozaril)

lumateperone (caplyta)

lurasidone (latuda)

quetiapine (seroquel, XR)

list ADRs of brexpiprazole (rexulti)

• weight gain

• dyspepsia

• diarrhea

• akathisia

list side effects of cariprazine (vraylar)

• EPS

• dystonia

• headache

what SGA is only indicated if patients fail 2 treatments?

clozapine (clorazil, flozclo, versacloz)

what SGA is very effective and has the lowest risk of EPS?

clozapine (clozaril, flozclo, versacloz)

what is the BBW for clozapine?

neutropenia/agranulocytosis

myocarditis and cardiomyopathy

orthostatic hypotension

seizures (dose related)

T/F there is a REMS program for clozapine (clozaril)

FALSE - there used to be but now we just monitor

when is the risk greatest for neutropenia with clozapine (clozaril)?

what will patients report?

first 18 weeks of therapy

“flu-like” symptoms

list adverse effects specific to clozapine (clozaril)

• sialorrhea (excessive drooling)

• severe constipation

• HIGH weight gain risk

at what ANC level do we initiate clozapine treatment?

a. < 500

b. > 1000

c. ≤ 1000

d. ≥ 1500

d.

what do we do with clozapine when a patient has mild neutropenia (ANC 1000 - 1499)? (SATA)

a. interrupt treatment

b. continue treatment

c. monitor ANC three times weekly

d. monitor ANC weekly

b. c.

what do we do with clozapine when a patient has moderate neutropenia (ANC 500 - 999)? (SATA)

a. interrupt treatment

b. continue treatment

c. monitor ANC three times weekly

d. monitor ANC daily

a. d.

what do we do with clozapine when a patient has severe neutropenia (ANC < 500)? (SATA)

a. interrupt treatment

b. continue treatment

c. monitor ANC three times weekly

d. monitor ANC daily

e. recommend hematology consultation

a. d. e.

list side effects of lumateperone (caplyta)

• somnolence

• EPS

what SGA needs to be given with food (≥ 350 calories)?

a. olanzapine (zyprexa)

b. lurasidone (latuda)

c. paliperidone (invega)

d. risperidone (risperdal)

b.

what SGA is contraindicated with strong CYP3A4 inhibitors/inducers?

a. clozapine (clozaril)

b. lumateperone (caplyta)

c. lurasidone (latuda)

d. quetiapine (seroquel, XR)

c.

list ADRs of lurasidone (latuda)

• somnolence

• EPS

• nausea

what is the boxed warning for the olanzapine long acting injectable (zyprexa relprevv)?

how do we monitor?

sedation and delirium following injection

must be monitored for 3 hours post injection (REMS)

what SGAs have a side effect of metabolic syndrome?

end with “-pine” or “-done”, but not all

olanzapine

quetiapine

paliperidone

risperidone

what is metabolic syndrome?

• weight gain

• incr. blood glucose

• incr. lipids

what are counseling points for paliperidone oral tablet (invega)?

do NOT break or crush

ghost tablet in stool

what SGA is the active metabolite of risperidone?

similar side effects

paliperidone

list side effects of paliperidone and risperidone

incr. prolactin

EPS (especially at high doses)

metabolic syndrome

how is quetiapine XR (seroquel XR) administered?

at night WITHOUT food or light meal

T/F quetiapine (seroquel) has HIGH EPS risk

FALSE - low EPS risk

list side effects of quetiapine (seroquel)

• somnolence

• metabolic syndrome

• ocular effects (cataracts)

what SGA comes as an oral tablet, IM long-acting injectable, and SQ long-acting injectable?

risperidone

list the IM long-acting risperidone injectables

• risperdal consta

• rykindo

list the SQ long-acting risperidone injectables

• uzedy

• perseris

how do you administer ziprasidone (geodon)?

what is it contraindicated in?

oral and IM (acute) injection

-take oral WITH food

CI in QT prolongation

list side effects of ziprasidone (geodon)

• somnolence

• EPS

• dizziness

checkpoint

when educating a patient on a new prescription for lurasidone, which statement would be considered the most appropriate regarding taking the medication?

a. take the dose prior to bedtime for full effect

b. avoid grapefruit and grapefruit juices

c. all side effects are short lived

d. take dose on an empty stomach

b.

checkpoint

a patient presents to your clinic and is found to have hyperprolactinemia from his risperidone. what additional antipsychotic should be avoided?

a. clozapine

b. olanzapine

c. paliperidone

d. quetiapine

c.

what is the BBW for all antipsychotics?

increased risk of mortality if used for dementia-related psychosis

mortality related to CV outcomes and infection

list the endocrine adverse effects of antipsychotics

prolactin elevation

weight gain

type 2 DM

adverse effects

when do we monitor prolactin levels (elevation)?

when symptoms are present —> may need to switch agents

women: galactorrhea, amenorrhea, and anovulation

men: impotence and gynecomastia

adverse effects

who is at greater risk of weight gain?

younger age

antipsychotic naïve

low BMI before treatment

polypharmacy

list CV adverse effects of antipsychotics

orthostatic hypotension

ECG changes —> QT prolongation

lipid changes

if QTc interval exceeds ________ we should discontinue the antipsychotic

500 msec

what antipsychotic drug is the side effect myocarditis specific to?

clozapine

T/F all antipsychotics should be monitored for lipid changes (elevation) and they can cause metabolic syndrome to develop

TRUE

list the extrapyramidal system (EPS) symptoms

antipsychotic induced movement disorders

• dystonia

• akathisia

• pseudoparkinsonism

• tardive dyskinesia (TD)

come back to the table on slide 66

checkpoint

a 67 yo patient that has been taking risperidone 0.5 mg PO BID x 4 weeks presents to your outpatient clinic with bradykinesia and tremor at rest. what is the most likely EPS the patient is experiencing?

a. akathisia

b. dystonia

c. tardive dyskinesia

d. pseudoparkinsonism

d.

checkpoint

which of the following is a black boxed warning of clozapine? (SATA)

a. constipation

b. myocarditis

c. agranulocytosis

d. death with dementia related psychosis

b. c. d.

idk if we need to know

what is key for tardive dyskinesia?

what are first line agents for treatment?

prevention is key

tx: VMAT2 inhibitors

• Ingrezza

• Austedo

reduce dose if CYP2D6 poor metabolizer

what drug is approved for psychosis in parkinson’s disease?

Pimavanserin (Nuplazid)

-inverse agonist and antagonist at serotonin receptors

-does NOT affect dopamine

adverse effects

list risk factors for seizures

• high doses

• rapid dose incr.

• history of seizures

• meds that lower seizure threshold

• clozapine

adverse effects

what are signs/symptoms of neuroleptic malignant syndrome (NMS)?

• incr. body temp

• altered consciousness

• autonomic dysfunction

  • tachycardia

  • labile BP

  • diaphoresis

• muscle rigidity —> telltale sign

• leukocytosis and incr. CK

what drug has a BBW for drug reaction with eosinophilia and systematic symptoms (DRESS)?

olanzapine

T/F all antipsychotics can cause photosensitivity and blue-gray/purple skin coloration

FALSE — all can cause photosensitivity, but only chlorpromazine can cause blue-gray/purple skin

since smoking is a potent inducer of CYP1A2 what drug to we have to watch out for if they stop smoking?

what can happen?

clozapine

incr. levels —> incr. seizure risk

first-episode patients should be started at _________ of normal dosage range

a. 25%

b. 50%

c. 75%

d. 100%

b.

what is considered an adequate trial for antipsychotics at therapeutic dose?

a. 2-4 weeks

b. 4-6 weeks

c. 6-8 weeks

d. 12 weeks

b.

what is the goal of maintenance treatment?

prevent relapse

what is a mainstay of treatment for improving adherence?

long-acting injectable antipsychotics (LAIA)

list disadvantages of long-acting injectable antipsychotics

• appointment required for administration

• delayed disappearance of distressing side effects after d/c