SCHIZOPHRENIA MANAGEMENT Gresh Kumar.pptx

Management of scizoprenia

1. MANAGEMENT OF SCHIZOPHRENIA BY: DR. GRESH KUMAR

2. MANAGEMENT DIAGNOSTIC EVALUATION TREATMENT HISTORY EXAMINATION MSE INVESTIGATION PHARMACO-LOGICAL NON-PHARMACOLOGICAL COMBINATION

3. PHASES OF TREATMENT IN SCHIZOPHRENIA ACUTE PHASE - characterized by psychotic symptoms that require immediate clinical attention. Treatment during this phase focuses on alleviating the most severe psychotic symptoms. Usually last from 4 to 8 weeks. Acute schizophrenia is typically associated with severe agitation, which can result from such symptoms as frightening delusions ,hallucinations or suspiciousness or from other causes ,including stimulant abuse.

4. STABLIZATION PHASE: In which acute symptoms have been controlled ,but patients remain at risk for relapse if treatment is interrupted or if the patients are exposed to stress. During this phase, treatment focuses on consolidating therapeutic gains, with similar treatments as those used in the acute stage. This phase last as long as 6 months following recovery from acute symptoms. STABLE OR MAINTANENCE PHASE- When illness is either in a relative stage of remission or symptomatically stable. Goals during this phase are to prevent psychotic relapse or exacerbations and to assist patients in improving their level of functioning.

5. REASON FOR HOSPITALIZATION INDICATED FOR: For Diagnostic purposes For Stabilization of medications For patients /relatives safety(suicidal and homicidal ideation) For grossly disorganized or inappropriate behaviour (including the inability to take care of basic needs such as food , clothing and shelter) Hospital treatment plans should be oriented towards practical issues of self –care , quality of life ,employment and social relationships

6. ASSESSMENT Before starting medication patients should receive a physical examination with neurological examination ,a mental status examination, and a laboratory evaluation. Blood tests for complete blood count (CBC),electrolytes , fasting glucose , lipid profile , liver , renal , and thyroid function should be ordered. Other evaluations that should be considered are pregnancy test in women, and hiv test. Individuals with schizophrenia are at a higher risk for cardiovascular disease than the population at large.

7. Treatment of schizophrenia: Pharmacological Non pharmacological Combined

8. Antipsychotic medications-the mainstay of pharmacological treatment –are effective for reducing the impact of psychotic symptoms such as hallucinations, delusions and suspiciousness. In many symptoms can be completely eliminated , once these symptoms are minimized , medications can decrease the likelihood that symptoms will recur.

9. SELECTION OF AN ANTIPSYCHOTIC DRUG Antipsychotics are categorized into two main groups 1 st generation (FGAs) 2 nd generation(SGAs)or dopamine receptor antagonists(DAs) serotonin dopamine antagonist (SDAs) FGAs are further categorized as being low, mid or high potency. Higher potency drugs – more specificity and greater affinity for D2 receptor and greater tendency to cause EPS. Lower potency drugs are less likely to cause EPS, but likely to cause hypotension, sedation, and anticholinergic effects. Basically selection of drug is based on individual patient profile.

10. SELECTION OF DRUGS DEPENDS ON: Availability Side effect profile Symptoms Specifics contraindications Familiarity Cost

11. DRUG MINIMUM EFFECTIVE DOSE 1 ST EPISODE MINIMUM EFFECTIVE DOSE MULTIPLE EPISODE MAXIMUM EFFECTIVE DOSE FGAs Chlorpromazine 200 mg 300 mg 1000 mg /day Haloperidol 2 mg 4 mg 20 mg /day Sulpiride 400 mg 800 mg 2400 mg /day Trifluoperazine 10 mg 15 mg 30 mg /day SGAs Amisulpride 400 mg Unclear ? 400mg 1200 mg /day Aripiprazole 10 mg 10 mg 30 mg/day Asenapine 10 mg 10 mg 20 mg (sublingual) Olanzapine 5 mg 7.5 mg 20 mg/day Quetiapine 150 mg 300 mg 750 mg /day Risperidone 2 mg 3 mg 16 mg/day Ziprasidone 40 mg 80 mg 160 mg/day

12. EQUIVALENT DOSES DRUG EQUIVALENT DOSE chlorpromazine 100 mg/kg Haloperidol 2 mg/kg Trifluoperazine 5 mg/kg Olanzapine 7.5 -10 mg Risperidone 3 mg Queitiapine 300 mg Aripiprazole 10 mg

13. TREATMENT OF FIRST EPISODE SCHIZOPHRENIA

14. Either ; Agree choice of antipsychotic with patient Or, If not possible; Start 2 nd generation antipsychotic Titrate , if necessary , to minimum affective dose Adjust dose according to response and tolerability Assess over 2-3 weeks

15. Change drug and follow above process consider use of either a SGAs or a FGAs If poor compliance related to poor tolerability, discuss with pt and change the drug. If poor compliance related to other factors, consider early use of depot. Continue at dose established as effective Clozapine (THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12 TH EDITION) effective Not effective Not tolerated or poor complianc e Not effective

16. TREATMENT OF RELAPSE OR ACUTE EXACERBATIONS (Full adherence to medication confirmed)

17. Investigate social or psychological precipitants Provide appropriate support and or therapy. Continue usual drug treatment Add-short term sedative Or Switch to different, acceptable discuss choice with pts and assess over at least 6 weeks Switch to clozapine (THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12 TH EDITION) Acute drug treatment required Treatment ineffective

18. TREATMENT OF RELAPSE OR ACUTE EXACERBATIONS (ADHERENCE DOUBTFUL OR KNOWN TO BE POOR)

19. Confused or disorganised Lack of insight poorly tolerated t/t Or support Investigate reasons for poor adherence Simply drug regimen Reduce anticholinergic load Consider depot Discuss with the patient consider depot antipsychotics Discuss with patient switch to acceptable drug

20. First generation drugs may be slightly less efficacious than some SGAs. FGAs should be probably be reserved for 2 nd line use because of the possibility of poorer outcome compared with FGAs and higher risk of movement disorder ,particularly tardive dyskinesia. Choice is, however, based largely on comparative adverse effect profile and relative toxicity. patients seem able to make informed choices based on these factors, although in practice they may only very rarely be involved in drug choice. Where there is prior treatment failure olanzapine or risperidone may be better options than quetiapine . Olanzapine because of the wealth of evidence suggesting slight superiority over other antipsychotics , should always be tried before clozapine unless contraindicated. Where there is confirmed treatment resistance evidence supporting the use of clozapine is overwhelming.

21. MANAGING AGITATION IN ACUTE PSYCHOSIS Agitation in acute schizophrenia can result from disturbing psychotic symptoms such as frightening delusions or suspiciousness or from other including stimulants abuse or EPS, particularly akathisia . If pts are receiving agent associated with EPS, usually a first generation , a trial with anticholinergic anti-parkinsonism medication or propranolol may be helpful in making the discrimination. An advantage of an antipsychotic is that a single i.m injection of haloperidol, fluphenazine ,olanzapine , aripiprazole or ziprasidone will often result in calming without an excess of sedation.

22. Intramuscular ziprasidone , aripiprazole , and olanzapine are similar to their counterparts in not causing substantial EPS during acute treatment. Rapidly dissolving oral olanzapine, risperidone or aripiprazole may also be helpful as an alternative to an intramuscular injection. Benzodiazapines are also effective for agitation during psychosis. Lorazepam has the advantage of reliable absorption when administered either orally or intramuscularly. The combination of lorazepam + antipsychotic  found safer and more effective than large doses of DAs in controlling excitement and motor agitation.

23. ACUTE MANGEMENT OF PSYCHOTIC EPISODE With exception of Canadian guidelines ,all other recommend the use of either SGAs (1 st line) or FGAs (2 nd line) as standard drugs. The Canadian guidelines only recommend the use of SGAs such as olanzapine , risperidone or quetiapine . Based on recent evidence, the unified guidelines recommends the use of either 1 st or 2 nd generation antipsychotics based on clinical and economic needs at a dosage of 300-1000 chlorpromazine equivalents.

24. PROPHYLAXIS OF SCHIZOPHRENIA All guidelines recommend the continued use of the same antipsychotic used to manage the acute episode for prophylaxis. In longer term a balance needs to be made between effectiveness and adverse-effects. Very low doses increase the risk of psychotic relapse.

25. HOW AND WHEN TO STOP? Decision to stop antipsychotic drugs require a through risk- benefit analysis for each pt. Withdrawal of drug after long term t/t should be gradual and closely monitored. The relapse rate in 1 st 6months after abrupt withdrawal is double that seen after gradual withdrawal (slow taper down over at least 3wks for oral antipsychotics or abrupt stopping of depot preparation)

26. DURATION OF PHARMACOTHERAPY The APA and Canadian guidelines recommended similar duration of acute( , stabilization ,and stable phase treatment. The NICE and Maudsley guidelines recommend acute treatment to last 2 years and give no specific recommendation on duration of prophylaxis. The unified guidelines recommends: The acute phase treatment : last at least 12 weeks, The stabilization phase :last at least 12 months, The stable phase : last at least 2 years for a first episode and 5 years to lifetime for multiple episodes.

27. Anti psychotic side effects EPSEs Acute Dystonia: Contraction of muscle group to maximal limit (typically sternocleidomastoid and tongue) Treatment: Parenteral anti muscarinic Parkinsonism: Tremor, rigidity and bradykinesia occurring >1 week after administration Treatment: consider dose reduction or oral anti muscarinic.

28. Akathisia: restlessness, usually of lower limb and drive to move usually occur >1 month after initiation of anti psychotic drugs. Treatment: propanol and benzodiazepines Tardive dyskinesis: continuous slow writhing movements and sudden involuntary movements (typically oral lingual region) It tend to be irreversible (but there is little evidence that reduction in dose of anti psychotic improves symptoms in the short or long term)

29. Anti cholinergic side effects Dry mouth, blurred vision, difficulty passing urine, constipation, rarely glaucoma and ileus.

30. Anti histamine side effects Sedation and weight gain

31. Anti adrenergic side effects Postural hypotension, sexual dysfunction (particularly erectile dysfunction), tachycardia (sometime bradycardia)

32. Thank you