Schizophrenia/Psychosis

Symptoms of Schizophrenia

hallucinations, delusions, disorganized thinking/behavior

NTs involved in schizophrenia

DA, 5-HT, glutamine

meds/drugs that cause psychotic symptoms

anticholinergics

dextromethorphan

dopamine/dopamine agonists (requip, mirapex, sinemet)

interferons

stimulants (includes amphetamines)

systemic steroids (typically w/ lack of sleep)

bath salts (syntehtic cathinones, MDPV)

cannabis

cocaine (especially crack cocaine

lysergic acid diethylamid LSD, hallucinogenics

methamphetamine, ice, crystal

phencyclidine (PCP)

Negative signs of schizophrenia include ____ while positive signs include ___

negative signs: lack of emotion (apathy), social withdral, loss of motivation (avolition), lack of speech (alogia)

positive signs: hallucinations, delusions, disorganized thinking/behavior

Natural products used for psych disorders

fish oils, but prescription medications are often needed

antipsychotic moa

block dopamine receptors, some newer ones also block serotonin

drugs can more easily treat _____ symptoms while ______ symptoms are harder to treat with medications

positive symptoms are easier to treat with medications than negative symptoms

_____ generation antipsychotics are first line due to lower incidence of ______

second generation are first line due to less incidence of EPS

name for muscle contractions (EPS)

dystonias

abnormal movements (EPS)

dyskinesias

repetitive involuntary movements

tardive dyskinesias

restlnessness, inability to remain still

akathisia

T/F: tardive dyskinesia (TD) can be irreversible, the drug causing TD must be discontinued

True

formulation for AAs that can prevent cheeking

ODTs

Do not combine ____ and _____ due to risk of excessive sedation and breathing difficulty

olanzapine and benzodiazepines

antipsychotics are not indicated for ________ due to increased risk of mortality

agitation control in elderly patients with demential-related psychosis

First-generation antipsychotics work by _____ and are in the ______ class ending in -____

block dopamine-2 (D2)

Phenothiazine class

end in -azine

in addition to increased mortality risk, there is an increased risk of ____ in elderly for AAs

stroke

haloperidol is a _____ generation AA of the class _____

first generation

class: butyrophenone

decanoate haloperidol is given

IM monthly

AA first generation warnings

sedation, dizziness, anticholinergic effects

EPS, give anticholinergic to limit/avoid dystonic dystonic rxns

warnings for FGAs

qt prolongation w/ thiordazine, haloperidol, chlorpromazine, orthosasis, orthosasis/falls

anticholinergic effects

CNS depression

EPS

hyperprolactinemia

NMS

notes with FGAs potency

lower potency drugs: higher sedation and lower eps

higher potency drugs: lower sedation and higher eps

haloperidol is a _____ potency FGA

high potency

(lower sedation, higher eps)

Aripiprazole, brexipiprazole, and cariprazine MOA

D2 and 5-HT1A partial agonists

brexipiprazole is also a 5-HT2A antagonists

SGA with a REMS program

cloazpine

Baseline ANC to start clozapine must be ______

1500+

Clozapine should be discontinued if ANC __________

<1000

Boxed warning on Zyprexa Relprevv

used for acute agitation

sedation (including coma) and delirium

patients must be monitored for 3 hours post-injection

Invega generic

paliperidone

SGAs that increase prolactin (cause sexual dysfunction, galactorrhea, change in menstrual cycle)

paliperidone, risperidone

Asenapine is a _____ that can cause a side effect of _____

SGA, can cause tongue numbness

Geodon is brand name

ziprasidone

Lurasidone is contraindicated in

concomitant use with strong inhibitors of cytochrome P450 isozyme 3A4 (CYP3A4) (e.g., ketoconazole, an antifungal) and strong CYP3A4 inducers (e.g., rifampin)

Side effects of clozapine

agranulocytosis, seizures, constipation, increased weight, hypersalivation (sialorrhea)

clozapine place in therapy

no sooner than 3rd line due to severe side effect potential

Abilify Maintena and Aristada frequency

Maintena: monthly

Aristada: Q4-8 weeks

Invega Sustenna is given

monthly

invega trinza is given

every 3 months

invega hafyera is given

every 6 months

SGA often given for psychosis in parkinson disease (has low EPS risk)

quetiapine (seroquel)

Avoid this SGA in patients with QT risk due to its QT prolongation

ziprasidone (geodon)

Boxed warning on clozapine

neutropenia/agranulocytosis (REMS)

myocarditis and cardiomyopathy: DC if suspected

antipsychotic with the highest efficacy

clozapine

however it is NOT first line due to serious side effects

(agranulocytosis, seizures, myocarditis)

When can clozapine be tried?

after failure with at least two other antipsychotics (at least 1 SGA)

an adequate trial of an antipsychotic is _____

6 weeks

Antipsychotics (any generation) with cardiac risk/QT prolongation

ziprasidone, haloperidol, thioridazine, chlorpromazine

Drugs to avoid in parkinson disease (think avoiding risk of EPS)

FGAs, risperidone, paliperidone (at higher doses)

QUETIAPINE IS PREFERRED IN PARKINSONS

Drugs to consider in a patient who is overweight/metabolic risk (exe high TGs)

lower metab. risk with aripiprazole, ziprasidone, lurasidone, asenapine

drugs to avoid in a patient with metabolic risk/is overweight

olanzapine, quetiapine

A cocktail for agitation may include

haldol, diphenhydramine, lorazapam

(sedation, acute agitation, reduce EPS)

Drug approved specifically for psychosis with parkinson disease

pimavanserin (nuplazid)

Nuplazid MOA

pimavanserin

inverse agonist and antagonist at serotonin 5-HT2A receptors and a lesser extent at 5-HT2C receptors, doesn't affect DA receptors and doesn't worsen parkinson disease

T/F: all antipsychotics can prolong the QT interval

true

FGA with boxed warning for QT prolongation

thioridazine

Avoid drugs that lower the seizure threshold with _____

clozapine

Risperidone oral solution counseling

can be mixed with water, coffee, orange juice, or low-fat milk

NOT with cola or tea

Medications approved for the treatment of TD

valbenazine (ingrezza)

deutetrabenazine (austedo)

ingrezza generic

valbenazine

MOA of valbenazine and deutetravbnazine

reversible inhibitor of vesicular monoamine transporter 2 (VMAT2), a transporter that regulates monoamine uptake from the cytoplasm to synaptic vesicle for storage and release

VMAT2 reversible inhibitors include:

valbenazine(ingrezza) and deutetravenazine (austedo)

warnings for VMAT2 inhibitors

somnolence

contraindication of austedo

(deutetrabenazine)

hepatic impairment

T/F: Neuromalignant syndrome is rare but highly lethal

true

Signs of NMS include

hyperthermia (high fever/profuse sweating)

extreme muscle rigidity (lead pipe rigidity - resp. failure)

AMS

tachycardia/BP changes

Treatment of NMS

STOP the antipsychotic

give supportive care

control temp.

give fluids

relax the muscles: give dantrolene/benzos

some cases require a dopamine agonist (bromocriptine)

afterwards consider a different antipsychotic

Given to relax the muscles in NMS

benzos, dantrolene