Schizophrenia- Disorder And Treatment

1.

A patient MZ has recently been diagnosed with schizophrenia. His doctor wants to start him on a second generation antipsychotic that can be taken orally, but later switched over to an IV or IM formulation that is LONG ACTING, since MZ has had a history of non-compliance. The doc can't remember what options he has... you tell him:

A.

Geodon
B.

Zyprexa
C.

Risperdal
D.

Haldol
E.

All of the above

Correct Answer
C. Risperdal

Explanation
Geodon does not come in an injectable dosage form. Zyprexa does, however it is a SHORT acting IM formulation (remember do not give it within 4 hours of an injected benzodiazapine like lorazepam). Haldol does come in a long acting depot preparation, however it is a FIRST generation antipsychotic. Risperidal is the best choice-the Risperdal Consta can be given 25-50mg q2 weeks. Note: it will take up to 3 weeks to see the full effect, so the patient should take oral Risperdal 1-2mg BID during this time. Another possible choice not listed: Paliperidone (Invega Sustenna).

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2.

The two SGA's listed with the HIGHEST tendency to cause QT prolongation as a side effect are:

A.

Iloperidone and Ziprasidone
B.

Aripiprazole and Ziprasidone
C.

Aripiprazole and Thioridizine
D.

Iloperidone and Thioridizine
E.

Thioridizine and Ziprasidone

Correct Answer
A. Iloperidone and Ziprasidone

Explanation
Thioridizine (Mellaril) is a FGA with a blackbox warning for QT prolongation. However, this question was asking for the SGA's with QT prolongation- Ziprasidone (Geodon) being most noteworthy, and Iloperidone (Fanapt). Note: patients on Geodon should take w/ FOOD, also- a baseline EKG should be performed... any drugs that can prolong QT interval should be avoided: thioridizine, amiodarone, quinidine

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3.

Which of the following are a BLACK BOX warning for clozapine

A.

Agranulocytosis
B.

Myocarditis
C.

Respiratory Depression
D.

A and C
E.

All of the above

Correct Answer
E. All of the above

Explanation
In addition to the above listed: seizures, increased risk for sudden cardiac death, orthostasis

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4.

A patient is taking clozapine for over a month at a dose of 200mg per day. WBC is being monitored weekly and today the patients WBC count is at 2550/mm^3. You suggest:

A.

Keep the patient going on the medication; the drop in WBC is expected
B.

Perform twice weekly WBC counts now
C.

Stop therapy until WBC counts go back above 3000 with no signs of infection
D.

A and B
E.

B and C

Correct Answer
E. B and C

Explanation
Schizo notes pg 8. Remember if counts go below 2000, you would never recommend RECHALLENGE with clozapine. Also, the only way patients should be on clozapine is if they have treatment-resistant schizophrenia AKA they have failed at least 2 therapies.

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5.

Which of the following are positive symptoms of schizophrenia?

A.

Hallucinations
B.

Anhedonia
C.

Poor hygeine/grooming
D.

Alogia
E.

None of the above

Correct Answer
A. Hallucinations

Explanation
Hallucinations is the only correct answer. Other correct answers would be: delusions, disorganized speech/behavior. Negative symptoms are choices B-D. Anhedonia is reduced interest or pleasure. Alogia is reduced speech.

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6.

Choose the INCORRECT pair of EPS and its treatment:

A.

Acute dystonia- Benztropine IM
B.

Akathisia- Diphenhydramine PO
C.

Pseudoparkinsonism- Trihexyphenidyl PO
D.

Neuroleptic Malignant Syndrome- Bromocriptine and Dantroline
E.

All of the above are correct

Correct Answer
B. Akathisia- Diphenhydramine PO

Explanation
Akathisia is characterized by motor restlessness and not being able to sit still. Propranolol two to three times daily is the correct treatment for this EPS. Aripiprazole (Abilify) is a SGA that is very likely to cause akathisia for patients taking it. These patients should definitely be put on propranolol!!!!!

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7.

Which is true of antipsychotics in the treatment of shizophrenia?

A.

A perfect drug would INCREASE dopamine in the Mesocortical pathway but DECREASE dopamine in the Mesolimbic pathway.
B.

FGA's tend to treat the positive symptoms of shizophrenia, while SGA's tend to treat both positive AND negative symptoms.
C.

FGA's differ from SGA's in the fact that SGA's have less incidence of EPS and better mood stabilizing properties.
D.

A common side effect of antipsychotics is that they decrease the seizure threshold.
E.

All of the above.

Correct Answer
E. All of the above.

Explanation
All of the statements provided are true regarding antipsychotics in the treatment of schizophrenia. A perfect drug for schizophrenia would increase dopamine in the Mesocortical pathway (which is associated with cognitive functioning) while decreasing dopamine in the Mesolimbic pathway (which is associated with positive symptoms). First-generation antipsychotics (FGA's) primarily treat the positive symptoms of schizophrenia, while second-generation antipsychotics (SGA's) treat both positive and negative symptoms. SGA's have less incidence of extrapyramidal symptoms (EPS) and better mood stabilizing properties compared to FGA's. Additionally, a common side effect of antipsychotics is a decrease in the seizure threshold.

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8.

Select the true statement regarding FGAs.

A.

Haloperidol, a low potency agent, tends to have more EPS but less anticholinergic effects.
B.

Haloperidol, a high potency agent, tends to have more EPS but less anticholinergic effects.
C.

Chlorpromazine, a low potency agent, tends to have more EPS but less anticholinergic effects.
D.

Chlorpromazine, a high potency agent, tends to have more EPS but less anticholinergic effects.

Correct Answer
B. Haloperidol, a high potency agent, tends to have more EPS but less anticholinergic effects.

Explanation
High potency: more EPS and endocrine effects, less anticholinergic and antihistiminic effects.
Low potency: less EPS and endocrine effects, more sedation and orthostasis

Chlorpromazine and Thioridizine- low potency
Haloperidol and Fluphenazine- high potency

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9.

When switching from oral Haldol to Haldol Depot injection:

A.

Oral medication should be tapered over 16 weeks.
B.

It is okay to start the depot formulation if the patient was not on oral haloperidol first.
C.

The depot injection dose given should be 10X the oral dose.
D.

None of the above.
E.

All of the above.

Correct Answer
C. The depot injection dose given should be 10X the oral dose.

Explanation
Oral medication should be tapered over 2-4 weeks. You should never start a patient on the depot formulation without a prior trial of the oral formulation- make sure they aren't allergic.

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10.

What is your favorite SGA and why?

A.

Clozapine because it's got so many black box warnings
B.

Ziprasidone because it has very few side effects besides its silly QT prolongation warnings
C.

Paliperidone because its brand name is so awesome: Invega Sustena
D.

Olanzapine because it makes people Fatties!
E.

All of the above

Correct Answer(s)
A. Clozapine because it's got so many black box warnings
B. Ziprasidone because it has very few side effects besides its silly QT prolongation warnings
C. Paliperidone because its brand name is so awesome: Invega Sustena
D. Olanzapine because it makes people Fatties!
E. All of the above

Explanation
they are all winners

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