Antipsychotics

Question 1

Fluphenazine (Prolixin) Dosing

Answer 1

Tablet: 1,2.5,5,10mg
Oral Elixir: 2.5mg/5ml
Concentrate: 5mg/ml
Injection (IR): 2.5mg/ml
LA Depot: 25mg/ml
Initiate 2.5-10mg/day Q6-8 hrs; dose range: 1-50mg/day; MAX: 100mg/day

Question 2

Fluphenazine (Prolix) Clinical

Answer 2

2D6 substrate

Question 3

Haloperidol (Haldol) Dosing

Answer 3

Tablet: 0.5,1,2,5,10,20mg
Oral Soln: 2mg/ml
Injection (IR): 5mg/ml
LA Depot: 50mg/ml, 100mg/ml
Initiate 1-15mg/day, divide doses if needed, MAX: 100mg/day

Question 4

Haloperidol (Haldol) Clinical

Answer 4

2D6, 3A4 substrate

Question 5

Loxapine (Loxitane, Adasuve) Dosing

Answer 5

Oral inhalation powder: 10mg/dose

10mg dose Q24 hrs

Question 6

Loxapine (Loxitane, Adasuve) Clinical

Answer 6

“Atypical typical”

Adasuve oral inhalation power has REMS - must be in hospital setting w/ emergency service access, CI’d w/ hx of lung disease, monitor closely for bronchospasm

Question 7

Perphenazine (Trilafon) Clinical

Answer 7

Increased use in recent years due to CATIE study

Question 8

Pimozide (Orap) Clinical

Answer 8

3A4 substrate, QTc prolongation limits use, usual clinical use limited to Tourette’s disorder

Question 9

Thioridazine (Mellaril) Clinical

Answer 9

Significant QTc prolongation limits use, not generally initiated as new therapy, informed consent necessary

Question 10

Thiothixene (Navane) Clinical

Answer 10

1A2 substrate

Question 11

Aripiprazole (Abilify and Abilify Maintena) Dosing

Answer 11

Tablet: 2,5,10,15,20,30mg
LA Depot: 300mg/vial, 400mg/vial
Liquid: 1mg/ml
Initiate 10-15mg QD, titrate Q2 weeks, MAX: 30mg/day
IR Injection: 9.75mg IM, 2 hrs between doses, MAX: 3 injections/day
LA Depot: 400mg IM once monthly, overlap w/ oral x2 weeks

Question 12

Aripiprazole (Abilify and Abilify Maintena) Clinical

Answer 12

2D6, 3A4 substrate
Very long T1/2
FDA approved for MDD in combo with antidepressant (not LAI)

Question 13

Aripiprazole lauroxil (Aristada) Dosing

Answer 13

LA Depot: 442mg/vial, 662mg/vial, 882mg/vial
Initiate based on oral dose:
10mg QD: 442mg
15mg QD: 662mg
20mg QD: 882 mg
Any dose can be given Q4 weeks, 882mg Q6 weeks if tolerated, MUST overlap oral aripiprazole x3 weeks

Question 14

Aripiprazole lauroxil (Aristada) Clinical

Answer 14

2D6, 3A4 substrate

LAI dosage form only, dose adjustments for 2D6/3A4 inhibitors and/or 3A4 inducers

Question 15

Asenapine (Saphris) Dosing

Answer 15

Sublingual tablet

Question 16

Asenapine (Saphris) Clinical

Answer 16

1A2 substrate

Must be taken SL, bioavailability improved to 25-30%, must not eat, drink, smoke for 10 min after dose

Question 17

Brexpiprazole (Rexulti) Clinical

Answer 17

2D6, 3A4 substrate
Lower risk of akathisia compared to aripiprazole, higher risk of weight gain, dose adjustments for severe hepatic impairments, D2/D3 partial agonist

Question 18

Cariprazine (Vraylar) Clinical

Answer 18

3A4 substrate
Greater risk of akathisia vs aripiprazole or brexpiprazole, moderate weight gain, may have serotonin effects for better efficacy in negative symptoms, D2/D3 partial agonist

Question 19

Clozapine (Clozaril, Fazaclo) Dosing

Answer 19

Initiate 12.5-25mg/day at bedtime, titrate in increments of 25-50mg/day wkly to target of 300-450mg/day, MAX: 900mg/day, can divide dose for tolerability

Question 20

Clozapine (Clozaril, Fazaclo) Clinical

Answer 20

1A2 substrate
WBC/ANC must be monitored wkly x6 months, Q2 wks x6 months, then Q4 wks, maintain ANC above 1500, boxed warning for agranulocytosis, myocarditis, dose-related seizures, and orthostatic hypertension, constipation, weight gain, metabolic syndrome, hypersalivation, Pregnancy B

Question 21

Iloperidone (Fanapt) Dosing

Answer 21

Initiate 1mg BID, increase by 2mg/day until target dose: 12-24mg/day, MAX: 24mg/day

Question 22

Iloperidone (Fanapt) Clinical

Answer 22

2D6, 3A4 substrate

Titrate slowly due to significant orthostatic hypotension, QTc prolongation

Question 23

Lurasidone (Latuda) Dosing

Answer 23

Initiate 40mg QD, MAX: 160mg/day

Question 24

Lurasidone (Latuda) Clinical

Answer 24

3A4 substrate

Pregnancy B, must take with food to improve bioavailability and Cmax (400 calorie meal)

Question 25

Olanzapine (Zyprexa) Dosing

Answer 25

Initiate 2.5-10mg QD, dose range: 5-20mg/day (may see clinically higher doses)
IR injection: 10mg, MAX: 3 injections Q24 hrs, given 2-4 hrs apart
LA Depot: 150-300mg IM Q2 wks or 405mg IM Q4 wks

Question 26

Olanzapine (Zyprexa) Clinical

Answer 26

1A2 substrate
IR injection: Don’t give in same syringe as lorazepam injection: boxed warning for respiratory depression
LA Depot: REMS for PDSS

Question 27

Paliperidone (Invega, Invega Sustenna, Invega Trinza) Dosing

Answer 27

ER tablet
LA Depot (Q4 wks): 39,78,117,156,234mg
LA Depot (Q12 wks): 273,410,546,819mg
Initiate 6mg QD, MAX: 12mg/day
LA Depot (Q4 wks): 234mg load, 117mg booster on day 8, maintenance Q5 wks after load, 39-234mg IM Q4 wks
LA Depot (Q12 wks): based on stable 4 wks of Invega Sustenna:
78mg Invega: 273mg Trinza
117mg: 410mg
156mg: 546mg
234mg: 819mg

Question 28

Paliperidone (Invega, Invega Sustenna, Invega Trinza) Clinical

Answer 28

Renal elimination, ER leaves ghost tabs, 9-OH metabolite of risperidone
Trinza: specific instructions for vigorous shaking to suspend, important to avoid incomplete suspension

Question 29

Quetiapine (Seroquel) Clinical

Answer 29

3A4 substrate
25-50mg used for sleep (NOT RECOMMENDED)
Street use: $1/mg
Recent boxed warning for QTc prolongation

Question 30

Risperidone (Risperdal) Dosing

Answer 30

LA depot injection doesn’t provide appreciable serum concentrations until between 2nd and 3rd dose, must overlap oral for efficacy, EPS prominent at doses beginning at 6mg/day

Question 31

Ziprasidone (Geodon) Dosing

Answer 31

Initiate 20mg BID WITH FOOD, dose range: 80mg BID, min effective dose: 120mg/day, MAX recommended: 160mg/day, MAX clinically: 240mg/day

Question 32

Ziprasidone (Geodon) Clincal

Answer 32

Must be given with food to improve bioavailability (400 calorie meals), clinically given QD with evening meal, QTc prolongation, DRESS