Psych Inpatient

For tx resistant schizophrenia

clozapine

treat with _____ if risk for suicide attempts/suicide remains high despite other tx

clozapine

treat with _____ if risk for aggressive behavior remains high despite other tx

clozapine

tx for hx poor adherence

LAI

positive symptoms of schizophrenia

suspiciousness, delusions, hallucinations, conceptual disorganization

negative symptoms of schizophrenia

affective flatteningalogia- inability to speak because of dysfunction in the central nervous systemanhedonia-the inability to feel pleasureavolition-lack of motivation that makes it hard to get anything done

cognitive symptoms of schizophrenia

impaired attention, memory, executive function

pro SGA vs FGA

-few/no EPS-some have enhanced efficacy (for negative and cognition) -no tardive dyskinesia-no effect on serum prolactin

con of SGA

metabolic side effects

metabolic AE

-Weight gain-hyperlipidemia-DM

tx algorithm

0

SGA

-aripiprazole-olanzapine-quetiapine-risperidone-ziprasidone

SGA not recommended in first episode and why

quetiapine, olanzapine-metabolic side effects, weight gain

SGA recommended in first episode

-aripiprazole-risperidone-ziprasidone

SGA with least weight gain

-aripirazole-ziprasidone

Oral vs LAI risperidone

In first episode patients, LAI more effective than oral

prior to initiating LAI

start with stabilization on oral dosage form of same agent for 4-14determine patient tolerance, AE, etc

inadequate clinical improvement on first med OR relapse while taking med

monotx with FGA or SGA not previously used

consider clozapine at stage 2 if

- suicidal patient- hx violence- comorbid SA

poor sx improvement with two different antipsychotics -->

clozapine

induce psychosis or exacerbate psychosis in patients with pre existing psychiatric illness

-amphetamines/other CNS stimulants-cocaine-corticosteroids-indomethacin-marijuana

initiation dosing strategy

the dose of most antipsychotic medications can be increased relatively quickly to a typical therapeutic dose once an initial dose has been tolerated.

should be titrated more slowly than other antipsychotics (2)

-iloperidone-clozapine

Why does clozapine need to be titrated slowly

-minimize risk of seizures, orthostatic HTN, excessive sedation

clozapine dosing

From a starting dose of 12.5 mg once or twice daily, the daily clozapine dosage can be increased by, at most, 25-50 mg/day to a target dose of 300-450 mg

patients who might need slower clozapine titration

initial episode oldersensitive to AECNS conditions

clozapine minimize sedation

take at night

Clozapine REMS monitoring

ANC

severe neutropenia

ANC <500

Clozapine highest risk of severe neutropenia

initial 6mo of tx

clozapine AE that resolve vs those that persist

improve after first several days/weeks: sedation, hypotension, nausea, dry mouth, constipation, difficulty urinating persist: Parkinsonism, akathisia

Because ______ patients have an increased sensitivity to side effects, particularly ______, typical dosing ranges are approximately ____ of the doses used in chronically ill individuals

first-episode psychotic, weight gain, 50%

If a patient has shown at least 20% reduction in sx improvement after ______ at a therapeutic dose then later clinical response is unlikely

2 weeks

Why isn't clozapine first-line treatment for schizophrenia?

1. safety2. WBC monitoring

why should iloperidone, quetiapine, and clozapine be titrated more slowly than other antipsychotics

strong alpha1 Rant --> hypotension

acute dystonia can be life threatening if associated with

laryngospasm

first generation antipsychotics

chlorpromazinelevomepromazinepromazinetriflupromazineMesoridazinePericyazinePipotiazineThioridazinePerphenazineFluphenazineTrifluoperazine

augmentation of tx for pt with negative sx or depression

add an antidepressant

pts who exibit catatonia

add benzo-lorazepam

hyper prolactinemia can lead to

breast enlargement, galactorrhea, sexual dysfunction, menstrual dustirbances

hyperlipidemia common in

clozapine + olanzapine

clozapine CV related AE

myocarditiscardiomyopathy QTc prolongation

constipation common in

clozapine

Neuroleptic Malignant Syndrome triad

rigidityhyperthermia HTN and tachycardia

NMS tx

benzo-lorazepam

tardive dyskinesia

involuntary movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of antipsychotic drugs that target certain dopamine receptors

tardive dyskinesia onset

months to years, later in tx

tardive dyskinesia may persist and may even increase, despite ____ or ____ of the antipsychotic medication

reduction in dosedc

higher risk for tardive dyskinesia

age >55, female, white or AA, mood disorder, intellectual disability, CNS injury, past akathisia

clozapine + high risk of seizure

PPX with anticonvulsant

DM/glucose dysregulation AE

clozapine, olanzapine

stabalization tx: when should symptom improvement occur

over 6-12w

dose titration for stabilization tx

q1-2w

Preventing Relapse

continuous lifetime therapy

How to d/c antipsychotics

taper slowly over 1-2wwhile second antipsychotic is initiated and dose titrated

discontinuation of antipsychotics can lead to

withdrawal symptoms

withdrawal symptoms

insomniaheadachenightmaresGIrestlessnessincreased salivationsweating

eight LAI

Risperidone (2 formulations)PaliperidoneAripiprazoleolanzapine heloperidolfluphenazine ri

treatment resistance

persistent sx of moderate severitytwo antipsychotic tx failures at adequate dosage for at least 6wwith good tx adherence

sialorrhea

excessive salivation

sialorrhea AE, and tx

clozapine, chew gum

acute dystonia

prolonged contraction of muscles, usually of the head and neck

Akathisia

motor restlessness

Parkinsonism

tremor, rigidity/stiffness, slowed movement

Only ____ has shown superiority over other antipsychotics for the management of treatment-resistant schizophrenia

clozapine

____ is a common problem among tx resistant pt, and ____ reportedly ____ water drinking

polydipsiaclozapinedecreases

FGA MOA

High D2 antagonismlow 5-HT3 antagonism

SGA MOA

High D2 antagonism high 5-HT3 antagonism

clozapine MOA

Low D2 antagonism high 5-HT3 antagonism

SGA with highest prolactinemia rates

risperidone paliperidone

Hyperprolactinemia side effects

gynecomastiamesntrual irregularities infertilitysexual dysfunction

For women with schizophrenia who suffer from amenorrhea due to antipsychotic-induced hyperprolactinemia, ____/day has been shown to restore menstrual function, with improvements being associated with a reduction in prolactin level

metformin 750 to 1,500 mg

weight gain typically seen in _____

first 12 weeks

highest rate of AIWG

Clozapineolanzapine

American Diabetes Association consensus task force recommends consideration of a change in antipsychotic if a patient gains more than ____ of baseline body weight after starting the drug.

5%

_____ is effective in treating antipsychotic-induced weight gain

metformin

highest risk of orthostatic hypotension

clozapinequetiapine

Clozapine max dose

900 mg/day

when should clozapine levels be drawn

3 days after dose change 12 hours after last dose

In most patients, efficacy will be highest at levels greater than _____ of clozapine

350 ng/mL

option for patient who acute dystonia associated with antipsychotic therapy

tx with anticholinergic medication

anticholinergic medication used to tx acute dystonia

diphenhydraminebenztropine

Once the acute dystonia has resolved, it may be necessary to continue an ______ medication to prevent recurrence,

oral anticholinergic

benztropine vs diphenhydramine for preventing acute dystonia

benztropine preferred bc longer half life, diphenhydramine also has more sedation

options for antipsychotic induced Parkinsonism

reduced doseswitchanticholinergic

For individuals who are highly sensitive to medication-induced parkinsonism, ______ may be considered.

clozapine

______ can be worsened by use of anticholinergic medications

tardive dyskinesias

options for patients with have akathisia induced by antipsychotic tx (4)

lower doseswitchbenzoBeta adrenergic blocking agent

benzo for akathisia

lorazepam, clonazepam

BB for akathisisa, dose

propranolol 30-120

akathisia tends not to respond to ______

anticholinergic agents

patients who have moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy be treated with a ______

VMAT2

VMAT2 stands for

reversible inhibitor of the vesicular monoamine transporter 2

VMAT2 options, which is preffered?

Deutetrabenazine, Valbenazine>> Tetrabenazine,

BPD mood stabilizers

lithiumvalproatecarbamazepine/oxcarbazepinelamotriginetopiramategabapentin

_______ or other manic inducing substances should be stopped in patients experiencing a manic, hypomanic, or mixed manic episode.

antidepressants

taper antidepressants over _____

3-5d

severe mania or severe mixed episode should be started on

lithium or valproate + SGA

serum concentration of lithium should be maintained between

0.8-1.2mEq/L

serum concentration of valproate should be maintained between

50-125mcg/ml

serum concentration of carbamazepine should be maintained between

4-12mcg/ml

patient with mania should be started on

lithiumvalproatecarbamazepine any SGAlithium/valproate+SGA

patients with mixed episode should be started on

valproate carbamazepineziprasidonearipiprazolerisperidoneolanzapine

medications not recommended in mania or mixed episode

topiramatelamotriginegabapentin

BPD meds will take how long to show positive effect

5-10d

remission in mania, hypomania, mixed episode

2 months without significant sx of mania, hypomania, mixed episode

mania, hypomania, mixed episode options if patient does not respond to monotx

-switch to another monotx-add on a SGA

BP depression first line

monotx:quetiapinelamotriginelithium

BP depression second line

Olanzapine/fluoxetine combination

Olanzapine/fluoxetine combination reason for second line

adverse effects (weight gain, risk of diabetes, hypertriglyceridemia)

______ NOT recommended for monotherapy in the treatment of acute bipolar depression

aripiprazole

BD depression who do not respond to monotx

lamotrigine+lithium augmentation with SSRI, SNRI, bupropion, and MAO for short term

if medications are to be discontinued, they should be slowly and gradually tapered over at least a ____ period

2 to 4 week

PPX mania

lithium or olanzapine

PPX depression

lithium or lamotrigine