Atypical antipsychotics

Question 1

Atypical antipsychotics: side FX

Answer 1

Hypotension, sedation, metabolic syndrome (ie. glucose intolerance or diabetes, weight gain)
Doses below are given for schizophrenia unless otherwise noted.

Question 2

Low doses of ________ (3) can be used in augmentation of antidepressants in depression treatment.

Answer 2

olanzapine, aripiprazole and risperidone

Question 3

Risperidone

Answer 3

(RISPERDAL) – start at 0.5mg (target 1-8mg). The most ‘typical’ of the atypical. Increases prolactin (Amenorrhea in women and sexual dysfunction in men is not uncommon). Higher risk of EPS. Rapid-dissolving ‘M-Tab’ (same dose as po). IM injection ‘Consta’ ( 25-50mg q2weeks, continue oral meds for three weeks because of delayed absorption IM).

Question 4

Paliperidone

Answer 4

(INVEGA) – risperidone metabolite. Available as ‘INVEGA SUSTENNA` which is given q4 weeks. Dose day 1 injection 150mg, Day 8 injection 100mg, then q4 weeks at 75 or 100mg. The monograph says you can stop orals as soon as you start Sustenna, but in practice we usually continue the oral medication for 1-2 weeks.

Question 5

Olanzapine

Answer 5

(ZYPREXA) – start at 5-10mg (target 10-20mg) Available as ‘Zydis’ which dissolves sublingually but is absorbed enterically. Sedating. Weight gain ++.

Question 6

Quetiapine

Answer 6

(SEROQUEL) – start at 50-100mg (target 150-300mg for MDD, 400-800mg in mania/psychosis). Regular release or XR. Antidepressant effects. Less risk of EPS. Note you will also sometimes see it used to treat insomnia at 50 dose but this is off label and should not be used for this sole indication.

Question 7

Aripiprazole

Answer 7

(ABILIFY) –start at 5-10mg (target 15mg-30mg). Higher risk of akithisia. Weight neutral. Because of the low metabolic side effects, very popular especially in the first episode psychosis program.

Question 8

Ziprasidone

Answer 8

(ZELDOX) – start 20mg BID (40 mg/d), target 60-80mg BID (120-160 mg/d) with food; max 200 mg/d. May have a greater risk of prolonged QT. Unpredictable absorption if you don’t take it with food and it’s the only antipsychotic that requires BID dosing (more difficult compliance). Weight neutral.

Question 9

Clozapine

Answer 9

(CLOZARIL)– start at 50mg and then creep up to 450mg by 2 weeks later. GOLD STANDARD ANTIPSYCHOTIC and should be tried in refractory cases. Decreases risk of suicide in schizophrenic patients. STRONG anticholinergic activity (watch for constipation or even bowel obstruction) and essentially very low likelihood of EPS. Sialorrhea, weight gain++, sedation, hypotension. Risk of myocarditis/cardiomyopathy. Decreased seizure threshold especially at higher doses. Blood monitoring for agranulocytosis: weekly CBC x 6 months, then biweekly x 6 months, then monthly.

Question 10

Lurasidone

Answer 10

(LATUDA) – start 20-40mg (target 80-120mg QD with food). Limited weight gain and metabolic side effects. Minimal binding to alpha1, histaminic, muscarinic receptors. Somnolence, akithisia, parkinsonism.

Question 11

Asenapine

Answer 11

(SAPHRIS) – 5mg BID (target 5-10mg BID). Sublingual administration as poor GI absorption. Moderate weight gain compared to other second generation antipsychotics. Has an FDA warning for serious allergic reactions.

Question 12

Weight gain / diabetes: highest to lowest

Answer 12

clozapine > olanzapine > quetiapine > risperidone > aripiprazole

Question 13

EPS: highest to lowest

Answer 13

risperidone > olanzapine, quetiapine, aripiprazole > clozapine

Question 14

Sedation: most to least

Answer 14

clozapine, olanzapine, quetiapine > risperidone, aripiprazole

Question 15

Decreased sex drive/fnc, amenorrhea, galactorrhea

Answer 15

risperidone > olanzapine, quetiapine > clozapine