Definition of dystonias

Prolonged contraction of muscles during drug initiation, including painful muscle spasms

Definition of akathisia

restlessness with anxiety and inability to remain still

Definition of parkinsonism

looks similar to parkinson disease, with tremors, abnormal gait and bradykinesia

Definition of tardive dyskinesias

abnormal facial movements, primarily in the tongue or mouth

Definition of dyskinesias

abnormal movements, more common with dopamine replacement for parkinson disease

What is schizophrenia

chronic, severe and disabling thought disorder

Common symptoms of schizophrenia

hallucinations, delusions, disorganized thinking/behavior

Definition of hallucinations

sensing something that is not present, such as imaginary voices

Definition of delusions

a belief about something real that is not true, such as imagining that your family (which is real) wishes to hurt you (delusion)

Definition of disorganized thinking/behavior

inability to focus attention and communicate organized thoughts

How is schizophrenia diagnosed

based on behavior which includes both negative and positive signs and symptoms

Schizophrenia pathophysiology

includes altered brain structure and chemistry, primarily involving dopamine, serotonin and glutamate

Negative signs and symptoms

loss of interest in everyday activities, lack of emotion (apathy), inability to plan or carry out activities, poor hygiene, social withdrawal, loss of motivation (avolition), lack of speech (alogia)

Positive signs and symptoms

hallucinations (auditory, visual, somatic), delusions, disorganized thinking/behavior, difficulty paying attention

Medications that can cause psychotic symptoms

anticholinergics, dextromethorphan, dopamine agonists, interferons, stimulants, systemic steroids, illicit/recreational substances, cannabis

Antipsychotics primarily block

dopamine receptors (newer antipsychotics also block serotonin and other receptors)

Decreasing dopamine activity helps control psychosis but

negatively affects dopamine pathways involved in focus, attention and movement

What class of medications are used first-line due to a lower incidence of EPS

second generation antipsychotics (SGAs)

Benefits of long-acting injections

eliminate the need for daily oral tablets or capsules. They are given IM

Benefits of orally disintegrating tablets (ODTs)

useful with dysphagia (difficulty swallowing) and prevents cheeking

Benefits of oral solutions/suspension

useful with children and people with a feeding tube

Benefits of acute IM injections

provide "stat" relief to calm down an agitated, psychotic patient

IM antipsychotic are often mixed with

other drugs in "cocktail" such as BZDs (anxiolytic/sedative effects) and anticholinergics (to reduce dystonia)

Why should olanzapine and BZDs not be given together

due to risk of excessive sedation and breathing difficulty

How do first generation antipsychotics work

mainly by blocking dopamine (D2) receptors with minimal serotonin receptor blockade

Low potency FGAs

chlorpromazine and thioridazine

Mild potency FGAs

loxapine and perphenazine

High potency FGAs

haloperidol, fluphenazine, thiothixene, trifluoperazine

Brand name of haloperidol

Haldol

Treatment/prophylaxis for dystonia

anticholinergics (benztropine), diphenhydramine

Treatment for akathisia

BZDs and propranolol

Treatment for tardive dyskinesia

stop the drug and replace with an SGA with low risk of EPS

MOA of SGAs

block dopamine (D2) and serotonin (5-HT2A) receptors

Which SGAs are D2 and 5-HT1A partial agonist

aripiprazole, brexpiprazole and cariprazine

Abilify Maintena is a

IM suspension given monthly

Brand name of clozapine

Clozaril

When can clozapine be prescribed

only if failed to respond to 2 standard AP treatments or had significant ADRs

Brand name for lurasidone

Latuda

Brand name for olanzapine

Zyprexa

Brand name for paliperidone

Invega

Brand name for risperidone

Risperdal

Brand name for ziprasidone

Geodon

Paliperidone is the active metabolite of

risperidone

Brand name for cariprazine

Vraylar

Brand name for asenapine

Saphris

Invega Sustenna is a

IM injection given monthly

Invega Trinza is a

IM injections given every 3 months

Invega Hafyera is a

IM injection, given every 6 months

Which risperidone is an IM injection given every 2 weeks

Risperdal Consta

SGA metabolic side effects

weight gain, increased cholesterol, increased triglycerides, increased blood glucose

Clozapine boxed warnings

agranulocytosis, seizures, myocarditis

Antipsychotics used for acute psychosis (STAT)

haloperidol (sometimes in combination with lorazepam and diphenhydramine), ziprasidone and olanzapine

What medication is used for psychosis in parkinson disease

Nuplazid

Generic name of Nuplazid

pimavanserin

Asenapine sublingual can cause

tongue numbness

MOA of Nuplazid

inverse agonist and antagonist at 5-HT2A receptors

First medication approved for tardive dyskinesia

Valbenazine

Brand name of valbenazine

Ingrezza

MOA of Ingrezza

reversibly inhibits vesicular monoamine transporter 2 (VMAT2) which is a transporter that regulates monoamine uptake from the cytoplasm to the synaptic vesicle for storage and release

Brand name and indication for deutetrabenazine

Austedo for tardive dyskinesia

What can occur with all antipsychotics

Neuroleptic malignant syndrome (NMS) - rare but highly lethal

Signs of NMS

hyperthermia, extrema muscle rigidity, mental status changes, tachycardia, tachypnea and blood pressure changes

Treatment for NMS

stop the antipsychotic and provide supportive care (relax muscles with BZDs, dantrolene or bromocriptine