Anti-Psychotics Part II Flashcards
What is the mechanism of action of atypical anti-psychotics and how is this clinically relevant?
Antagonize serotonin-2A –> makes them better at treating negative symptoms
T/F: Atypical anti-psychotics increase depression.
False: The serotonin-2A receptor has no impact on depression
In addition to psychosis, what is the other indication for atypical anti-psychotics?
Bi-polar manic phase –> insomnia, risky behavior, grandiosity, etc.
What common medication can trip a manic episode in bi-polar patients?
SSRIs or other antidepressants
What are the disadvantages of atypical anti-psychotics?
Weight gain, even more than typical anti-psychotics
Acceleration of development of DM
Hyperlipidemia –> increase cardiovascular morbidity and mortality in patients older than 65
Cost
What are the advantages of atypical anti-psychotics?
Less risk of EPS
Treats negative symptoms
Available in a variety of dosage forms (helps with adherence)
List groups of atypical antipsychotics that are “related”.
Risperidone and Paliperidone
Olanzapine, Quetiapine, and Clozapine
Aripiprazole and Brexiprazole
What are the effects of quetiapine at various doses?
Low dose: hypnotic (great for insomnia)
Medium dose: antidepressant
High dose: anti-psychotic
What are the main advantages and disadvantages of quetiapine?
Adv: very low risk of EPS and hyperprolactinemia
Disadv: causes weight gain
What was the first atypical anti-psychotic?
Clozapine
T/F: Clozapine is commonly used. State why or why not.
False: Used last line because it has 5 black box warnings
What are the black box warnings associated with clozapine?
Agranulocytosis (monitor WBC count) Orthostatic hypotension Seizures Increased mortality in elderly with dementia related psychosis Myocarditis/cardiomyopathy
What is the advantage of utilizing olanzapine?
It is structurally similar to clozapine but it has no black box warnings
What is the major disadvantage of olanzapine?
Significant weight gain –> decreases adherence
What are the primary advantages and disadvantages of risperidone?
Adv: less weight gain
Disadv: significant hyperprolactinemia (must monitor prolactin level)
What S/S result from hyperprolactinemia?
Galactorrhea, sexual dysfunction, bone density changes
What are the indications for use of risperidone?
Schizophrenia in adults and adolescents
Acute bipolar mania
Behavioral disturbances in autistic children
What is the difference between paliperidone and risperidone?
Same effects –> paliperidone is an active metabolite of risperidone
When would you prescribe paliperidone over risperidone?
If the patient could not tolerate risperidone, they may be able to take paliperidone since it is an active metabolite of risperidone.
What are the advantages of lurasidone?
Less sedating and low metabolic risk (less weight gain, hyperlipidemia, etc.)
How is lurasidone administered?
Taken with a 500 calorie meal to increase absorption
What is the advantage of ziprasidone?
Low risk of metabolic effects
What are the advantages and disadvantages of aripiprazole?
Adv: low risk of: weight gain, hyperprolactinemia, sedation, and dyslipidemia
Disadv: high cost
T/F: Aripiprazole is a commonly used atypical anti-psychotic.
True –> one of the cleanest anti-psychotics
What is an additional use of aripiprazole in addition to its use as an anti-psychotic?
Added to an SSRI/SNRI for severe depression
What effect will administration of anti-psychotic medications have on Parkinson’s Disease?
Worsen Parkinson’s because anti-psychotics decrease dopamine
What drug can be given for psychosis in a Parkinson’s patient and why?
Pimavanserin –> modulates hallucinations and delusions without antagonizing dopamine
What is the primary indication for administration of Lithium?
Mood stabilizer in bi-polar disorder
If Lithium is not used for bi-polar disorder, what other class of medications is likely used?
Anti-psychotics
Describe and state the dose range of Lithium and state what affect this has on patient management.
It has a narrow therapeutic window –> 0.4 - 1.0 mmol/L.
Monitor serum Li weekly until stabilized.
What affect will most diuretics have on serum lithium levels?
Lithium has an inverse relationship with Na. Diuretics waste Na causing lithium levels to rise.
When are therapeutic effects seen after lithium administration is started?
2-3 weeks after the drug is started
What are the AEs of Lithium?
Fine tremor, polyuria, polydipsia, hypothyroidism, weight gain, metallic taste, rash
What is the hallmark sign of lithium toxicity?
Coarse tremor
What serum lab must be monitored in patients on lithium and why?
TSH –> monitor for elevation of TSH as indication of hypothyroidism
Name an anti-epileptic medication that has an off label use for agitation.
Valproic acid –> not first line for agitation
What are the AEs of valproic acid?
Alopecia, weight gain, sedation
What serum levels must be monitored in patients taking valproic acid?
Serum valproic acid, LFTs, ammonia if hepatic encephalopathy is suspected
Describe the dosing availability of valproic acid.
Available in many dosage forms –> PO tablets, capsules, oral syrup, IV, etc.
What are the concerns of using second generation anti-psychotics in patients over 65 years of age?
Increased morbidity and mortality from cardiovascular events
Increased rates of metabolic syndrome –> dyslipidemia, development of DM, etc.
Describe the use of anti-psychotic medications in pregnancy.
Can’t use anti-psychotics in the third trimester - should try to avoid throughout pregnancy
List some drugs that sound like anti-psychotics but are not anti-psychotics.
Brand name Zyrtec (antihistamine) sounds like Zyprexa
Clonazepam (BZD) sounds like Clozapine
All the PPIs sound like Aripiprazole
Name all the drugs approved by the FDA for treatment of tardive dyskinesia.
Only one –> valbenazine
What is the mechanism of action of valbenazine?
Vesicular Monoamine Transporter-2 (VMAT-2) inhibitor
