57 - Pharmacotherapy of schizophrenia and psychotic disorders Flashcards
Warnings for all Antipsychotics
- Boxed Warning: increased risk of death in ___ patients treated with antipsychotics for dementia with related behaviors
- ___ adverse effects
- EPS
- risk of somnolence, postural ___ , and motor/sensory instability increases the risk for falls/fractures
- fall risk assessment should be performed for patients taking other medications or having other disease states that also have a fall/fracture/somnolence/hypotension risk
- assess when initiating antipsychotic and repeat routinely if on continuous long term treatment
- elderly
- metabolic
- hypotension
fluphenazine and haloperidol decanoate
fluphenazine
- given every 2 weeks
- short onset of action - dont need oral overalp dosing
- oil based - need to Z-track
haloperidol
- given every ___ weeks
- load: ___ x oral dose
- maintenance: ___ x oral dose
- if only use maintenance, may need ___ overlap
- oil-based - Z-track
- 4
- 20x
- 10x
- oral
Risperdal Consta (risperidone)
starting dose = 25 mg IM every week
MUST supplement with ___ risperidone (or another oral antipsychotic) for the first few weeks of treatment
- Otts tells providers until ___ injection (week 4)
oral
3rd
Perseris (risperidone)
- abdominal ___ injections
- ___ inducers - use ___ mg dose or may need ___ supplementation
- SubQ
- 3A4, 120, oral
Rykindo (risperidone)
- every ___ week ___ injection
- oral dose overlap is shorter than Risperdal Consta ( ___ days vs ___ days)
- 2, IM
- 7, 21
Uzedy (risperidone)
- abdominal or upper arm ___ injection
- initiate the day after the last oral dose
- can switch to Uzedy only from oral risperidone
- given once ___ or every ___ months
- SubQ
- monthly, 2
Invega Sustenna (paliperidone)
- ___ dose, then booster, then every ___ weeks (starting ___ weeks after loading injection)
- initial loading and booster does must be given in ___ to improve absorption consistency
- if loading strategy followed, no need for ___ overlap
- may require dose adjustment in moderate to severe ___ impairment
- loading, 4, 5
- deltoid
- oral
- renal
Invega Trinza (paliperidone q3mo)
- may be initiated for a patient who has been on a stable monthly IM injection of ___ (only way that it should be used)
- at least ___ stable ___ doses
- recommended to be given in the ___; ___ administration results in lower Cmax
- not recommened if CrCl < ___ mL/min
- VERY EXPENSIVE
- Invega Sustenna
- 4, invega Sustenna
- deltoid, gluteal
- 50
Invega Hafyera (paliperidone q6mo)
- may be initiated after stable Invega Sustenna for ___ months or stable Invega Trinza after one ___ month dose
- ___ injection only
- SUPER EXPENSIVE
- not recommended in renal impairment (CrCl < 90 mL/min)
- 4, 3
- gluteal
Zyprexa Relprevv (olanzapine)
SE similar to oral olanzapine
___ - requires registration of patient, facility giving injection, prescriber, adn pharmacy with Eli Lilly
PDSS - ___
- significant sedation
- must be done by clinic staff
- must be monitored 3 hours after dose and have accompanied ride home
Dosing for IM q 2 weeks only compare to up to 20 mg oral dose daily. Most patients take more than 20 mg.
- will have to do oral supplementation in addition to shot
REMS
post dose sedation syndrome
Abilify Maintena (aripiprazole)
MUST overlap with ___ aripiprazole (or another oral anntipsychotic) for at least ___ days after first injection
- ___ or ___ injection
oral, 14
- deltoid, gluteal
Abilify Maintena (aripiprazole) CYP interaction dose adjustments
Abilify Asimtufii (aripiprazole)
Abilify Maintena Dose Adjustments for CYP Interactions
if taking ___ or ___ inhibitors or ___ inducers for more than ___ days as concomitant therapy
2D6, 3A4, 3A4, 14
Abilify Asimtufii (aripiprazole)
- every 2 ___ dosing
- ___ injection only
- must establish tolerability to aripiprazole with oral dosing up to ___ weeks to assess; after tolerability is established, continue oral aripiprazole for ___ weeks after first injection
- month
- gluteal
- 2, 2
Aristada (aripiprazole lauroxil)
- ___ of aripiprazole
- overlap with oral aripiprazole for ___ weeks after first injection
prodrug
3
Aristada Initio
- developed to ___ need for 21 day oral overlap of antipsychotic
- avoid in patients who are ___ poor metabolizers or with strong ___ or ___ inhibitors
- avoid
- 2D6, 3A4, 2D6
Immediate Release Antipsychotic Injections / Psychiatric Emergencies
- ___ , ___ , and ___ are used
- ___ is the most common
- often given with lorazepam in the same syringe
- ___ immediate release IM - CANNOT be given at the same time as a ___ immediate release injection - boxed warning for respiratory depression
- ___ for inhalation (Adasuve) - not commonly used due to REMS - bronchospasm. Developed to improve patient acceptance
- haloperidol, chlorpromazine, fluphenazine
- haloperidol
- olanzapine, benxodiazepine
- loxapine
Clinical Treatment Strategies for EPS
Acute Dystonia - not life threatening, but very frightening
- IM ___ NOW dose ( ___ 2mg, ___ 50 mg)
anticholinergic
- benztropine, diphenhydramine
Clinical Treatment Strategies for EPS
Drug-Induced Parkinson’s - longer term side effect, months into antipsychotic treatment
- oral ___ (3)
- amantadine
anticholinergics
- benztropine, trihexyphenidyl, diphenhydramine
Clinical Treatment Strategies for EPS
Akathisia - subjective feeling of restlessness; increases risk for suicidal thinking
- BB - ___ preferred first line
- benzodiazepine - usually ___
- propranolol
- lorazepam
Clinical Treatment Strategies for EPS
Tardive Dyskinesia - ___ dose of antipsychotic if possible or switch to antipsychotic with less risk
- ___ inhibitors
lower
- VMAT
VMAT inhibitors
inhibit the vesicular monoamine trasporter to ___ storage / ___ release of dopamine, serotonin, and norepinephrine
decrease, increase
VMAT inhibitors
tetrabenazine (Xenazine)
- not FDA-approved to treat TD, indicated for ___
- boxed warning for suicidality/depression
- CI in actively suicidal pts, undertreated depression, hepatic impairment
- ___ prolongation
- Huntington’s chorea
- QTc
VMAT inhibitors
___ (Ingrezza)
- ___ / ___ substrate
- SE: ___ prolongation, somnolence, hypersensitivity reactions, anxiety, insomnia, dose-related __ increase, increased weight and BG
valbenazine
- 2D6, 3A4
- QTc
VMAT inhibitors
___ (Austedo)
- FDA approved for both ___ and ___
- ___ substrate
- SE: ___ prolongation, neuroleptic malignant syndrome, Parkinson’s symptoms, sedatioin, somnolence, anxiety, insomnia, fatigue, diarrhea
deutetrabenazine
- TD, Huntington’s chorea
- 2D6
- QTc
neuroleptic malignant syndrome
- life threatening - medical ___
- may happen with first dose, dose increase, or earlier course of treatment
- hyper ___ , ___ cardia, labile blood pressure
- muscle ___ - significantly elevated CK, myoglobinuria
- treatment is supportive - d/c antipsychotics, consider ___ agonist
future antipsychotic use is NOT CI
- may use same drug, likely to switch to another agent
- emergency
- hyperpyrexia, tachycardia
- rigidity
- dopamine
metabolic adverse effects
- hyper ___ , hyper ___ , hyper __
- weight gain
atypical antipsychotic risk
- clozapine = ___ >
- quetiapine = ___ = paliperidone = asenapine - iloperidone = cariprazine = brepiprazole >
- ziprasidone = lurasidone = ___
- hyperglycemia, hyperlipidemia, hypertension
- olanzapine
- risperidone
- aripiprazole
metabolic monitoring
- personal/family Hx
- weight (BMI)
- waist circumference
- BP
- FPG/A1c
- fasting lipids
medications for weight loss/diabetes
___ most commonly used
- ___ treatment for weight gain
___ studied for weight loss
GLP-1s can also be considered
metformin
topiramate
