NURS 6630 Therapy for Patients With Schizophrenia

Sample Answer for NURS 6630 Therapy for Patients With Schizophrenia Included After Question

NURS 6630 Therapy for Patients With Schizophrenia

 

According to the Schizophrenia and Related Disorders Alliance of America, approximately 3.5 million people in the United States are diagnosed with schizophrenia (n.d.), and it is one of the leading causes of disability. In practice, patients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals. Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders, such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for patients.

This week, as you examine antipsychotic therapies, you explore the assessment and treatment of patients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.

NURS 6630 Therapy for Patients With Schizophrenia Reference:

Schizophrenia and Related Disorders Alliance of America. (n.d.). About  schizophrenia.https://sardaa.org/resources/about-schizophrenia/#:~:text=Quick%20Facts%20About%20Schizophrenia.%20Schizophrenia%20can%20be%20found,is%20one%20of%20the%20leading%20causes%20of%20disability

NURS 6630 Therapy for Patients With Schizophrenia
NURS 6630 Therapy for Patients With Schizophrenia

Learning Objectives

Students will:

  • Assess client factors and history to develop personalized therapy plans for patients with insomnia
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for insomnia
  • Assess patient factors and history to develop personalized plans of antipsychotic therapy for patients
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring antipsychotic therapy
  • Synthesize knowledge of providing care to patients presenting for antipsychotic therapy
  • Analyze ethical and legal implications related to prescribing antipsychotic therapy to patients across the lifespan

Learning Resources

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Required Readings (click to expand/reduce)

 

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002

 

Medication Resources (click to expand/reduce)

 

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

 

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

  • amisulpride
  • aripiprazole
  • asenapine
  • brexpiprazole
  • cariprazine
  • chlorpromazine
  • clozapine
  • flupenthixol
  • fluphenazine
  • haloperidol
  • iloperidone
  • loxapine
  • lumateperone
  • lurasidone
  • olanzapine
  • paliperidone
  • perphenazine
  • pimavanserin
  • quetiapine
  • risperidone
  • sulpiride
  • thioridazine
  • thiothixene
  • trifluoperazine
  • ziprasidone

Required Media (click to expand/reduce)

 

Case study: Pakistani woman with delusional thought processes
Note: This case study will serve as the foundation for this week’s Assignment.

 

Optional Resources (click to expand/reduce)

 

Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., Miller, A. L., & Miller, D. D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124–134. https://doi.org/10.3371/CSRP.5.3.2

Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728–738. https://doi.org/10.2146/ajhp130471

Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107–121. https://doi.org/10.1007/s11126-014-9326-2

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Please read through the following information on writing a Discussion question response and participation posts.

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Important information on Writing a Discussion Question

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  • The Writing Center is a great resource

 

A Sample Answer For the Assignment: NURS 6630 Therapy for Patients With Schizophrenia

Title: NURS 6630 Therapy for Patients With Schizophrenia

Psychopharmacology for Schizophrenia 

The schizophrenia spectrum and other psychotic disorders are among devastating mental illnesses. These conditions are characterized by hallucinations, delusions, abnormal motor behavior, disorganized thought, and speech which collectively impair the social, occupational, and personal functioning of an individual. Consequently, they necessitate treatment. Interventions for schizophrenia spectrum and psychotic disorders are principally by antipsychotics. However, psychoeducation as an adjunct is central to preventing relapses. Antipsychotics are broadly categorized as typical and atypical antipsychotics. Atypical antipsychotics are the newer agents known for their less extrapyramidal side effects. All antipsychotics except clozapine have similar clinical effectiveness. Therefore, the choice of a particular antipsychotic will largely depend on the adverse effect profile and the patient’s clinical status. This piece of paper will extensively explore clozapine including its mechanism of action, pharmacokinetics, pharmacodynamics, dosing, and side effects among other aspects. 

Clozapine 

  • Clozapine is a second-generation antipsychotic. It is a dibenzodiazepine derivative. Clozaril, FazaClo ODT, and Versacloz are the chief brand names for this medication (Khokhar et al., 2018) 
  • It is FDA approved for the treatment of treatment-resistant schizophrenia (Khokhar et al., 2018). Schizophrenia is considered treatment-resistant if an adequate trial of 2 antipsychotic agents (at least one-second generation) offers suboptimal resistance. 
  • Clozapine is deployed in the reduction of suicidal risk particularly in patients with schizoaffective disorder or schizophrenia.  
  • Off-label uses of clozapine include management of dopaminomimetic psychosis and adolescents with bipolar disorder although its adverse effects have limited these clinical benefits (Rachamallu et al., 2019) 

 

Pharmacokinetics 

  • Pharmacokinetics refers to what the body does to the drug. It includes aspects such as absorption, distribution, metabolism, and excretion.  
  • Clozapine is rapidly and well absorbed after oral administration. Peak plasma concentrations are achieved after approximately 1.5 to 2.5 hours (Khokhar et al., 2018). Following oral administration, sedation is apparent within 15 minutes but optimal after 1 to 6 hours. The antipsychotic effect is delayed for 1 to numerous weeks after commencement.  
  • The duration of action of clozapine spans from 4 to 12 hours (Khokhar et al., 2018). However, food appears not to have any effect on clozapine. The drug is rapidly and extensively distributed. It crosses the blood-brain barrier and the placenta. An estimated 97% of the drug is ordinarily plasma protein bonded.  
  • The drug undergoes the first pass effect. It is metabolized by the liver (CYP1A2, CYP2D6, and CYP3A4 isoenzymes (Khokhar et al., 2018). Finally, 50% of the metabolized drug is excreted in the urine while 30% is via feces. 

Pharmacodynamics 

  • The precise antipsychotic mechanism is not fully known. However, a combination of adrenergic, cholinergic, and serotonergic neurotransmitter systems plays a crucial role alongside the more dominant dopaminergic system.  
  • The principal mechanism of action of clozapine is antagonism at D2 receptors and 5-HT2A receptors leading to diminished schizophrenic and suicidal behavior.  
  • Clozapine also binds to H1 receptors, alpha 1 and alpha 2 adrenergic receptors, and muscarinic M1 receptors. Antagonism at these receptor sites considerably contributes to therapeutic and adverse effects including constipation, somnolence, and orthostatic hypotension. 

 

 

Dosing, Administration Route, and Considerations 

  • Clozapine is administered orally. In adults, it is usually started at 25 mg given once or two times daily. This dosage is then increased by 25 to 50 mg/day over 2 weeks up to a target dose of 300 to 450 mg/day (Wells & McCormack, 2020). A further increase by 100 mg/day may be required once or twice daily although the total daily dosage should not exceed 900 mg/day (Wells & McCormack, 2020).  
  • A treatment period of at least 2 years is recommended. Safety of clozapine has not been established in children less than 16 years while elderly patients are at increased risk of mortality in the presence of dementia-related psychosis.  
  • Should never be used in pregnancy unless the benefits outweigh the risks. Finally, the drug should be discontinued during lactation or the mother may bottle-feed 

Half-Life 

  • Refers to the duration it takes for the amount of its active substance in the body to diminish by half.  
  • Directly proportional to the rate of metabolism and elimination of the drug. The half-life varies considerably across various pharmacological agents. It is used to determine the dosing frequency.  
  • The half-life of clozapine is approximately 8 to 12 hours. 

Side Effects and Contraindications 

  • Clozapine is contraindicated in patients with bone marrow suppression, uncontrolled epilepsy, severe CNS depression, and hypersensitivity (de Leon et al., 2020) 
  • The side effects of this drug include neuroleptic malignant syndrome, sedation, dizziness, QT interval prolongation, ventricular arrhythmias, agranulocytosis, leukopenia, hypotension, tachycardia, dry mouth, increased salivation, rash, sweating, visual disturbances, and extrapyramidal reactions (de Leon et al., 2020) 

 

Overdose Considerations, Diagnostics, and Lab Monitoring 

  • Clozapine overdose is devastating due to the risk of delayed effects. Patients should thus be monitored for a couple of days. The principal management of clozapine overdose is supportive therapy and activated charcoal.  
  • Prior to initiation of therapy, a complete blood count including absolute neutrophil count (ANC) should be obtained. During therapy, WBC and ANC should be monitored weekly for the first 6 months, then every 2 weeks, and finally, weekly for 4 weeks after discontinuation (Wells & McCormack, 2020) 

 

  • Similarly, blood glucose levels and lipid levels should be obtained initially and monitored throughout therapy. 

Comorbidities Considerations 

  • Clozapine is principally metabolized by the liver hence patients with hepatic impairment necessitate a dosage reduction due to increased concentrations. Similarly, the elimination of clozapine may be impaired in renal disease.  
  • Individuals with significant renal impairment also require dosage reduction (Dragoi et al., 2020). Geriatric patients have diminished renal, hepatic, and cardiac function as well as concomitant drug therapy. Consequently, necessary dosage adjustments should be made.  
  • Finally, the CYP2D6 isoenzyme metabolizes clozapine. Individuals with poor CYP2D6 metabolizer phenotype should also have their clozapine dosage adjusted accordingly (Dragoi et al., 2020) 

Legal, ethical Considerations 

  • Informed consent must be obtained before initiation of this drug as well as proper documentation (Carpenter & Buchanan, 2020) 
  • Additionally, all rights of safe drug administration must be strictly adhered to including the right dose, right patient, right drug, and right route among others (Carpenter & Buchanan, 2020) 
  • Finally, given the adverse effect profile of clozapine, it should only be reserved for FDA-approved indications. A cost-benefit analysis must always be conducted before initiating this drug. 

Patient Education 

  • The patient should be encouraged to take medication as directed. Those on prolonged therapy require gradual discontinuation over 1 to 2 weeks.  
  • Enlighten the patient on extrapyramidal symptoms and the need to promptly report their occurrence.  
  • Furthermore, the patient should be taken through the procedures and impetus of the Clozaril patient management system (Wells & McCormack, 2020) 
  • The patient should be educated on the best way of changing the position to avoid orthostatic hypotension. 
  •  Similarly, patients should be advised to stop cigarette smoking which diminishes clozapine levels.  

 

  • Female patients should be enlightened on the need to notify healthcare providers if planning a pregnancy or breastfeeding (Wells & McCormack, 2020) 
  • Likewise, the patient should be instructed to continue medical follow up including laboratory tests and eye exams.  
  • Finally, the patient should be enlightened on the possible adverse effects and the need to frequently rinse the mouth. 

Conclusion 

Clozapine is a second-generation antipsychotic with a generally poor adverse effect profile. It is therefore reserved for treatment-resistant schizophrenia. The use of clozapine in pediatric patients has not been established. It is important to understand the pharmacokinetics, pharmacodynamics, side effects, indications, and contraindications of a drug to offer the desired patient education. 

 

 

References 

Carpenter, W. T., & Buchanan, R. W. (2020). Antipsychotic medications: Flawed concepts and ethics. Schizophrenia Bulletin, 46(5), 1030. https://doi.org/10.1093/schbul/sbaa076 

de Leon, J., Ruan, C.-J., Schoretsanitis, G., & De Las Cuevas, C. (2020). A rational use of clozapine based on adverse drug reactions, pharmacokinetics, and clinical pharmacopsychology. Psychotherapy and Psychosomatics, 89(4), 200–214. https://doi.org/10.1159/000507638 

Dragoi, A. M., Radulescu, I., Năsui, B. A., Pop, A. L., Varlas, V. N., & Trifu, S. (2020). Clozapine: An updated overview of pharmacogenetic biomarkers, risks, and safety-particularities in the context of COVID-19. Brain Sciences, 10(11), 840. https://doi.org/10.3390/brainsci10110840 

Khokhar, J. Y., Henricks, A. M., Sullivan, E. D. K., & Green, A. I. (2018). Unique effects of clozapine: A pharmacological perspective. Advances in Pharmacology (San Diego, Calif.), 82, 137–162. https://doi.org/10.1016/bs.apha.2017.09.009 

Rachamallu, V., Elberson, B. W., Vutam, E., & Aligeti, M. (2019). Off-label use of clozapine in children and adolescents-A literature review. American Journal of Therapeutics, 26(3), e406–e416. https://doi.org/10.1097/MJT.0000000000000894 

Wells, C., & McCormack, S. (2020). Clozapine initiation for schizophrenia: A review of clinical effectiveness and guidelines. https://www.ncbi.nlm.nih.gov/books/NBK562945/