Clozapine and Pimozide Overview
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Questions and Answers

What is the prevalence of tardive dyskinesia in patients on long-term antipsychotics?

20-30%

Which medication can be prescribed as a treatment for tardive dyskinesia according to the provided content?

Valbenazine

Name two risk factors for developing tardive dyskinesia.

Extreme of age and being female.

What is a commonly used medication to alleviate acute dystonia?

<p>Diphenhydramine</p> Signup and view all the answers

What is the onset time for tardive dyskinesia after the withdrawal of oral antipsychotics?

<p>4 weeks.</p> Signup and view all the answers

What should be done if a patient experiences a clozapine-induced tonic-clonic seizure?

<p>Decrease the next clozapine dose and add an antiepileptic.</p> Signup and view all the answers

What is the initial action to take after a clozapine-induced seizure?

<p>Stop clozapine for one day.</p> Signup and view all the answers

After stopping clozapine for one day, what is the recommended approach to resuming treatment?

<p>Resume clozapine at half of the previous dose.</p> Signup and view all the answers

Why is it important to add an antiepileptic when managing clozapine-induced seizures?

<p>To provide additional seizure control and prevent recurrence.</p> Signup and view all the answers

What long-term strategy may assist in managing the risk of seizures in patients on clozapine?

<p>Regular monitoring and dosage adjustments as needed.</p> Signup and view all the answers

Which atypical antipsychotic is known for having a lower risk of extrapyramidal symptoms (EPS) compared to others?

<p>Clozapine</p> Signup and view all the answers

What are the medications associated with dose-related akathisia and parkinsonian symptoms?

<p>Olanzapine and Ziprasidone</p> Signup and view all the answers

Name two atypical antipsychotics that are part of the group least associated with EPS.

<p>Quetiapine and Olanzapine</p> Signup and view all the answers

Which medication is used to treat extrapyramidal symptoms (EPS)?

<p>Benztropine</p> Signup and view all the answers

Identify one antipsychotic known for causing akathisia.

<p>Olanzapine</p> Signup and view all the answers

What is the FDA approval indication for Pimozide?

<p>Pimozide is FDA approved for Tic disorder.</p> Signup and view all the answers

What is the starting dose of Clozapine?

<p>The starting dose of Clozapine is 12.5 mg once or twice daily.</p> Signup and view all the answers

What is the recommended maximum dose of Clozapine?

<p>The maximum dose of Clozapine is 900 mg.</p> Signup and view all the answers

How long does it usually take to achieve the target Clozapine dose of 300 mg?

<p>It can usually be achieved in 2 to 3 weeks.</p> Signup and view all the answers

State one reason why lower doses of Clozapine might be given.

<p>Lower doses are given to elderly patients or those who are medically ill.</p> Signup and view all the answers

What steps should be taken to manage resistant schizophrenia on Clozapine?

<p>Stop substance use, provide psychosocial intervention, and consider augmentation.</p> Signup and view all the answers

What are the risks associated with Clozapine use?

<p>The risks include agranulocytosis, seizures, and myocarditis.</p> Signup and view all the answers

What is the recommended action if a patient stops taking Clozapine for 48 hours?

<p>Restart titration at 12.5 mg after 48 hours of discontinuation.</p> Signup and view all the answers

Why is Clozapine not recommended during breastfeeding?

<p>Clozapine is not recommended during breastfeeding due to potential risks to the infant.</p> Signup and view all the answers

How does smoking affect Clozapine levels?

<p>Smoking decreases Clozapine levels through induction of enzyme 1A2.</p> Signup and view all the answers

What potential adverse effect is associated with Thioridazine?

<p>Severe hypotension</p> Signup and view all the answers

Name a medication mentioned alongside Thioridazine.

<p>Chlorpromazine</p> Signup and view all the answers

How does Thioridazine's risk profile compare to that of Chlorpromazine?

<p>Thioridazine may have a higher risk of severe hypotension compared to Chlorpromazine.</p> Signup and view all the answers

What class of drugs does Thioridazine belong to?

<p>Antipsychotics</p> Signup and view all the answers

What is a critical monitoring consideration when prescribing Thioridazine?

<p>Monitoring for blood pressure changes.</p> Signup and view all the answers

What is the first step in managing akathisia?

<p>Decrease dose</p> Signup and view all the answers

What is the primary reason for akathisia development in a 40-year-old male patient on risperidone 1mg?

<p>Dose of medication</p> Signup and view all the answers

Which antipsychotic injection is associated with post-injection delirium sedation syndrome (PDSS)?

<p>Olanzapine</p> Signup and view all the answers

What is the rate of PDSS occurrence in patients injected with specific antipsychotics?

<p>Less than 10%</p> Signup and view all the answers

Which factor is not associated with an increased risk of QTc prolongation?

<p>Ampicillins</p> Signup and view all the answers

Flashcards

Tonic-clonic Seizure

A type of seizure characterized by muscle rigidity followed by rapid jerking movements.

Antiepileptic

A medication used to treat seizures.

Clozapine

A medication used to treat schizophrenia, but it can potentially cause seizures.

Clozapine Seizure: Step 1

If someone on clozapine experiences a tonic-clonic seizure, the first step is to stop the medication for one day.

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Clozapine Seizure: Step 2

After stopping clozapine for a day, the next step is to resume it at half the previous dose.

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Severe Hypotension

A serious drop in blood pressure that can lead to dizziness, fainting, and even shock.

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Chlorpromazine and Hypotension

Chlorpromazine is an antipsychotic medication that can cause severe hypotension as a side effect.

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Name the following SGAs: Ziprasidone, Aripiprazole, Risperidone, Paliperidone.

Atypical antipsychotics (SGAs), known for their effectiveness in treating schizophrenia and bipolar disorder.

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Which SGAs are considered 'least effective'?

Clozapine, Quetiapine, and Olanzapine are all atypical antipsychotics (SGAs) that have been shown to be less effective compared to other SGAs.

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Which 2 SGAs are linked to more EPS?

Olanzapine and Ziprasidone are SGAs that are linked to increased dose-related extrapyramidal symptoms (EPS) like akathisia (restlessness) and parkinsonism.

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What are extrapyramidal symptoms (EPS)?

Extrapyramidal symptoms (EPS) are the side effects of antipsychotic medications that affect movement. Akathisia is the feeling of restlessness, while parkinsonism involves slowing of movement and rigidity.

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How are extrapyramidal symptoms (EPS) usually treated?

Different types of therapies and medications can be used to treat EPS. For example, anticholinergics (like benztropine) can help to reduce the severity of symptoms.

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Tardive Dyskinesia

A serious adverse effect of antipsychotics characterized by involuntary, repetitive movements, particularly of the face, tongue, and limbs. It can emerge after prolonged use and may persist even after discontinuation of the medication.

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Lower EPS Risk Antipsychotics

Antipsychotics that have a lower risk of Extrapyramidal Symptoms (EPS) are preferred for individuals with a history of EPS or who are at higher risk for developing them.

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Akathisia

A condition characterized by involuntary, repetitive movements primarily affecting the legs and feet. It is often described as restlessness, an inability to stay still, and a strong urge to move.

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Priapism

A serious, though rare, side effect of certain antipsychotics, particularly thioridazine. It involves a persistent and painful erection that can last for hours or even days.

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Acute Dystonia

A rare but potentially serious side effect of certain antipsychotics, characterized by involuntary muscle contractions and spasms, often affecting the neck, face, and back.

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What is akathisia?

A type of movement disorder characterized by restlessness, an urgent need to move, and an inability to sit still. It is a common side effect of antipsychotic medications.

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How to manage akathisia initially?

To manage akathisia caused by antipsychotic medications, the first step is typically to decrease the dose of the medication. If symptoms persist, other medications may be considered.

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What is Post-injection Delirium Sedation Syndrome (PDSS)?

A rare but serious complication that can occur after injection of certain antipsychotic medications. It is characterized by delirium, sedation, and hypotension.

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What is the rate of occurrence for Post-injection Delirium Sedation Syndrome?

The rate of occurrence for Post-injection Delirium Sedation Syndrome (PDSS) after injection of antipsychotics is less than 10%.

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Risk factors for increasing QTc

Factors that can increase the risk of a prolonged QT interval, which can lead to potentially serious heart rhythm problems.

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What is Clozapine?

Clozapine is a medication used for treatment-resistant schizophrenia, meaning it's used when other medications haven't been effective. It's known for its effectiveness but requires careful monitoring.

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What is the typical starting and maximum dosage of Clozapine?

Clozapine is typically started at a low dose of 12.5 mg once or twice daily and gradually increased. The maximum dose is 900 mg, with a minimum effective dose of 150 mg.

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What are the major side effects of Clozapine?

Clozapine use has a risk of serious side effects, including seizures, myocarditis, and agranulocytosis, a potentially life-threatening condition affecting white blood cell count.

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What is Agranulocytosis?

Agranulocytosis is a serious side effect of Clozapine where the body doesn't produce enough white blood cells, increasing the risk of infections. It's a rare occurrence, affecting around 0.3% of patients.

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Is Clozapine safe for pregnancy and breastfeeding?

Clozapine is category B in pregnancy, meaning animal studies show no risk to the fetus, but human studies are lacking. It's not recommended during breastfeeding.

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What kind of monitoring is required for Clozapine?

Patients on Clozapine need regular blood tests to monitor for agranulocytosis and other side effects. ECG monitoring is also crucial to assess heart health.

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How is Clozapine's effectiveness maximized?

Clozapine's effectiveness in treating schizophrenia is often enhanced by combining it with other treatments, like psychosocial interventions and addressing substance use.

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What are the advantages of Clozapine?

Clozapine is an antipsychotic drug that's known for a unique combination of features, including its limited impact on sexual function and prolactin levels, which can help minimize side effects.

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What is the approach to restarting Clozapine?

The decision to restart Clozapine after a discontinuation period requires careful consideration and a structured approach, often involving professional guidance.

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What factors influence Clozapine dosage?

Several factors can influence the dosage of Clozapine. Smokers usually require higher doses than non-smokers, and females generally need lower doses than males.

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Study Notes

Pimozide and Clozapine

  • Pimozide is FDA-approved for tic disorders, augmentation in trichotillomania, and delusional disorder, also reducing paranoid ideation in paranoid personality disorder.
  • Clozapine is used for resistant schizophrenia (25-40% prevalence). Management includes stopping substance abuse, psychosocial interventions, and augmentation strategies.
  • Clozapine dosage starts at 12.5mg, increasing by 25-50mg daily up to a maximum of 900mg. A minimum effective dose of 150mg is required, with response generally occurring between this range. Plasma levels should be 350-420ng/ml, though UK uses 450mg as a target dose (achievable in 2-3 weeks)

Clozapine Dosage Adjustments

  • Dosage adjustments are influenced by smoking status & age. Smokers require a higher dose (e.g. 550mg for males, 450mg for females). Non-smokers require a lower dose (e.g., 350mg for males, 250mg for females).
  • Elderly patients and those with medical illnesses, or who are taking enzyme inhibitors (2D6, 3A4, and 1A2) may require lower doses.

Restarting Clozapine

  • A table from the Maudsley 13th edition details restarting clozapine:
    • Up to 48 hours—restart at previous dose without re-titration.
    • 48-72 hours—rapid re-titration as soon as possible. First day: half the previous daily dose in divided doses 12 hours apart, then 75% on day 2, the full dose on day 3.
    • 72 hours to 1 week—start re-titration with 12.5-25mg, increasing by 12.5-25mg per day to normal daily doses over 3 days.
    • More than 1 week—treat as a new patient, re-titrating to the previous dose within 2-4 weeks, increasing based on patient tolerance.
  • A new approach is detailed using Maudsley 14th edition that suggests 12.5 mg after discontinuation for 48 hours.
  • Dosage adjustments are recommended if stopping medication over 12 to 16 weeks or through cross-titration over 6 to 8 weeks.

Additional Monitoring and Drug Interactions

  • Initial work-up includes physical exams, blood tests (CBC, LFT, urea, electrolytes, lipids, glucose/HbA1c), and ECG, with other tests dependent on clinical need.
  • Monitoring, especially metabolic syndrome monitoring involves baseline and follow-up (monthly) weight, BMI, waist, plasma glucose, and lipids, and Liver Function Tests.
  • Interactions exist with agranulocytosis and bone marrow suppression drugs (carbamazepine, phenytoin, etc).
  • Clozapine interacts with numerous drugs, affecting seizure thresholds and agranulocytosis risks through increasing or decreasing clozapine's concentration levels.

Other Antipsychotics and Side Effects

  • Various antipsychotics and their side effects are discussed, including risks, monitoring and treatment protocols (such as those related to Clozapine-induced myoclonus or agranulocytosis).
  • Side effects like seizures, myocarditis, neutropenia, agranulocytosis, akathisia, TD (tardive dyskinesia) are extensively discussed in terms of frequency and potential causes as well as their respective management strategies.
  • Paliperidone and risperidone dosages and administration information (oral and long-acting formulations) are summarized in tables.
  • Olanzapine use, including efficacy and comparative data in CATIE, is detailed.
  • Antipsychotic-induced hyperprolactinemia, its causes, and potential associated symptoms (reproductive dysfunction) are also listed

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Description

This quiz covers key information about Pimozide and Clozapine, including their uses, dosage guidelines, and management strategies for various psychiatric disorders. Participants will also learn how factors like smoking status and age can affect dosage adjustments.

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