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Digital PharmD

Informatics in Pharmacy

Schizophrenia

August 13, 2018 By Dr. G, PharmD

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Diagnosis:

  • Brief Psychiatric Rating Scale (BPRS)
  • Positive and Negative Symptom Scale (PANSS) – 7-point, 30 item scale.  Requires a 45-minute interview
  • Positive Symptom Rating Scale (PSRS) – 1-7 scale
  • Brief Negative Symptoms Assessment (BNSA) 1-6 scale

Treatment:

  • Antipsychotics are the first line
  • The Joint Commission recommends 1 antipsychotic unless:
    • 3 failed attempts at monotherapy
    • A plan to taper to monotherapy
    • Augmentation of clozapine
    • Other documentation

Antipsychotics:

  • First-generation:
    • Mostly treat positive symptoms (hallucinations, delusions, disorganized behavior)
    • All lower seizure threshold, cause weight gain, liver toxicity, QT prolongation
    • Low potency (anticholinergic > EPS)
      • Chlorpromazine (blue-grey skin, also treats hiccups, N/V, RLS) and thioridazine
    • High potency (EPS>>anticholinergic)
      • Fluphenazine (comes in depot shot), haloperidol (depot too), loxapine (bronchospasm risk), perphenazine, trifluoperazine (don’t give greater than 6 mg/day longer than 12 weeks)
    • Smoking may increase metabolism, so may need to decrease dose if patients quits, especially olanzapine and clozapine
  • Second Generation (aka atypical):
    • Treats mostly positive symptoms, but can improve negative symptoms as well.  Cause less extrapyramidal symptoms and tardive dyskinesia. Overall, 2nd generations are better tolerated.
    • Some seizure threshold lowering, risk for diabetes and hyperlipidemia, some QT prolongation, hyperprolactinemia, antihistamine effects
    • Weight gain worst to least: clozapine > olanzapine > risperidone, paliperidone, iloperidone, quetiapine > ziprasidone, aripiprazole, lurasidone
    • Clozapine only for refractory cases due to agranulocytosis risk.  Monitor ANC.  If <1000, interrupt therapy, if <500 stop.
      • May add lamotrigine to clozapine. No data for other anticonvulsants
    • Olanzapine should never be taken with lorazepam.
    • Risperidone has greater EPS and TD with 6mg or more dosing.
    • Ziprasidone has more QT prolongation than others.
    • Aripiprazole has more akathisia, low EPS and TD
    • Iloperidone causes orthostasis if not properly titrated
    • Paliperidone s the active metabolite of risperidone.
    • All patients prescribed second-generation antipsychotics should be monitored for weight, blood pressure, fasting, glucose, lipids and waist circumference.
    • Benzos may be useful during the acute phase
  • Neuroleptic malignant syndrome:
    • Can occur with any agent, but more common with high potency first-generation antipsychotics
    • Manifested by agitation, confusion, changing levels of consciousness, fever, tachycardia, labile blood pressure, sweating.
    • High mortality rate.
    • Treatment: Discontinue agent, give supportive therapy including fluids and cooling.  Bromocriptine and dantrolene can be used.

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020