Antipsychotics

Question 1

Best/worst antipsychotics for metabolic syndrome

Answer 1

– Worst: Clozapine and olanzapine
– Moderate: Paliperidone, quetiapine, risperidone
– Best: Aripiprazole, lurasidone, ziprasidone

Question 2

Best/worst antipsychotics for sedation

Answer 2

– 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

Question 3

Best/worst antipsychotics for cardiac issues (QT prolongation)

Answer 3

– Worst: Ziprasidone
– Moderate: Chlorpromazine, haloperidol, quetiapine
– Best: Aripiprazole, clozapine, loxapine, lurasidone, olanzapine, risperidone

Question 4

Best/worst antipsychotics for EPS

Answer 4

– Most EPS: Haloperidol, paliperidone, risperidone
– Most akathisia: Aripiprazole, brexpiprazole
– Least EPS: Chlorpromazine, clozapine, iloperidone, olanzapine, quetiapine, ziprasidone

Risperidone and paliperidone worst for prolactinemia

Question 5

Concerns with abrupt antipsychotic discontinuation

Answer 5

Sensitivity psychosis (rebound)

Withdrawal dyskinesia

Cholinergic rebound: SLUD. Salivation, Lacrimation, Urination, Defecation

Question 6

Switching antipsychotics

Answer 6

Clinicians typically cross-taper, however, meta analyses indicate that abrupt switches are generally well-tolerated.

Question 7

Monitoring protocol for patients on SGAs

Answer 7

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.

Question 8

Antipsychotic black box warning

Answer 8

Suggests a substantially higher mortality rate in geriatric patients with dementia-related psychosis

Question 9

Treatment algorithm for psychosis, not agitated

Answer 9

Aripiprazole
Risperidone
Latuda (expensive

Question 10

Treatment algorithm for psychosis, agitated, accepting meds

Answer 10

Olanzapine ODT (prevents cheeking)

Quetiapine

Question 11

Treatment algorithm for psychosis, agitated, not accepting meds

Answer 11

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)

Question 12

Treatment algorithm for psychosis with negative symptms

Answer 12

Cariprazine or clozapine

Add mirtazapine to any antipsychotic

Question 13

Treatment algorithm for psychosis, treatment-resistant

Answer 13

Clozapine
Olanzapine
Augment with valproate
Antipsychotic combination (clozapine + aripiprazple, clozapine + risperidone

Question 14

Aripiprazole starting-max rage

Answer 14

10-30 mg daily

Question 15

Clozapine starting-max rage

Answer 15

12.5-450 mg BID

Question 16

Lurasidone starting-max rage

Answer 16

40-160 mg daily

must be taken with food

Question 17

Olanzapine starting-max rage

Answer 17

10-20 mg daily

IM 10 mg for acute agitation

Question 18

Paliperidone starting-max rage, etc

Answer 18

6-12 mg daily

Good for patient’s with hepatic impairment.

Increases prolactin

Question 19

Quetiapine starting-max rage

Answer 19

50-800 mg daily, divided doses BID to TID

Question 20

Risperidone starting-max rage

Answer 20

2-6 mg daily to BID

increases prolactin

Question 21

Ziprasidone

Answer 21

20-80 mg BID

IM 20 mg for agitation

Question 22

Chlorpromazine starting-max rage

Answer 22

(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

Question 23

Fluphenazine starting-max rage

Answer 23

(prolixin)

2-20 mg daily

Question 24

Haloperidol starting-max rage

Answer 24

2-20 mg daily

5 mg IM for agitation

Question 25

Clozapine labs

Answer 25

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

Question 26

Cogentin info

Answer 26

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.

Question 27

Metformin

Answer 27

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.

Question 28

Akathisia management, first line

Answer 28

● 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.

Question 29

Akathisia management, second line

Answer 29

● 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.

Question 30

Management of xerostomia (dry mouth)

Answer 30

● 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.