Antipsychotic meds Flashcards
Typical (1st Generation)
Decrease dopamine
Works best on positive symptoms
EPS and Anti-HAM side effects
Atypical (2nd Generation)
Decrease dopamine AND increase serotonin
Works on positive and negative symptoms
Metabolic side effects
antipsych meds
Class warnings
Black box warning- higher mortality rate in geriatric pts with dementia-related psychosis
Adverse cerebrovascular events
Neuroleptic malignant syndrome
Tardive dyskinesia
Weight gain, hyperglycemia, new-onset or worsening diabetes, hyperlipidemias (especially for kids)
Antipsychotic Side Effects
Metabolic Dysfunction
Anti-HAM
Neuromalignant Syndrome
Extrapyramidal Syndrome
Dystonia
Akathisia
Parkinsonian Syndrome
Tardive Dyskinesia
1st Generation Antipsychotics- think EPS and ANTI-HAM side effects
2nd Generation Antipsychotics- think more metabolic side effects
Extrapyramidal Syndrome
Sx
Dystonia: repetitive movements sometimes painful
Akathisia:restlessness, agitation
Parkinsonian Syndrome
Tardive Dyskinesia
Metabolic Dysfunction
Weight gain
Hyperglycemia
hyperlipidemia
More common with second generation antipsychotics
Need to check labs every 6-12 months (Lipids, weight, BP, A1C)
Tx: treat dysfunction respectively or consider changing antipsychotics if severe
Anti-HAM
Antihistamine - weight gain and sedation
Antiadrenergic - orthostatic hypotension, cardiac abnormalities, sexual dysfunction
Antimuscarinic (anticholinergic effects) - (dry mouth, tachycardia, urinary retention, blurry vision, constipation, precipitation of narrow-angle glaucoma
Hyperprolactinemia - low libido, galactorrhea, gynecomastia, impotence, amenorrhea
Neuromalignant Syndrome (NMS)
and tx
Occurs in up to 3% of patients taking neuroleptics
Extreme rigidity, AMS, fever, unstable BP, myoglobinemia
Can be FATAL
Tx: STOP medication, dantrolene and bromocriptine, supportive care
Extrapyramidal Symptoms (EPS) - MC 1st Gen
Akathisia
inner restlessness, can’t sit still
Not anxiety
Tx: reduce dose or change meds
Propranolol
Clonazepam
Parkinsonian syndrome
tremor, mask-like facies, rigidity, shuffling gait, bradykinesia
Typically starts within 1 month of starting medication
Elderly more at risk
Tx: change or reduce drug
Levodopa and other antiparkinsonian drugs
https://www.youtube.com/watch?v=f6yxH2bgkSY
Dystonia
Acute!
Typically starts within days of initiating drug
involuntary contractions of major muscle groups
Commonly tongue, face, neck, back
Tx: anticholinergics (benztropine), antiparkinsonian drugs
Diagnostic and curative!
https://www.youtube.com/watch?v=y2D5HAWPVC4
Tardive Dyskinesia
Involuntary movements - facial grimacing, tongue protrusion, lateral jaw movements, lip smacking, choreiform movements of the limbs (rarely)
Months to years to develop
Can develop at any time while on medication, 5% increase risk each year on FGA
Can be permanent
Tx: STOP agent once early symptoms arise.
VMAT2 Inhibitors - valbenazine and deutrabenazine
https://www.tardiveimpact.com/what-is-td
Tardive Dyskinesia
Involuntary movements - facial grimacing, tongue protrusion, lateral jaw movements, lip smacking, choreiform movements of the limbs (rarely)
Months to years to develop
Can develop at any time while on medication, 5% increase risk each year on FGA
Can be permanent
Tx: STOP agent once early symptoms arise.
VMAT2 Inhibitors - valbenazine and deutrabenazine
https://www.tardiveimpact.com/what-is-td
EPS Sx
Dystonia
Acute!
Typically starts within days of initiating drug
involuntary contractions of major muscle groups
Commonly tongue, face, neck, back
Tx: anticholinergics (benztropine), antiparkinsonian drugs
Diagnostic and curative!
https://www.youtube.com/watch?v=y2D5HAWPVC4
EPS sx
Akathisia
inner restlessness, can’t sit still
Not anxiety
Tx: reduce dose or change meds
Propranolol
Clonazepam
EPS Sx
AIMS
Screening for TD
Provider rates patient
Score of 2 indicates presence of TD
Performed every 6 months
Chlorpromazine (Thorazine)
typical
First antipsychotic developed, not commonly used
Effective Dose: 60mg - 800mg
FDA indications- Psychosis, mania, nausea and vomiting, intractable hiccups
Off label- bipolar disorder, behavioral disturbances, impulse control
Route: PO or IM
Monitoring- ECG if cardiac disease
Cost- pretty expensive
Side Effects- sedation, orthostasis, tachycardia, drowsiness, dry mouth, constipation, blurred vision, prolactin elevation, skin pigmentation, ocular changes, jaundice, photosensitivity
Fluphenazine (Prolixin)
typical
Effective Dose: 3 - 45mg
FDA indications- psychosis, schizophrenia
Off label- dementia associated psychosis or agitation
Route- PO and IM
Cost- cheap
Side Effects- EPS, headache, drowsiness, dry mouth
Haloperidol (Haldol)
typical
Effective Dose: 1-40mg
FDA indications- psychosis, Tourette’s disorder
Off label- bipolar disorder, behavioral disturbances, impulse control disorders, delirium
Route: PO, IM short acting and long acting
Cost- cheap
Side Effects- EPS, headache, drowsiness, dry mouth, prolactin elevation
Quetiapine (Seroquel)
atypical
Effective Dose: 300 - 800mg
FDA indications- Schizophrenia (13+yo), bipolar manic/mixed (10+), bipolar depression, maintenance for bipolar, major depression (as adjunct)
Off label- insomnia, anxiety disorders, behavioral disturbances, impulse control disorders
Monitoring- fasting glucose, lipids
Cost- cheap
Side Effects- somnolence, hypotension, dry mouth, dizziness, constipation, weight gain, fatigue, orthostatic hypotension
Ziprasidone (Geodon)
atypical
Effective Dose: 120 - 160mg
FDA indications- Schizophrenia, bipolar disorder (acute tx of mania/mixed episodes, Bipolar maintenance as adjunct, acute agitation in schizophrenia (IM only)
Off label- bipolar disorder, behavioral disturbances, impulse control disorders
Monitoring- fasting glucose, lipids, ECG if cardiac disease
Route: PO or IM
Cost- cheap
Side Effects- somnolence, dizziness, akathisia, rash, QT prolongation, DRESS
Need to take with 500 cals
Less weight gain than clozapine, olanzapine, quetiapine, and risperidone
More QT prolongation than any other atypical antipsychotic
Lurasidone (Latuda)
atypical
Effective Dose: 40mg to 120mg
FDA indications- Schizophrenia (adults and adolescents 13-17), bipolar depression (as monotherapy and adjunct in adults and children 10-17)
Off label- mixed depression, treatment resistant depression, manic episodes, impulse control disorders
Monitoring- fasting glucose, lipids
Cost- expensive
Side Effects- sedation, akathisia, nausea, parkinsonism, agitation, orthostatic hypotension, syncope
Administer with at least 350 calories to increase absorption
Appears relatively weight neutral
Aripiprazole (Abilify)
atypical
Effective Dose: 10 - 30mg
FDA indications- schizophrenia (13-17, adults), bipolar disorder (acute mania: adults and 13-17, maintenance: adults), major depression as adjunct (adults), irritability in autism (children 6-17), Tourette’s disorder (children 6-17)
Off label- bipolar depression, behavioral disturbances
Monitoring- fasting glucose, lipids
Route- PO and IM
Cost- cheap
Side Effects- akathisia, anxiety, insomnia, sedation, tremors
Minimal weight and metabolic side effects but risk of akathisia
Olanzapine (Zyprexa)
atypical
Effective dose: 5 - 20mg
FDA indications- schizophrenia (13+), acute or mixed bipolar 1 manic episodes (13+), maintenance tx of bipolar, bipolar depression (as Symbyax, 13+), treatment resistant depression (as Symbyax), acute agitation in schizophrenia and bipolar mania (injectable form)
Off label- behavioral disturbances, impulse control disorders
Monitoring- fasting glucose, lipids
Route - PO and IM
Cost- cheap
Side Effects- somnolence, dry mouth, constipation, weight gain (10-30lb is common), increased appetite, EPS
High prevalence of weight gain and metabolic side effects
Symbyax is an expensive combination of olanzapine and fluoxetine (just write as separate generic medications)
Paliperidone (Invega)
atypical
MOA- dopamine D2 and serotonin 5-HT2A receptor antagonist
FDA indications- Schizophrenia (13+), schizoaffective disorder
Monitoring- fasting glucose, lipids, prolactin if symptoms
Cost- expensive
Side Effects- akathisia, EPS, tremor, tachycardia, insomnia, somnolence, weight gain, orthostatic hypotension, headache, elevated prolactin
”Ghost pills” osmotic delivery system
Not highly effective in acute mania
Along with risperidone, **causes the most EPS and hyperprolactinemia of all atypicals **
Risperidone (Risperdal)
atypical
Effective Dose: 4 - 16mg
FDA indications- schizophrenia (13+), bipolar disorder (manic/mixed 10+), irritability in autism (children 5+)
Monitoring- fasting glucose, lipids, prolactin if symptoms
Cost- cheap
Route: PO and IM
Side Effects- EPS, somnolence, anxiety, constipation, nausea, dyspepsia, dizziness, prolactin elevation, weight gain, orthostatic hypotension
Along with paliperidone, causes most EPS and hyperprolactinemia of all atypicals
Asenapine (Saphris)
Atypical
Effective Dose: 10 - 20mg
FDA indications- Schizophrenia, bipolar disorder (acute and maintenance of manic/mixed episodes in adults and kids 10-17)
Off label- bipolar maintenance, bipolar depression, behavioral disturbances, impulse control disorders
Monitoring- fasting glucose, lipids
Cost- expensive
Side Effects- akathisia, oral hypoesthesia, somnolence, dizziness, EPS, weight gain
Sublingual and patch formulation, good if swallowing pills is an issue
Cariprazine (Vraylar)
atypical
Effective Dose: 3 - 6mg
FDA indications- Schizophrenia, bipolar I depression, Major depressive disorder
Cost- expensive
Side Effects- GI upset, dizziness, insomnia, increased appetite. Typically very well tolerated and effective
Clozapine (Clozaril)
atypical
Dose: 300 - 600mg
FDA indications- treatment resistant schizophrenia, reduction in risk of suicide in schizophrenia and schizoaffective disorders
Monitoring- fasting glucose, lipids, baseline ANC (>1000) then weekly for 6 months, then biweekly for another 6-12 months, then monthly after 12 months
Cost- pretty cheap
Side Effects- sedation, orthostatic hypotension, hypersalivation, weight gain, constipation, tachycardia, potentially life-threatening neutropenia (1-2%)
Must be in risk evaluation and mitigation strategy program (REMS) in order to prescribe
