Ptx Ii Final - Schizophrenia

Front 1

KS is a 23 year old male who has been receiving haloperidol on and off for the past year for treatment of schizophrenia. Adherence has been a problem for this patient and his family due to the occurrence of extrapyramidal side effects.

Which of the following most correctly describes extrapyramidal symptoms?
a. dizziness, postural hypotension, reflex tachycardia
b. galactorrhea, gynecomastia, menstrual irregularities
c. blurred vision, constipation, dry mouth, urinary retention
d. dystonias, akathisia, tardive dyskinesia

Back 1

d. dystonias, akathisia, tardive dyskinesia

Selections a, b, and c describe effects related to actions of haloperidol and other anti-psychotics on different peripheral and central receptors.

Front 2

KS is a 23 year old male who has been receiving haloperidol on and off for the past year for treatment of schizophrenia. Adherence has been a problem for this patient and his family due to the occurrence of extrapyramidal side effects.

KS’s psychiatrist desires to discontinue haloperidol and begin therapy with olanzapine. Which of the following is most correct regarding this strategy?
a. good strategy – olanzapine is comparably efficacious to haloperidol and less likely to cause extra-pyramidal symptoms;
b. good strategy – olanzapine is less efficacious than haloperidol but less likely to cause extra-pyramidal symptoms;
c. bad strategy – olanzpine is less efficacious than haloperidol on both positive and negative symptoms;
d. bad strategy – olanzpine is less efficacious than haloperidol and is likely to cause of bone marrow suppression.

Back 2

a. good strategy – olanzapine is comparably efficacious to haloperidol and less likely to cause extra-pyramidal symptoms;

Front 3

REFER TO CASE 1

After your interview with her and her mother you find out that Ms OB has been
experiencing a tremor and it is difficult to get her moving in the morning. Her
mother has to help her out of bed. Her physician feels that Ms OB is experiencing
pseudoparkinsonism. What are Olivia’s risk factors for this apparent adverse
effect?
a. Increasing age, male, first generation antipsychotic (FGA)
b. Increasing age, female, second generation antipsychotic (SGA)
c. Increasing age, female, recent dose increase, FGA
d. Increasing age, male, recent dose increase

Back 3

c. Increasing age, female, recent dose increase, FGA

Selection “A” is incorrect: Females are at greater risk for pseudoparkinsonism than
males.
Selection “B” is incorrect: FGA have a greater risk of EPS than SGA including
pseudoparkinsonism; SGA have little to no risk of EPS
Selection “C” is correct: Increasing age, a recent dose change, female and treatment
with FGA are all risk factors
Selection “D” is incorrect: Females are at greater risk than males for
pseudoparkinsonism

Front 4

REFER TO CASE 1

Which of the following describes the best treatment for this patient apparent
pseudoparkinsonism?
a. Adding an anticholinergic agent for 6-12 weeks
b. No therapy is needed. The patient should be asked to tolerate the clinical
manifestations.
c. Stop the thioridazine and restart after a 2 week period off of antipsychotics
d. Add a SGA to the patient’s thioridazine therapy

Back 4

a. Adding an anticholinergic agent for 6-12 weeks

Selection “A” is correct. Use of benztropine, trihexyphenidyl, benadryl or biperiden may be added for 6wk to 3 months. Symptoms resolve in 3-4 days and full response is expected in 2 weeks. Switching to an SGA is an option and should be done if this is a reoccurrence of the symptoms.
Selection “B” is incorrect. Side effects that are not tolerated by patients should
prompt a change in therapy because adverse effects are a primary reason patients
are not compliant.
Selection “C” is incorrect. Therapy may continue with the addition of an
antipsychotic or switching to an SGA.
Selection “D” is incorrect. Such combination therapy has not been shown to improve
the patient’s symptom management and can actually increase the risk of adverse
effects.

Front 5

REFER TO CASE 1, (regarding adding an anticholinergic for pseudoparkinsonism)

Your recommendation to the psychiatrist is:
a. Haloperidol (Haldol) 5mg tid
b. Aripiprazole (Abilify) disintegrating tablet 10mg daily
c. Olanzapine disintegrating (Zyprexa Zydis) tablet 5mg daily
d. Risperidone (Risperdal) 8mg oral tablet daily

Back 5

b. Aripiprazole (Abilify) disintegrating tablet 10mg daily

"A" is Incorrect: This is an FGA and the patient may experience the same effects without adding an anticholinergic agent. It is also tid which does not promote compliance
"B" is Correct: This SGA has less weight gain, less risk for lipid changes and may not
affect blood glucose as much as olanzapine or clozapine
"C" is Incorrect: This patient is obese and has diabetes. The diabetes control is not optimal
and olanzapine can cause a >/7% increase in weight.
"D" is Incorrect: Doses above 6mg of Risperidone have a similar risk for EPS that the FGAs do.

Front 6

REFER TO CASE 2
RS has been diagnosed with paranoid schizophrenia. Which of the following is the most appropriate treatment goal for RS? (Obj: List the goals of treatment)

a. Maximize the medication by using the highest dose of a second generation agent
b. Change medications if the symptoms have not been eliminated with in the first week of therapy
c. Maximize the dose without regard to adverse effects because the medications are well tolerated with few adverse effects
d. Achieve the best possible compliance

Back 6

d. Achieve the best possible compliance

A, Incorrect: The lowest most effective dose should be used to minimize adverse effects
B, Incorrect: There should be an adequate trial of the medication especially if there has been some improvement in symptoms. An adequate trial could be as long as 3 months (6 months with clozapine)
C, Incorrect: Avoid undesirable side effects. There are many side effects with antipsychotics and some may not be resolved with discontinuation. Adding medications to treated side effects should be limited.
D, Correct: 100% compliance is unrealistic for most patients with schizophrenia as these patients have trouble understanding why they have to take medications in the first place.

Front 7

REFER TO CASE 2
11. The physician has asked you to assist in recommending treatment for RS. Which of the recommendations below is most appropriate?
(Obj: Recommend treatment for schizophrenia patients)

a. Olanzapine 10 mg orally once daily
b. Haloperidol 5 mg orally three times daily
c. Aripiprazole 150 mg orally once daily
d. Risperidone 12 mg orally once daily

Back 7

a. Olanzapine 10 mg orally once daily

A, Correct: A second generation agent is first line treatment. 10mg is the starting dose.
B, Incorrect: First generation agents are not first line agents because of their high potential for adverse effects including tardive dyskinesia which may be an irreversible side effect.
C, Incorrect: This is a second generation agent but the correct dose is 15mg daily.
D, Incorrect: Doses above 6mg of Risperidone have a similar risk for EPS as the FGAs do.

Front 8

REFER TO CASE 2
The physician elects to follow/ignore your recommendation and starts Olanzapine 10mg daily and asks you to review his lab orders for baseline monitoring. Which of the answers below includes the most complete list of baseline monitor parameters?
(Obj: Describe appropriate monitoring parameters associated with treatment)

a. Blood pressure only
b. Family history annually, side effects and blood pressure
c. Blood pressure, fasting plasma glucose, weight, fasting lipid panel,
complete blood count, basic metabolic panel
d. No baseline lab monitoring is necessary

Back 8

c. Blood pressure, fasting plasma glucose, weight, fasting lipid panel, complete blood count, basic metabolic panel

A, Incorrect: Blood pressure is not the only monitoring parameter
B, Incorrect: These are important to monitor but this is not a complete list
C, Correct: This is a more complete list of baseline information. BP, BG, weight, lipids is important as the medications can affect these parameters. CBC and metabolic panel will rule out other illnesses or complications of schizophrenia
D, Incorrect: Olanzapine can affect lipids, blood glucose, weight and blood pressure. Baseline monitoring is important in order to be able to identify changes in these monitoring parameters.

Front 9

REFER TO CASE 2
RS has returned for a follow-up visit after 4 weeks of treatment with Olanzapine. Her blood pressure is 130/80 mmHg, Fasting Blood Glucose 100 mg/dL, weight 80 kg. The physician is happy with the efficacy of the medication. Which of the recommendations below is most correct given the
clinical findings above? (Obj: Describe appropriate management of adverse events associated with treatment)
a. No change as the patient has responded well to treatment
b. Switch to Aripiprazole 15 mg orally once daily because the patient has
had more than a 5% weight gain
c. Switch to a first generation agent since the second generation agent has
failed
d. Orlistat should be started to help the patient lose weight

Back 9

b. Switch to Aripiprazole 15 mg orally once daily because the patient has had more than a 5% weight gain

A, Incorrect: ADA recommends a change in medication if weight gain is > 5% and there are other medication options with less weight gain.
B, Correct: ADA recommends switching medications if there has been a >5% weight gain. Aripiprazole and Ziprasidone have the least affect on weight gain.
C, Incorrect: In most cases a second and sometimes third second generation agent should be tried before starting a first generation agent.
D, Incorrect: Initiating medication to treat side effects should be limited as this can add to the adverse effects. A switch to aripiprazole or ziprasidone should be the recommendation.

Front 10

REFER TO CASE 3

RS has been diagnosed with paranoid schizophrenia. Which of the following statements regarding RS’ treatment is most correct? (Obj: List the goals of treatment)
a. Minimize adverse effects of medication by using the lowest effective dose of a second generation agent.
b. Change medications if the symptoms have not been eliminated with in the first week of therapy.
c. Maximize the dose without regard to adverse effects because the medications are well tolerated with few adverse effects.
d. Compliance is not a goal for these patients because they will always be compliant.

Back 10

a. Minimize adverse effects of medication by using the lowest effective dose of a second generation agent.
A, Correct: The lowest most effective dose should be used to minimize adverse effects. Second generation agents are first line treatment.
B, Incorrect: There should be an adequate trial of the medication especially if there has been some improvement in symptoms. An adequate trial could be as long as 3 months (6 months with clozapine)
C, Incorrect: Avoid undesirable side effects. There are many side effects with antipsychotics and some may not be resolved with discontinuation. Adding medications to treated side effects should be limited.
D, Incorrect: 100% compliance is unrealistic for most patients with schizophrenia as these patients have trouble understanding why they have to take medications in the first place. Compliance is a goal to include with these patients.

Front 11

REFER TO CASE 3
The physician has asked you to assist in recommending treatment for RS. Which of the following recommendations is most correct? (Obj: Recommend treatment for schizophrenia patients)
a. Olanzapine 10mg orally daily
b. Haloperidol 0.5mg intravenously three times daily
c. Aripiprazole 150mg orally daily
d. Risperidone 12mg orally daily

Back 11

a. Olanzapine 10mg orally daily

A, Correct: A second generation agent is first line treatment and the starting dose is 10mg daily.
B, Incorrect: First generation agents are not first line agents because of their high potential for adverse effects including tardive dyskinesia which may be an irreversible side effect. IV would not be the best route for an outpatient.
C, Incorrect: This is a second generation agent but the starting dose is 10-15mg daily.
D, Incorrect: Doses above 6mg of Risperidone have a similar risk for EPS that the FGAs do.

Front 12

REFER TO CASE 3
What baseline monitoring should be recommended prior to initiating a second generation antipsychotic? (Obj: Describe appropriate monitoring parameters associated with treatment)
a. No baseline lab monitoring is necessary
b. Blood pressure, fasting plasma glucose, weight, fasting lipid panel, complete blood count, basic metabolic panel
c. Blood pressure only
d. Family history annually, side effects and blood pressure

Back 12

b. Blood pressure, fasting plasma glucose, weight, fasting lipid panel, complete blood count, basic metabolic panel

A, Incorrect: SGAs can affect lipids, blood glucose, weight and blood pressure. Baseline monitoring is important in order to be able to identify changes in these monitoring parameters.
B, Correct: This is a more complete list of baseline information. BP, BG, weight, lipids is important as the medications can affect these parameters. CBC and metabolic panel will rule out other illnesses or complications of schizophrenia
C, Incorrect: Blood pressure is not the only monitoring parameter
D, Incorrect: These are important to monitor but this is not a complete list

Front 13

REFER TO CASE 3
RS has returned for a follow-up visit after 4 weeks of treatment with a second generation antipsychotic. Her blood pressure is 130/80 mmHg, fasting blood glucose is 100 mg/dL, and body weight is 80kg. The physician is happy with the efficacy of the medication. The patient is complaining of weight gain. Which of the following recommendations would be most correct? (Obj: Describe appropriate management of adverse events associated with treatment)
a. No change as the patient has responded well to treatment
b. Switch to a first generation agent since the second generation agent has failed
c. Switch to Ziprasidone 20mg orally twice daily because the patient has had more than a 5% weight gain
d. Orlistat should be started to help the patient lose weight

Back 13

c. Switch to Ziprasidone 20mg orally twice daily because the patient has had more than a 5% weight gain

A, Incorrect: ADA recommends a change in medication if weight gain is > 5% and there are other medication options with less weight gain.
B, Incorrect: In most cases a second and sometimes third second generation agent should be tried before starting a first generation agent.
C, Correct: ADA recommends switching medications if there has been a >5% weight gain. Aripiprazole and Ziprasidone have the least affect on weight gain.
D, Incorrect: Initiating medication to treat side effects should be limited as this can add to the adverse effects. A switch to aripiprazole or ziprasidone should be the recommendation.