RxPrep: Chapter 64, Schizophrenia/Psychosis Flashcards

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1

What is schizophrenia?

A chronic, severe and disabling thought disorder

2

What are common positive symptoms of schizophrenia?

  • Hallucinations
  • Delusions
  • Disorganized thinking/behavior
  • Difficulty paying attention

3

What are common negative symptoms of schizophrenia?

  • Lack of emotion (apathy)
  • Social withdrawal
  • Loss of motivation (abolition)
  • Lack of speech (alogia)
  • Loss of interest in everyday activities
  • Inability to plan or carry out activities
  • Poor hygiene

4

Definitions of extrapyramidal side effects (EPS): Dystonias

  • Prolonged contraction of muscles during drug initiation, painful muscle spasms
  • Higher risk in younger males
  • Centrally-acting anticholinergics like diphenhydramine and benztropine can be used for prophylaxis or treatment

5

Definitions of extrapyramidal side effects (EPS): Akathisia

  • Restlessness with anxiety and inability to remain still
  • Treated with BZDs or propanolol

6

Definitions of extrapyramidal side effects (EPS): Parkinsonism

  • Tremors, abnormal gait and bradykinesia
  • Treat with anticholinergics or propranolol if tremor is main symptom

7

Definitions of extrapyramidal side effects (EPS): Tradive dyskinesias (TD)

  • Abnormal facial movements (primarily in tongue or mouth)
  • Higher risk with elderly females
  • Can be irreversible, must stop drug and replace with SGA with low EPS risk (quetiapine, clozapine)

8

Definitions of extrapyramidal side effects (EPS): Dyskinesias

  • Abnormal movements
  • More common with dopamine replacement for Parkinson disease

9

Which molecules are primarily involved in the pathophysiology behind schizophrenia?

  • Dopamine
  • Serotonin
  • Glutamine

10

Medications/Illicit drugs that can cause psychotic symptoms

  • Anticholinergics (Centrally-acting, high doses)
  • Dextromethorphan
  • Dopamine or DA agonists (Requip, Mirapex, Sinemet)
  • Interferons
  • Stimulants, especially if already at risk
  • Systemic steroids (ICU psychosis)
  • Bath salts, cocaine, cannabis, LSD, methamphetamine, PCP (phencyclidine)

11

T/F: FGAs block dopamine (DA-2) receptors

True

12

What is a natural product used for psychosis and other psychiatric disorders (ex: ADHD, depression)

Fish oils

13

T/F: SGAs are used first-line due to lower incidence of EPS

True

14

Formulations of antipsychotics (d/t poor adherence in schizophrenia patients)

  • Long-Acting injections, given IM
  • ODTs (useful with dysphagia and prevents cheeking)
  • Oral solutions/suspensions (PEG tube)
  • Acute IM injections, given IM to provide "stat" relief and calm an agitated patient

15

Haldol cocktail

Haloperidol, lorazepam and diphenhydramine

16

T/F: It is okay to give olanzapine and BZDs

False

17

T/F: Antipsychotics are not indicated for agitation control in elderly with dementia-related psychosis due to increased risk of mortality

True

18

High potency FGA still used

Haloperidol (Haldol, haldol decanoate)

19

How often is haldol decanoate administered intramuscularly?

Monthly

20

Which long-acting injections are administered every 4 weeks?

  • Haldol Decanoate
  • Invega Sustenna
  • Abilify Maintena

21

Which long-acting injections are administered every 2 weeks?

  • Risperdal Consta
  • Fluphenazine decanoate

22

Which long-acting injection is administered every 3 months?

Invega Trinza

23

Which drugs are available as fast-acting injections?

  • Haloperidol
  • Zyprexa
  • Geodon
  • Fluphenazine

24

Which drugs are available as orally disintegrating tablets?

  • Abilify Discmelt
  • Clozapine Fazaclo
  • Risperdal M-Tab
  • Zyprexa Zydis
  • Saphris (SL)

25

How do you convert Haldol PO to monthly injection?

Use 10-20x the PO dose

26

Boxed warning for FGA, thioridazine

QT prolongation

27

Warnings: First-generation antipsychotics

  • QT prolongation
  • Anticholinergic effects
  • CNS depression
  • EPS
  • Hyperprolactinemia
  • Neuroleptic malignant syndrome (NMS) -- monitor for mental status changes, fever, muscle rigidity, autonomic instability

28

Side effects: First-generation antipsychotics

  • Sedation, sissiness, anticholinergic effects
  • EPS

29

T/F: Lower potency FGAs have increased sedation and decreased EPS

True

30

T/F: Higher potency FGAs have increased sedation and decreased EPS

False

31

What drug class is Haldol also apart of?

Butyrophenone, also used for Tourette syndrome

32

SGAs block which receptors?

D2 and 5-HT2A

33

Which antipsychotics are unique in that they are D2 and 5-HT1A partial agonists?

  • Aripiprazole
  • Brexpiprazole (also 5-HT2A antagonist)
  • Cariprazine

34

T/F: Aripiprazole is also approved for irritability with autism and Tourette disorder

True

35

Side effects: Aripiprazole

Akathisia, activating or sedating, HA, anxiety, constipation

36

Different formulations of Aripiprazole and their differences

  • Abilify Maintena -- IM suspension, give monthly
  • Aristada -- IM suspension, given every 4-8 weeks dependent on dose

37

Indication: Clozapine

Must be used only if failed to respond to treatment with 2 standard AP treatments, or had significant ADRs

38

Why is Clozapine used no sooner tha3rd-line

Due to severe side effect potential

39

What is the boxed warning for SGA, Clozapine?

Severe neutropenia/agranulocytosis (REMS)

40

Define severe neutropenia related to clozapine use

  • ANC > 1500 required to start
  • Discontinue if ANC < 1000
  • Monitor Weekly x 6 months, then Qbiweekly x 6 months, then monthly for life

41

Side effects: Clozapine

  • Seizures (dose-related)
  • Myocarditis and cardiomyopathy
  • Constipation, weight gain

42

T/F: Pharmacies must be REMS certified and patient must be enrolled with Clozapine REMS prior to initiating treatment

True

43

T/F: Smoking reduces drug levels of clozapine and olanzapine

True

44

Highest QT prolongation of antipsychotics

Thioridazine < Haloperidol < Ziprasidone

45

Counseling points with Lurasidone (Latuda)

  • Take with food ≥ 350 kcal
  • Somnolence, EPS (dystopias), nausea
  • Weight, lipid and blood glucose neutral

46

Brand name for Olanazpine injection

Relprevv IM suspension, lasts 2-4 weeks, restricted use, monitor for 3-hours post-injection

47

Side effects: Olanzapine

  • Somnolence
  • Metabolic syndrome (increase weight, blood glucose and lipids)

48

Can patient start on Invega trinza?

Only after receiving Invega Sustenna x 4 months

49

Active drug in Invega

Paliperidone

50

Side effects: Paliperidone

  • Increase prolactin -- sexual dysfunction, galactorrhea, irregular/missed periods
  • EPS, especially at higher doses
  • Metabolic syndrome (increase weight, BG and lipids)

51

Side effects: Quetiapine

  • Somnolence, metabolic syndrome
  • LOW EPS RISK
  • Take XR at night without food or with a light meal

52

Side effects: Risperidone

  • Increase prolactin -- sexual dysfunction, galactorrhea, irregular/missed periods
  • EPS, especially at higher doses
  • Metabolic syndrome (increase weight, BG and lipids)

53

Paliperidone is the active metabolite of what agent/drug?

Risperidone

54

T/F: Risperidone is also approved for irritability associated with autism

True

55

Side effects: Ziprasidone

  • Take with food
  • QT prolongation
  • IM injection 10mg Q2H or 20mg Q4H
  • Max injection: 40mg/day IM

56

Active ingredient in SL tablet, Saphris

Asenapine

57

T/F: Saphris SL tablet can cause tongue numbness

True

58

Important AEs of SGAs

Metabolic side effects -- highest risk

  • Clozapine, Olanzapine, Quetiapine

59

Important AEs of SGAs

Metabolic side effects -- lowest risk

  • Aripiprazole, Ziprasidone, Lurasisone, Asenapine

60

Important AEs of SGAs

EPS -- lowest risk

  • Quetiapine

61

Important AEs of SGAs

Hematologic effects -- highest risk

Clozapine (agranulocytosis)

62

Important AEs of SGAs

Increased prolactin -- highest risk

  • Risperidone, paliperidone

63

Important AEs of SGAs

Seizure -- highest risk

Clozapine (Dose-dependent)

64

Drug of choice to treat psychosis in Parkinson disease d/t low risk of EPS

Quetiapine

65

Drug approved for psychosis with Parkinson disease; dose not affect DA receptors

Pimavanserin (Nuplazid)

66

T/F: Only some antipsychotics can prolong the QT interval

False

67

What is Valbenazine (Ingrezza) indicated for?

Treatment of TD

68

How does Valbenazine work?

Reversibly inhibits vesicular monoamine transporter 2 (VMAT2), a transporter that regulates monamine uptake from the cytoplasm to synaptic vesicle for storage and release

69

Other than Valbenazine, what is another VMAT2 inhibitor indicated for TD?

Deutetrabenazine (Austedo)

70

Deutetrabenazine (Austedo) is also approved for what indication?

Chorea associated with Huntington's disease

71

Side effect: Valbenazine (Ingrezza) and Deutetrabenazine (Austedo)

Somnolence

72

Contraindication for use of Deutetrabenazine (Austedo)

Hepatic impairment, administration within 14 days of MAOI

73

Valbenazine (Ingrezza) and Deutetrabenazine (Austedo) are substrates of CYP3A4 and 2D6, therefore dose reduction is required when given with _____________________

Strong inhibitors of CYP3A4 (itraconazole, clarithromycin) or 2D6 (paroxetine, fluoxetine)

74

Because Valbenazine (Ingrezza) is a P-gp inhibitor, it can increase the concentration of what cardiac drug?

Digoxin

75

What are signs of Neuroleptic Malignant Syndrome (NMS)?

  • Hyperthemia (high fever, profuse sweating)
  • Extreme muscle rigidity, can lead to respiratory failure
  • Mental status changes
  • Tachycardia, tachypnea, and BP changes

76

In addition to stoping the antipsychotic, what is a drug that can be used to relax the muscles in treatment of NMS

Dantrolene (Ryanodex, Dantrium, Revonto)

77

Correct chemical class for chlorpromazine?

Phenothiazine

The phenothiazines are strong DA blockers; when used for other conditions (nausea), movement disorders are possible side effects and sedation is expected.

78

CD presents to the pharmacy with a prescription for lurasidone. What is an appropriate substitute?

Latuda

Latuda is the brand name for lurasidone.

79

BG is a 34 yr old male diagnosed with schizophrenia. He presents to the clinic for routine follow-up and for his monthly injection of Invega Sustenna, which he has been taking for 11 months. His PMH includes obesity, HTN, HLD, and 2 suicide attempt. His medications include amlodipine 10mg PO daily and atorvastatin 40mg PO at bedtime. He smokes 1/2 pack of cigarettes per day. Which of the following medications can be given monthly or less frequently than monthly (ex: every 3 months)? SATA

  • Haloperidol decanoate
  • Abilify Maintena
  • Invega Trinza

Abilify Maintena and haloperidol decanoate are both administered monthly. Invega Trinza is administered every 3 months

Both fluphenazine decanoate and Risperdal Consta are given more frequently than monthly (every 2 weeks)

80

Which of the following is the generic name for the once-monthly injection Invega Sustenna?

Paliperidone

Invega Sustenna is a once-monthly injection of paliperidone. Nonadherance with therapy is the #1 problem with drug therapy in patients with schizophrenia. The long-acting formulations are important because they help improve adherence.

81

A physician has a patient who is forgetful and dose not take her antipsychotic on a regular basis. The physician wishes to use an atypical ("second generation") agent that can be administered every 2 weeks. Which agent comes in a 2-week intramuscular injection?

Risperidone

Risperdal Consta is given every 2 weeks.

82

A 23 yr old male was picked up by the police for acting erratically and threatening patrons at a subway stop. He was placed into the acute lock-down ward of the psychiatric hospital and given an injection of haloperidol and lorazepam. He quickly developed a very painful sustained contraction of his neck and trunk. Which medication can be administered to treat this side effect?

Benztropine

The treatment for dystonic reactions (in this case caused by haloperidol) includes a centrally-acting anticholinergic (such as benztropine and diphenhydramine). These are administered by injection for fast relief, or can be given orally for prophylaxis during therapy initiation.

83

A pharmacist will counsel a patient beginning therapy with Zyprexa. Which of the following are correct counseling statements? SATA

  • The other name for this medication is olanzipine
  • This medication can cause the patient to gain wait and can increase blood sugar and cholesterol. It is important to try and get regular exercise, such as walking, and to eat healthy foods

Olanzapine is sedating and is take QHS. It causes weight gain, elevated blood glucose and lipids and (like the others that cause similar problems) the patient will need all of these monitored, along with the blood pressure.

84

Select the correct chemical class for Haldol

Butyrophenone

The butyrophenones haloperidol (Haldol) and droperidol (Inapsine) are among the agents with the highest QT-prolongation risk. They work mainly by blocking D2 receptors

85

A patient gave the pharmacist a prescription for Seroquel 25mg BID #60. Which of the following is an appropriate generic substitution for Seroquel?

Quetiapine

The generic name of Seroquel is quetiapine

86

Haloperidol is available in which of the following formulations? SATA

  • Oral tablet
  • Fast-acting injection
  • Four-week depot injection

Haloperidol comes in an oral tablet, a short-acting injection and a monthly "decanoate" injection that is useful option for patients who have adherence issues.

87

VT is an 18 yr old male high school student who no longer wishes to socialize with his former friends. He is speaking little and has little desire for social interaction. When asked by his mother if he is interested in seeing his former friends, he states that he does not care. When considering the diagnosis criteria for schizophrenia, VT would best be described as exhibiting which type of symptoms?

Negative symptoms

Negative symptoms include a flat affect (emotionless face), alogia (hardly speaking) and abolition (not motivated to do anything). The negative symptoms contribute to social withdrawal and apathy. People with schizophrenia may also display disorganized speech and behavior.

88

A patient gave the pharmacist a prescription for Geodon 60mg PO BID #60. Which of the following is an appropriate generic substitution for Geodon?

Ziprasidone

The generic name of Geodon is ziprasidone

89

A female patient with a congenital heart defect is being started on an antipsychotic for treatment of schizophrenia. Which drug should be considered contraindicated due to the high risk for QT prolongation?

Ziprasidone

Thioridazine, haloperidol, chlorpromazine and ziprasidone have the highest risk of QT prolongation

90

BY is an elderly gentleman with advanced Parkinson disease. He has lived in a SNF for about 1 yr since he because unable to feed himself. BY tried to hit his roommate with a butter knife. He explained to the nurse that the roommate was planning to attack him when he was sleeping in order to take his eyes out and sell them. Which of the following medcaitions are possibly contributing to BY's psychosis?

  • Sinemet
  • Requip XL

Both levodopa/carbiodpa and dopamine agonists can aggravate psychosis; the DA agonists are higher risk.

91

Antipsychotics such as chlorpromazine and haloperidol exert their mechanism of action by blocking this receptor

Dopamine

Antipsychotics are primarily dopamine (D2) blocking agents, which is why they cause movement disorders. Some of the newer drugs act on serotonin receptors as well.

92

DB is a 72 yr old male suffering from dementia. Recently, DB struck his wife while she was helping him eat. The wife asked the physician for help and DB was prescribed risperidone 1mg BID. The pharmacist is concerned about which safety issue if DB takes the medication prescribed?

Cerebrovascular accident

93

An 18 yr old female is given a drug she has never used before, and it results in a drug-induced psychosis. Which of the following drugs can cause drug-induced psychosis?

  • PCP/MDPV (bath salts_
  • LSD
  • Dextromethorphan
  • Methamphetamine

94

AB has been taking an atypical antipsychotic as an adjunctive agent to treat resistant depression. After beginning the antipsychotic, she began to have feelings of restlessness and an urge to move. She states she cannot keep her legs still. AB is displaying what adverse effect from the use of an antipsychotic?

Akathisia

95

Which antipsychotic has the lowest risk of EPS?

Quetiapine

96

A pharmacist will counsel a patient who is starting treatment with asenapine. Which fo the following counseling statements is correct?

The medcication is a SL tablet that can make the tongue numb

97

A patient gave the pharmacist a prescription for Zyprexa 5mg PO QHS #30. Which of the following is an appropriate generic substitution for Zyprexa?

Olanzapine

98

A patient gave the pharmacist a prescription for Risperal 1mg PO TID #90. Which of the following is an appropriate generic substitution for Risperal?

Risperidone

99

RR is a 27 yr old female graduate student who is seen mumbling to herself repeatedly in class. When confronted, it is apparent that RR believes she is talking to someone. Choose the response that best describes the symptom of schizophrenia displayed by this patient

Hallucination

100

Which of the following prescription drug classes may induce or exacerbate psychotic symptoms? SATA

  • Mirapex
  • Adderall
  • Sinemet
  • Systemic steroids

101

A patient prescribed risperidone experienced weight gain and had trouble managing his diabetes. Which of the following antipsychotics has a lower risk of metabolic side effects?

Aripiprazole

102

A 28 yr old female patient experienced high prolactin levels while using the atypical agent risperidone. She experienced decreased, irregular menstrual periods. She found this very bothersome and discontinued the drug. Which of the following agents would put her at repeated risk for the same adverse reaction?

Paliperidone

103

BM is a 24 yr old male who has failed trails with olanzapine and ziprasidone. The psychiatrist plans to initiate clozapine therapy and sends the patient to have a CBC drawn. The patient cannot be started on clozapine if the ANC is below:

1500/mm3

104

A patient gave the pharmacist a prescription for Abilify 10mg PO daily #30. Which of the following is an appropriate generic substitution for Abilify?

Aripiprazole

105

JK is a 72 yr old female with a variety of medical conditions. 2 years ago, her family reported that she was displaying paranoid delusions, including the belief that her daughter was trying to kill her by poisoning her food. The physician prescribed risperidone, which has been helpful. At clinic today, JK is darting her tongue in and out and blinking in an involuntary manner. She is displaying the following AE from the use of an antipsychotic:

Tardive dyskinesia

106

SJ has failed several trials of antipsychotics. He continues to respond to "voices" that constantly torment him. He has tried to commit suicide several times. His other medical conditions include seizures (well-controlled since childhood), depression, anxiety, elevated cholesterol and prediabetes. SJ's HCP would like to start clozapine. His WBC count in 5,500 cells/mm3 and his ANC is 1,890/mm3. Choose the correct statements. SATA

  • Clozapine could worsen the patient's seizure disorder
  • It is reasonable to consider clozapine since the patient has failed several antipsychotics
  • The patients ANC is appropriate to begin clozapine therapy
  • The patient should be counseled on the side effect of hypersalivation

107

A female patient has been taking haloperidol 1mg BID. Her family noticed an unusual "smacking" motion made with her lips and unusual eye movements. What is the best course of action?

Switch to quetiapine

108

RD is a 52 yr old female patient with schizophrenia, depression, elevated cholesterol, pre-diabetes and hypothyroidism. The physician is considering a trial with olanzapine. Choose the correct statements regarding the use of olanzapine in this patient. SATA

  • It can increase cholesterol
  • It can increase blood glucose and weight
  • It is sedating and is generally taken at bedtime

109

What is the rationale behind the production of several different formulations of ODTs for schizophrenia?

Some patients with schizophrenia will "cheek" the medication and spit it out later

110

CF is 74 yr old female who has a unilateral tremor in her right hand consistent with Parkinson disease. The physician needs to choose an antipsychotic for CF. Which of the following agents has the lowest risk for movement disorders?

Quetiapine

111

Which of the following drugs requires prescribers, pharmacists, and patients to participate in a REMS program?

Clozapine