Antipsychotics Flashcards
Best/worst antipsychotics for metabolic syndrome
– Worst: Clozapine and olanzapine
– Moderate: Paliperidone, quetiapine, risperidone
– Best: Aripiprazole, lurasidone, ziprasidone
Best/worst antipsychotics for sedation
– Worst (most sedating): Clozapine, olanzapine, quetiapine (note that sedation can sometimes be beneficial for
agitated, anxious, or manic patients)
– Moderately sedating: Lurasidone, risperidone, ziprasidone
– Best (not sedating): Aripiprazole, brexpiprazole
Best/worst antipsychotics for cardiac issues (QT prolongation)
– Worst: Ziprasidone
– Moderate: Chlorpromazine, haloperidol, quetiapine
– Best: Aripiprazole, clozapine, loxapine, lurasidone, olanzapine, risperidone
Best/worst antipsychotics for EPS
– Most EPS: Haloperidol, paliperidone, risperidone
– Most akathisia: Aripiprazole, brexpiprazole
– Least EPS: Chlorpromazine, clozapine, iloperidone, olanzapine, quetiapine, ziprasidone
Risperidone and paliperidone worst for prolactinemia
Concerns with abrupt antipsychotic discontinuation
Sensitivity psychosis (rebound)
Withdrawal dyskinesia
Cholinergic rebound: SLUD. Salivation, Lacrimation, Urination, Defecation
Switching antipsychotics
Clinicians typically cross-taper, however, meta analyses indicate that abrupt switches are generally well-tolerated.
Monitoring protocol for patients on SGAs
Weight: Baseline, every 4 weeks for 12 weeks, then every 3 months.
Waist circumference: Baseline, then annually.
BP/Pulse/fasting glucose/fasting lipids: Baseline, at 12 weeks, then annually.
Antipsychotic black box warning
Suggests a substantially higher mortality rate in geriatric patients with dementia-related psychosis
Treatment algorithm for psychosis, not agitated
Aripiprazole
Risperidone
Latuda (expensive
Treatment algorithm for psychosis, agitated, accepting meds
Olanzapine ODT (prevents cheeking)
Quetiapine
Treatment algorithm for psychosis, agitated, not accepting meds
Haldol 5/Lorazepam 1/Diphenhydramine 50, IM
Olanzapine 10 mg IM (may be as effective as B52)
Ziprasidone 20 mg IM (calming but less sedating)
Treatment algorithm for psychosis with negative symptms
Cariprazine or clozapine
Add mirtazapine to any antipsychotic
Treatment algorithm for psychosis, treatment-resistant
Clozapine
Olanzapine
Augment with valproate
Antipsychotic combination (clozapine + aripiprazple, clozapine + risperidone
Aripiprazole starting-max rage
10-30 mg daily
Clozapine starting-max rage
12.5-450 mg BID
Lurasidone starting-max rage
40-160 mg daily
must be taken with food
Olanzapine starting-max rage
10-20 mg daily
IM 10 mg for acute agitation
Paliperidone starting-max rage, etc
6-12 mg daily
Good for patient’s with hepatic impairment.
Increases prolactin
Quetiapine starting-max rage
50-800 mg daily, divided doses BID to TID
Risperidone starting-max rage
2-6 mg daily to BID
increases prolactin
Ziprasidone
20-80 mg BID
IM 20 mg for agitation
Chlorpromazine starting-max rage
(thorazine)
50-600 mg daily
IM 25 mg for agitation (not used often)
can cause corneal deposits which can lead to blindness if used long term
Fluphenazine starting-max rage
(prolixin)
2-20 mg daily
Haloperidol starting-max rage
2-20 mg daily
5 mg IM for agitation
Clozapine labs
Before starting, ANC must be >1500
Benign ethnic population (BEN), ensure two baseline ANCs ≥1000.
Repeat ANC weekly for first 6 months, then every 2 weeks from 6 months to 12 months, then monthly after 12 months.
If ANC falls below 1500, guidelines become complex depending on how low the value is; consult clozapine risk evaluation and mitigation strategy (REMS) (http://b.link/clozapine-rems) for advice
Cogentin info
FDA Indications: Drug-induced extrapyramidal symptoms (EPS); Parkinson’s disease.
Off-Label Uses: Sialorrhea (excessive salivation); hyperhidrosis (excessive sweating).
Dosage Guidance: ● Start 1 mg BID; max 3 mg BID. May be taken once daily at bedtime. ● For acute dystonic reactions, use 1 mg–2 mg IM x 1 and continue with oral, as above, to prevent recurrence.
Side Effects: ● Most common: Dry mouth, blurred vision, constipation, urinary retention, sedation. ● Serious but rare: In those at risk (elderly patients), may cause confusion or delirium; may worsen angle-closure glaucoma.
Clinical Pearl: If starting a patient on a high-potency antipsychotic such as haloperidol or risperidone, some clinicians will start benztropine prophylactically to prevent EPS. If you do so, consider taper and withdrawal of benztropine after 1–2 weeks to see if it’s really needed.
Metformin
Can be used to treat antipsychotic-induced weight gain.
Dosage Guidance: ● IR: Start 500 mg BID; ↑ by 500 mg/day increments weekly; max 2250 mg/day.
Akathisia management, first line
● Propranolol. Start 10 mg BID; can go up to 30 mg–90 mg daily in 2 or 3 divided doses. SE: Dizziness, fatigue, syncope, low BP.
● Inderal LA. Long-acting version of propranolol that can be dosed once a day. 60 mg–80 mg daily.
● Benzodiazepines. Any of them will work (eg, lorazepam 0.5 mg to 1 mg BID). Dosed at the equivalent of diazepam 10 mg BID or more frequently as needed.
Akathisia management, second line
● Benztropine 1 mg BID. ● Cyproheptadine 8 mg–16 mg/day. ● Amantadine 100 mg–200 mg BID. ● Clonidine 0.2 mg–0.8 mg/day. ● Gabapentin 1200 mg/day. ● Trazodone 100 mg/day. ● Mirtazapine 15 mg/day.
Management of xerostomia (dry mouth)
● Biotene line of products, OTC (most contain lubricants and humectants to “seal in” moisture):–Biotene gum, use as needed.–Biotene toothpaste, use as with any toothpaste.–Biotene oral rinse (mouthwash), rinse up to 5 times per day.–Biotene Oralbalance Gel, use 1 inch on tongue as needed (comes out of a tube).–Biotene moisturizing mouth spray, spray on tongue as needed. ● Many saliva substitutes are available, such as Oralube saliva substitute, Oasis mouth spray, and others. No studies have demonstrated superiority of any single brand.
