NURS 660 PSYCHOPHARM 2025

Minimum ANC level to prescribe Clozapine, general population: - -1,500 μL Severe Neutropenia - - 500μL Moderate Neutropenia - -500-999μL Mild Neutropenia - -μL BEN patients: Normal ANC range for Clozaril - -≥1,000 μL Clozaril BEN patient: severe neutropenia - -500 μL BEN neutropenia - -500-999 μL Lower ANC threshold for starting clozapine: General population - -≥1,500/μL Lower ANC threshold for starting clozapine: Benign ethnic neutropenia (BEN) - 1,000/μL Medical emergencies when prescribing anti-psychotics - -- NMS - Agranulocytosis - Serotonin Syndrome Clinical findings in agranulocytosis - - Clozaril: most likely side effect if pt develops fever within 6 weeks - -Myocarditis Clozaril: if pt develops fever within 6 weeks order a ______, _________ and _______. - -EKG, CRP, Troponin, as this is likely due to myocarditis Common complaints in patients with neutropenia: F,P, U, P - -- Fever (low grade) - painful swallowing (odynophagia) - URI (sinusitis, otitis, cough) - Perirectal pain/irritation Symptoms of neuroleptic malignant syndrome (NMS): - -- High fever - Tachycardia/irregular pulse - Increased respiratory rate - Muscle Rigidity - altered mental status NURS 660 NURS 660 NURS 660 Off label TX for NMS - -Amantadine (SYMMETREL) Serotonin Syndrome onset: - --24 hours of combining antidepressants Serotonin Syndrome Cardinal features - -- Myoclonic jerks - Hyperreflexia - Mental status changes - Shivering - Fever - Tachycardia, HTN, hypotension (AUTONOMIC instability) - Confused/ restless/ hyperactive/ unresponsive Management of Serotonin syndrome - -- Discontinue meds, stablize vitals Potentially helpful meds with Serotonin syndrome: - -Benzodiazepines for agitation Cyproheptadine (anti-serotonergic antihistamine) Methysergide (anti-serotonergic migraine medication) 5-HT "TWITCHY FROG" Serotonin Syndrome - --Agitated -Sweating -Fever -Hyperreflexia -Dilated pupils Neuroleptic Malignant Syndrome - -a potentially fatal hyperpyrexia with temp of over 104, looks like EPS except for temp Neuroleptic Malignant Syndrome- "can't bender(er)" - -Life-threatening muscle rigidity, fever, and rhabdomyolysis. Mental status changes Mechanism of NMS. -What's blocked? Where (2)? - -Dopamine blockade in the hypothalamus (fever) and nigrostriatal pathway (rigidity Onset of NMS - -30 days of starting or increasing antipsychotics or stoping a domaminergic drug NMS cardinal features - -High fever 100% by definition Rigidity 100% by definition Mental status changes 99% Elevated or labile BP most NMS motor activity - -Bradykinesia NURS 660 NURS 660 Brain regions affected by schizophrenia (aggression and impulse control) (2) - Orbitofrontal cortex and amygdala Pathways affected by schizophrenia (4): MMTN - --Mesolimbic - Mesocortical -Tuberoinfundibular -Nigrostriatal Mesolimbic DOPAMINE pathway: Increased dopamine activity in the: ___, ____, and ____. - -Nucleus accumbuns, amygdala, hippocampus Mesolimbic dopamine pathways are responsible for (adding something to the behavior): - -Positive symptoms - Delusions - bizarre behavior - hallucinations - disorganized speech Most antipsychotics treat ___________ symptoms. - -positive Mesocortical pathway: Responsible for a _______ in dopamine activity in ______ condition. - -decreased dopamine activity in schizophrenia mesocortical pathway are responsible for ____ symptoms, such as (3) - -Negative Symptoms 1. Flat affect 2. Poverty of Speech 3. Adhedonia Apathy Tuberoinfundibular pathways: Antipsychotics Decrease _______ causing side effects thru this pathway - -dopamine In the Tuberinfundibular pathway, dopamine inhibits ________. - -Prolactin Tuberoinfundibular pathway: Less dopamine means more ______, more _______ causes less ________ D = P = G - -Less dopamine = more prolactin = less Gonadotropins (GnRH) Tuberoinfundibular pathway: decreased _______ (a result of decreased dopamine and increased prolactin causes these side effects: - -GnRH = - Decreased labido - Sex dysfunction - galactohrrea - gynecomastia Tuberoinfundibular pathway: GNRH - -SEX and Boobs Nigrostriatal pathway is responsible for - -EPS symptoms NURS 660 NURS 660 Patients with agranulocytosis SUDDENLY present with the following: M.F.S.P. - -- Malaise - Fever - Stomatitis - Pharyngitis (difficulty swallowing). Fatal results due to clozapine - -1. Bowel obstruction (most common) 2. Agranulocytosis Start _________, ___________, and PRN _____________ prior to initiating clozapine. - -fiber, docusate and PRN milk of magnesia Avoid __________________ when prescribing clozapine. - -anticholinergics Clozapine is #1 cause of this combination of symptoms ____ and _____ - -constipation and sialorrhea (salivation) Clozapine causes constipation and salivation due to, respectively. - -Anticholinergic effect on the colon and cholinergic effect on salivary glands The S in the cholinergic SLUDGE mnemonic stands for salivation (page 59). Clozapine does not elevate prolactin levels. - - SLUDGE: - -- Salivation - Lacrimation (also lactation) - Urination - Diaphoresis (also diarrhea) - GI upset (diarrhea) - Emesis anticholinergic = - -antimuscarinic anticholinergic (antimuscarinic) blocks - -acetylcholine at muscarinic receptors. Anticholinergic general effects: - -- Tachycardia - Dry as a bone - Mad as a hatter (confusion) - Blind as a bat Blocking histamine causes: - -Sedation, weight gain Blocking Alpha 1 adrenergic causes (3) - -Orthostatic hypotension, cardiac problems, sexual dysfunction NURS 660 NURS 660 Blocking Muscarinic receptors causes (5) - -Anticholinergic side effects: -Dry mouth -Tachycardia -Urinary retention -Blurred vision -Constipation Anticholinergic side effects (5) - -Dry mouth Tachycardia Urinary retention Blurred vision Constipation Positive symptoms: (reflect the development of the symptoms of pyschosis). - Dramatic, reflect loss of touch with reality: Delusions Hallucinations Distortions or exaggerations in language and communication Disorganized speech Disorganized behavior Catatonic behavior Agitation Negative symptoms (reflect loss of normal function and feeling): - -Losing int