Antipsychotics - General & Typicals

Question 1

Side FX 1st vs 2nd generation

Answer 1

You have the choice of giving your patients diabetes and obesity with the second generation medications, or you can give first generation and give them dystonia and tardive dyskinesia. The newer medications aren’t really any more effective at treating psychosis but it’s possible that they are a little bit better on cognition.

Question 2

Besides EPS, 5-7 side FX of antipsychotics

Answer 2

• In general, antipsychotics have a propensity to lower seizure threshold and can cause an increase in QTc.
• Antipsychotics tend to reduce the body’s capacity to reduce core temperature (attn. with strenuous exercise, dehydration, extreme heat).
• Patients may complain of cognitive dulling, loss of libido.
• Hyperprolactinemia may occur which may be more likely with typical and with risperidone.
• BLACK BOX: ELDERLY PATIENTS ON ANTIPSYCHOTICS ARE AT HIGHER RISK OF DEATH. There is also a concern of increased cerebrovascular/stroke risk.

Question 3

When prescribing typical antipsychotics, keep in mind that _________ may be more at risk of NMS and dystonic reactions. In contrast, _________ tend to be more prone to tardive dyskinesia.

Answer 3

young men

older women

Question 4

First-generation antipsychotics side effect profiles: high potency vs low potency

Answer 4

Low potency (eg. chlorpromazine) – anticholinergic (hypotension, dry mouth, constipation) and sedating

High potency (eg. Haldol) – higher risk of EPS (Parkinsonism, tardive dyskinesia, dystonia, akathisia)

Question 5

Low-potency typical antipsychotic (1)

Answer 5

Chlorpromazine (LARGACTIL) - 200-800 mg/d divided TID-QID

Question 6

Medium-potency typical antipsychotics (3)

Answer 6

Loxapine (LOXAPAC, LOXITANE)
Perphenazine (TRILAFON)
Trifluoperazine (STELAZINE)

Question 7

High-potency typical antipsychotics (3)

Answer 7

Haloperidol (HALDOL)
Zuclopenthixol (CLOPIXOL, ACCUPHASE)
Flupenthixol (FLUANXOL)

Question 8

2 examples of typical antipsychotic depot medications

Answer 8

Flupenthixol (Fluanxol) - Available as decanoate (‘Depot’) (usual maintenance 20-40mg IM q2weeks but may go as high as 80mg)

Zuclopenthixol (Clopixol) - Available as decanoate (‘Depot’) (150-300mg q2weeks IM as maintenance) or as acetate (‘Acuphase’) (100-150mg q3d – typically given when the patient is dangerously agitated, especially where there is a history of violence)

Question 9

If there’s an agitated patient in ER and you know absolutely nothing about him, give _______.

Answer 9

Ativan 2mg po/IM. If he’s got drugs in his system you should be holding off on the antipsychotics.

Question 10

Your standard bread-and-butter first episode psychotic patient: how to manage? Which drug is a reasonable choice?

Answer 10

Choose an antipsychotic and use low doses especially to start (they will not want to continue if they have side effects and don’t even feel that they have a problem). First episode patients typically do not require high doses. Aripiprazole is a reasonable choice due to its better metabolic profile and once daily dosing.

Question 11

Elderly pt: how to adjust dose of antipsychotic? Which meds to avoid?

Answer 11

You’ve got an elderly patient? Cut your dose in half. Try not to use benzos (risk of falls and worsening of confusion) or medications with anticholinergic activity (eg. Benadryl, gravol, cyclobenzaprine, paroxetine).

Question 12

Egs. of meds with anticholinergic activity (4)

Answer 12

Benadryl, gravol, cyclobenzaprine, paroxetine

Question 13

What to prescribe if patient is agitated in the ER and needs PRN meds

Answer 13

a. JGH cocktail: Loxapine 25mg, Benadryl 25-50mg, Ativan 1-2mg – all po/IM Q1H PRN max 4 doses per 24h
b. The classic cocktail: Haldol 5mg, Ativan 2mg – po/IM Q1H PRN max 4 doses per 24h

Question 14

Very agitated patient, aggressive, and refusing antipsychotics: what to give?

Answer 14

Clopixol Accuphase 100-150mg q3days (no repeats within the 3 days!). If you prescribe it with Benadryl and Ativan he’ll be knocked out for a while and then will be less psychotic when he wakes up. Make sure they haven’t already gotten Clopixol or another depot med recently and that there is no medical reason they can’t have an antipsychotic (eg. they are agitated because they have NMS!)

Question 15

The patient’s QTC is >450ms and you need to give an antipsychotic – what to do?

Answer 15

You’ll need to monitor QTc carefully. Make sure there are no electrolyte abnormalities that put the patient at risk of torsades and consult cardiology if QTc is close to or exceeds 500ms.

Question 16

Your patient doesn’t take oral medications and/or you have a court order for forced treatment - options?

Answer 16

a. Invega Sustenna is the only long-acting injection that’s dosed q4 weeks
b. The other atypical IM is Risperidone Consta q2 weeks

Question 17

If the patient agrees to oral and there is a concern of cheeking consider ______ (2).

Answer 17

Zyprexa Zydis, or Risperidone M-Tab which both are fast dissolving.

Question 18

How to treat an acute dystonic reaction?

Answer 18

Benztropine (Cogentin) 1-2mg po/IM (IM works FAST) .

Note: Acute dystonic reactions become an emergency when they involve muscles involved in the airway/respiration (eg. laryngeal, diaphragm). Make sure you are not witnessing tardive dyskinesia because paradoxically benztropine (COGENTIN) and other anticholinergics can make TD worse.

Question 19

Tx of tardive dyskinesia?

Answer 19

There is no good treatment for tardive dyskinesia. Switch to an atypical, lower the dose, consider trying the patient on clozapine. If that doesn`t work you could try tetrabenazine.

Question 20

Loxapine

Answer 20

(LOXAPAC, LOXITANE) - start 10 mg PO BID; target 60-100 mg/d divided BID-QID (max 250 mg/d)

Question 21

Perphenazine

Answer 21

(TRILAFON) - start 4-8 mg PO TID (12-24 mg/d); target 16-64 mg/d divided BID-QID - max 64 mg/d

Question 22

Trifluoperazine

Answer 22

(STELAZINE) - start 1-2 mg PO BID; target 2-5 mg BID; max 40 mg/d

Question 23

Haloperidol

Answer 23

(HALDOL) - start 0.5-5 mg PO BID-TID; target 0.5-5 mg BID-TID; max 100 mg/d; use lowest effective dose and taper dose gradually to D/C if long-term use.

Question 24

Zuclopenthixol

Answer 24

(CLOPIXOL) - oral: start 10-50 mg/d divided BID-TID; target 20-60 mg/d divided BID-TID for acute psychosis, 20-40 mg/d DIE-BID for maintenance; max 100 mg/d

Question 25

Flupenthixol

Answer 25

(FLUANXOL) - oral: start 1 mg PO TID; target 3-6 mg/d in divided doses

Question 26

Flupenthixol decanoate 40 mg: equiv doses of 3 other depot antipsychotics

Answer 26

Fluphenazine decanoate 25 mg
Zuclopenthixol decanoate 200 mg
Haloperidol decanoate 50 mg