RxPrep: Chapter 64, Schizophrenia/Psychosis
What is schizophrenia?
A chronic, severe and disabling thought disorder
What are common positive symptoms of schizophrenia?
What are common negative symptoms of schizophrenia?
Definitions of extrapyramidal side effects (EPS): Dystonias
Definitions of extrapyramidal side effects (EPS): Akathisia
Definitions of extrapyramidal side effects (EPS): Parkinsonism
Definitions of extrapyramidal side effects (EPS): Tradive dyskinesias (TD)
Definitions of extrapyramidal side effects (EPS): Dyskinesias
Which molecules are primarily involved in the pathophysiology behind schizophrenia?
Medications/Illicit drugs that can cause psychotic symptoms
T/F: FGAs block dopamine (DA-2) receptors
True
What is a natural product used for psychosis and other psychiatric disorders (ex: ADHD, depression)
Fish oils
T/F: SGAs are used first-line due to lower incidence of EPS
True
Formulations of antipsychotics (d/t poor adherence in schizophrenia patients)
Haldol cocktail
Haloperidol, lorazepam and diphenhydramine
T/F: It is okay to give olanzapine and BZDs
False
T/F: Antipsychotics are not indicated for agitation control in elderly with dementia-related psychosis due to increased risk of mortality
True
High potency FGA still used
Haloperidol (Haldol, haldol decanoate)
How often is haldol decanoate administered intramuscularly?
Monthly
Which long-acting injections are administered every 4 weeks?
Which long-acting injections are administered every 2 weeks?
Which long-acting injection is administered every 3 months?
Invega Trinza
Which drugs are available as fast-acting injections?
Which drugs are available as orally disintegrating tablets?
How do you convert Haldol PO to monthly injection?
Use 10-20x the PO dose
Boxed warning for FGA, thioridazine
QT prolongation
Warnings: First-generation antipsychotics
Side effects: First-generation antipsychotics
T/F: Lower potency FGAs have increased sedation and decreased EPS
True
T/F: Higher potency FGAs have increased sedation and decreased EPS
False
What drug class is Haldol also apart of?
Butyrophenone, also used for Tourette syndrome
SGAs block which receptors?
D2 and 5-HT2A
Which antipsychotics are unique in that they are D2 and 5-HT1A partial agonists?
T/F: Aripiprazole is also approved for irritability with autism and Tourette disorder
True
Side effects: Aripiprazole
Akathisia, activating or sedating, HA, anxiety, constipation
Different formulations of Aripiprazole and their differences
Indication: Clozapine
Must be used only if failed to respond to treatment with 2 standard AP treatments, or had significant ADRs
Why is Clozapine used no sooner tha3rd-line
Due to severe side effect potential
What is the boxed warning for SGA, Clozapine?
Severe neutropenia/agranulocytosis (REMS)
Define severe neutropenia related to clozapine use
Side effects: Clozapine
T/F: Pharmacies must be REMS certified and patient must be enrolled with Clozapine REMS prior to initiating treatment
True
T/F: Smoking reduces drug levels of clozapine and olanzapine
True
Highest QT prolongation of antipsychotics
Thioridazine < Haloperidol < Ziprasidone
Counseling points with Lurasidone (Latuda)
Brand name for Olanazpine injection
Relprevv IM suspension, lasts 2-4 weeks, restricted use, monitor for 3-hours post-injection
Side effects: Olanzapine
Can patient start on Invega trinza?
Only after receiving Invega Sustenna x 4 months
Active drug in Invega
Paliperidone
Side effects: Paliperidone
Side effects: Quetiapine
Side effects: Risperidone
Paliperidone is the active metabolite of what agent/drug?
Risperidone
T/F: Risperidone is also approved for irritability associated with autism
True
Side effects: Ziprasidone
Active ingredient in SL tablet, Saphris
Asenapine
T/F: Saphris SL tablet can cause tongue numbness
True
Important AEs of SGAs
Metabolic side effects -- highest risk
Important AEs of SGAs
Metabolic side effects -- lowest risk
Important AEs of SGAs
EPS -- lowest risk
Important AEs of SGAs
Hematologic effects -- highest risk
Clozapine (agranulocytosis)
Important AEs of SGAs
Increased prolactin -- highest risk
Important AEs of SGAs
Seizure -- highest risk
Clozapine (Dose-dependent)
Drug of choice to treat psychosis in Parkinson disease d/t low risk of EPS
Quetiapine
Drug approved for psychosis with Parkinson disease; dose not affect DA receptors
Pimavanserin (Nuplazid)
T/F: Only some antipsychotics can prolong the QT interval
False
What is Valbenazine (Ingrezza) indicated for?
Treatment of TD
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
Other than Valbenazine, what is another VMAT2 inhibitor indicated for TD?
Deutetrabenazine (Austedo)
Deutetrabenazine (Austedo) is also approved for what indication?
Chorea associated with Huntington's disease
Side effect: Valbenazine (Ingrezza) and Deutetrabenazine (Austedo)
Somnolence
Contraindication for use of Deutetrabenazine (Austedo)
Hepatic impairment, administration within 14 days of MAOI
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)
Because Valbenazine (Ingrezza) is a P-gp inhibitor, it can increase the concentration of what cardiac drug?
Digoxin
What are signs of Neuroleptic Malignant Syndrome (NMS)?
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)
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.
CD presents to the pharmacy with a prescription for lurasidone. What is an appropriate substitute?
Latuda
Latuda is the brand name for lurasidone.
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
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)
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.
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.
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.
A pharmacist will counsel a patient beginning therapy with Zyprexa. Which of the following are correct counseling statements? SATA
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.
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
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
Haloperidol is available in which of the following formulations? SATA
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.
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.
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
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
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?
Both levodopa/carbiodpa and dopamine agonists can aggravate psychosis; the DA agonists are higher risk.
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.
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
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?
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
Which antipsychotic has the lowest risk of EPS?
Quetiapine
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
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
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
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
Which of the following prescription drug classes may induce or exacerbate psychotic symptoms? SATA
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
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
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
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
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
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
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
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
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
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
Which of the following drugs requires prescribers, pharmacists, and patients to participate in a REMS program?
Clozapine