Antipsychotic Medications Flashcards
conditions managed with antipsychotics
- Schizophrenia
- Bipolar Disorder
- Severe Depression
- Substance Abuse (maybe symptom of above)\
Manage severe agitation
Lesser uses: nausea, vomiting, hiccups
Sometimes used to treat dementia but must use caution - Very seldome
three types of symptoms for schizophrenia
positive
negative
cognitive
Positive
Exaggeration or distortion of normal function Hallucinations Delusions Agitation Tension Paranoia
Negative
Loss or diminution of normal function Lack of motivation Poverty of speech Blunted affect Poor self-care Social withdrawal
Cognitive
Disordered thinking Reduced ability to focus attention Prominent learning and memory difficulties Subtle changes* Florid changes: Thinking and speech may be completely incomprehensible to others
Primary neurotransmitter at work when we talk about schizophrenia
dopamine
Underactivity of D1 receptor
negative symtpoms
Overactivity of D2 receptors
positive symptoms
Three major objectives of treatment for shizophrenia
- Suppression of acute episodes
- Prevention of acute exacerbations
- Maintenance of the highest possible level of functioning
Strategic and therapeutic considerations for treatment of schizophernia
- Drug selection
- Dosing
- Route
- Oral (tablets, capsules, and liquids)
- Intramuscular
- Inhaled
First Gen Examples
Chlorpromazine (Thorazine) Fluphenazine(Prolixin) Perphenazine (Trilafon) Trifluoperazine (Stelazine) Thioridizine (Mellaril) Thiothixene (Navane) Haloperidol (Haldol)
2nd Gen
Olanzapine (Zyprexa) Clozapine (Clozaril) Risperidone (Risperdal) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega)
Typical action
Blocks post-synaptic D2 receptors in basal
ganglia, hypothalamus, limbic system and
medulla; lipid soluble
Atypical action
Less D2 blockade than the typicals. Hypothesis:
blocks serotonin receptors in cortex which
decreases inhibition of dopamine; thus more effect
on negative symptoms of schizophrenia
Typical intended effects
Reduces positive symptoms of Schizophrenia (hallucinations, tics) Treatment of nausea, vomiting, hiccups Reduces aggressive behaviors Not much effect on negative symptoms
Atypical intended effects
Reduces positive symptoms of schizophrenia but
less than typicals
Reduces negative effects of schizophrenia
Also used to augment treatment of bipolar disorder, depression, delusional disorders
Typical side effects
Extrapyramidal effects (EPS); tardive dyskinesia Anticholinergic effects Adrenergic effects Prolonged QT Sedation Hyperprolactinemia
A typical side effects
Less risk of EPS, tardive dyskinesia
Metabolic syndrome: insulin resistance, weight
gain*, hyperprolactinemia
Seizures, tachycardia,dizziness, sleep problems,
constipation, rhinitis
Prolonged QT
Sedation
Typical contraidincatiosn precaustions
Narrow angle glaucoma, severe liver or CVD,
bone marrow depression.
Caution: epilepsy, BPH, DM, CNS tumors.
mortality psychosis of dementia in elderly
Atypical contraindications/precautions
Drug specific
*wt gain differs by agent
METABOLISM AND
ELIMINATION
Liver
• Thorough metabolism: N+-oxidation, N-glucuronidation, and phases 1 and 2
biotransformation with final glucuronidation before renal excretion.
• Reduce dose elderly or patients with liver disease
Kidney (partially excreted) Kidney (partially excreted)
• Most drugs: <50% of drug eliminated unchanged by renals
• Reduce dose in renal impairment (see later slide)
Antipsychotic initiation
(first 7 days)
Goal: reduce agitation, tension, anxiety, hostility, aggression
Titrate up over several days; dose is about 50% of chronic dose
Monitor BP
Antipsychotic stabilization
(6-12 wks)
Goal: increase socialization, self-care habits over first 4 weeks
Thought disorder improvement another 6 weeks
Should see improvement 4-12 weeks
Can use rating scale to evaluate efficacy [+/- Symptom scale (PANNS), brief
psychiatric rating scale (BPRS)}
Antipsychotic Maintenance
Continue at least 12 months; may be lifetime
Taper slowly to avoid withdrawal
What drugs increase effects of antipsychotics
Antihypertensives CNS depressants Fluvoxamine Cipro Other Antipsychotics Anticholinergics Lithium Drugs that prolong QT
Drugs that decrease effects
Anticonvulsants
Tobacco
Typicals Monitoring
• Baseline: Assess for dementia; weight, labs: renal, liver, motor function; consider
EKG
• Ongoing: motor function (Abnormal Involuntary Movement Scale or AIMS),
Dyskinesia Identification System: Condensed User Scale (DISCUS); PROLACTIN, BP,
EKG, tardive dyskinesia, seizures
• AIMS http://www.cqaimh.org/pdf/tool_aims.pdf DISCUS
http://www.dhs.state.mn.us/main/groups/licensing/documents/pub/dhs_id_057837.pdf
Atypical Monitoring
- Baseline: waist circumference, BMI, BP, FBS, lipid profile.
- Repeat labs at 3 months, BMI quarterly
- Annual: BP, labs, waist circumference. Clozapine: CBC
Definition of bipolar disorder (BPD)
- Cyclic disorder
- Recurrent fluctuations in mood
- Episodes of mania and depression persist for months without treatment
Types of mood episodes seen with BPD
- Pure manic episode (euphoric mania) Pure manic episode (euphoric mania)
- Hypomanic episode (hypomania)
- Major depressive episode (depression)
- Mixed episode
Treatment for BPD
- Drugs
* Psychotherapy
Types of Drugs used for bi poloar disorder
mood stabilizers
antipsychotics
antidepressants
bpd mood stabilizers
Lithium, divalproex sodium, and carbamazepine
• Relieve symptoms during manic and depressive episodes
• Prevent recurrence of manic and depressive episodes
• Do not worsen symptoms of mania or depression; do not accelerate the rate of cycling Do not worsen symptoms of mania or depression; do not accelerate the rate of cycling
bpd antipsychotics
given during severe manic episodes
bpd antidepressants
given during depressive episodes
SNRI caution with bpd
can throw them into a manic episode
bpd drug selection
• Short-term therapy for manic episodes: Lithium and valproate
• Short-term therapy for depressive episodes: Lithium or valproate, bupropion,
venlafaxine, or a selective serotonin reuptake inhibitor
• Long term preventive treatment: Antipsychotic agents
bpd supporting compliance
- Short-term hospitalization
- Long-term prophylactic therapy
- Education for both patient and family
antipsychotids four facts when treating bpd
Used to acutely control symptoms during manic episodes
Used long term to help stabilize mood
Benefit patients with or without psychotic symptoms
Can be combined with mood stabilizer
antipsychotics approved for use in bpd
• Olanzapine [Zyprexa], quetiapine [Seroquel], risperidone [Risperdal],
aripiprazole [Abilify], and ziprasidone [Geodon]
Lithium therapeutic uses
- BPD
- Other uses
- Alcoholism
- Bulimia
- Schizophrenia
- Glucocorticoid-induced psychosis
Lithium MOA
- Neurotrophic
* Neuroprotective
Lithium excretion
- Short half-life
- Excreted by the kidneys
- Sodium levels: Lithium excretion reduced when sodium level is low
- Plasma levels
- 0.8 to 1.4 mEq/
Lithium plasma range
0.8 to 1.4
• Excessive lithium levels
• Greater than 1.5 mEq/L
Monitor lithium levels every
2 to 3 days at initiation of therapy and then every 3 to 6 months
lithium adverse effects
- Gastrointestinal effects
- Tremors
- Polyuria
- Renal toxicity
- Goiter and hypothyroidism
- Teratogenesis
Lithium drug interactions
- Diuretics
- Nonsteroidal antiinflammatory drugs
- Anticholinergic drugs
Lithium preperation, dosage and administration
- Lithium carbonate
- Lithium citrate
- Dosage is highly individualized
