Psychosis - Tx Guidelines, EPS

Question 1

First episode psychosis: What should be used?

Answer 1

2nd generation antipsychotic (less AEs and equal efficacy relative to first-gens)

Question 2

First episode psychosis: tx duration?

Answer 2

Min 18 mths

Question 3

T or F: First episode psychosis: indefinite tx is absolutely unnecessary

Answer 3

F

Indef tx is not unreasonable

Question 4

First episode psychosis: All antipsychotics are essentially equally effective

Answer 4

T (you would choose the one with the best AE profile, and you would use the lowest effective dose)

Question 5

First episode psychosis: how long would an adequate trial be?

Answer 5

4-6 weeks

Question 6

T or F: 2nd gen antipsychotics are better tolerated than 1st gens

Answer 6

T

Question 7

Acute exacerbation: what should we do first when tx’ing this?

Answer 7

Screen for nonadherence, substance use (e.g. cannabis), and drug interactions

Question 8

Acute exacerbation: Assuming no nonadherence, substance use, or drug interactions, what do we do next?

Answer 8

Increase antipsychotic dose OR change antipsychotic

Trial for 6-8 wks to determine effect

(if switching, cross taper is usually the preferred method to prevent AP withdrawal)

Question 9

Maintenance and relapse prevention: How to tx mood changes?

Answer 9

Mood stabilizers or antidepressants

Question 10

Maintenance and relapse prevention: How long should maintenance tx be?

Answer 10

2 yrs (possibly up to 5 yrs)

Question 11

Treatment resistant schizophrenia: When do we determine that someone’s schizophrenia is treatment-resistant?

Answer 11

≥ 2 positive sx’s of mod severity
OR
1 positive sx of severe severity

…after ≥ 2 adequate antipsychotic trials (6-8 wks long = ea. trial period) for po
OR
…after 6 weeks of steady state for long-acting injection

Question 12

Treatment resistant schizophrenia: Before tx’ing this, what should we do?

Answer 12

Ensure

1. adherence
2. no substance use
3. no DIs
4. appropriate dose

Question 13

Treatment resistant schizophrenia: 1st line tx?

Answer 13

Clozapine (an atypical antipsychotic)

Question 14

What drug is most effective for tx-resistant schizophrenia?

Answer 14

Clozapine

Question 15

Clozapine: important AEs

Answer 15

agranulocytosis, myocarditis, constipation

Question 16

Clozapine: Why is continuous blood monitoring req’d?

Answer 16

Risk of agranulocytosis

Question 17

Clozapine: Re-titrate up if doses are missed for how long?

Answer 17

> 48h

Question 18

Clozapine: When does clozapine become non-rechallengeable?

Answer 18

if total WBC < 2.0 x 10^9

OR

ANC (absolute neutrophil count) < 1.5 x 10^9

…during clozapine tx

Question 19

When a pharmacist is dispensing clozapine for tx-resistant schizophrenia, what must the pharmacist make sure of?

Answer 19

That the pt is enrolled with the A.A. Clozapine Program and ensure most recent bloodwork is in green or yellow zone

Question 20

T or F: Augmenting clozapine with an antipsychotic is well supported in the literature for partial responses to clozapine for clozapine-resistant schizophrenia

Answer 20

F

Evidence is mixed

Question 21

What’s last line tx if clozapine-resistance isn’t overcome with antipsychotic augmentation?

Answer 21

ECT

Question 22

What comorbidity should we screen all psychosis pts for?

Answer 22

substance use disorder (since substances like stimulants and cannabis are assoc w/ psychosis and worse outcomes)

Question 23

Tx for psychosis + substance use disorder?

Answer 23

Any antipsychotic (limited data saying clozapine)

Question 24

Most EPS’s are due to what?

Answer 24

DA blockade (MOA of antipsychotics)

Question 25

What’re acute dystonias?

Answer 25

Torsions and spasms of muscle groups

Question 26

1st line tx for acute dystonias?

Answer 26

IM benztropine

Question 27

What’s akathisia?

Answer 27

Inner restlessness; can’t sit still

Question 28

Akathisia tx

Answer 28

Reduce dose of antipsychotic OR change antipsychotic

and/or

benzos, BBs, mirtazapine

Question 29

What’s pseudoparkinsonism?

Answer 29

Parkinson-like sx’s: tremor (pill-rolling type), cogwheel rigidity, bradykinesia

Question 30

Acute pseudoparkinsonism tx?

Answer 30

Reduce/change antipsychotic

and/or

use an antiparkinsonian drug (benztropine, diphenhydramine, procyclidine, trihexyphenidyl)

Question 31

What’s pisa syndrome?

Answer 31

Leaning to one side

Question 32

Tx for pisa syndrome?

Answer 32

antiparkinsonian drug (benztropine, diphenhydramine, procyclidine, trihexyphenidyl)

Question 33

What’s rabbit syndrome?

Answer 33

fine tremor of lower lip

Question 34

Tx for rabbit syndrome?

Answer 34

antiparkinsonian drug (benztropine, diphenhydramine, procyclidine, trihexyphenidyl)

Question 35

What’s tardive dyskinesia

Answer 35

INVOLUNTARY abnormal movements

Question 36

Tardive dyskinesia tx

Answer 36

Best tx = second/third gen antipsychotics

and

stop offending agents

Question 37

Tx for tardive dystonia?

Answer 37

switch to 2nd/3rd gen antipsychotic

Question 38

Tx’s for tardive akathisia?

Answer 38

a. switch to 2nd/3rd gen antipsychotic
b. antichols
c. benzos, BBs

Question 39

What’s the name of the acute, life-threatening EPS?

Answer 39

Neuroleptic malignant syndrome

Question 40

What can cause neuroleptic malignant syndrome?

Answer 40

ANY antipsychotic

Question 41

Tx for neuroleptic malignant syndrome?

Answer 41

Stop antipsychotic IMMEDIATELY

+ supportive care + bromocriptine