Chapter 34 - Antipsychotics Flashcards
What is a ‘neuroleptic’?
an older name for antipsychotics that is usually used for major tranquilizers
What are antipsychotics used for?
-schizophrenia
-delusional disorders
-bipolar disorder
-depressive psychoses
-drug-induced psychoses
-anti-emetic
-Tourette’s syndroma
-Huntingtons’s chorea
Are antipsychotics used for dementia?
no, especially in older adults
What are some risk factors for schizophrenia?
-family hx
-life experience (poverty, stress, danger)
-pregnancy and birth issues (exposure to toxins or virus)
-taking psychoactive drugs at young age
What are the POSITIVE schizophrenia symptoms?
-exaggeration of normal function
-hallucinations
-delusions
-agitation
-tension
-paranoia
What are the NEGATIVE schizophrenia symptoms?
-loss of normal function
-lack of motivation
-poverty of speech
-blunted affect
-poor self-care
-social withdrawal
What are the COGNITIVE schizophrenia symptoms?
-disordered thinking
-impaired attention
-learning and memory difficulty
-incomprehensible thinking and speech
How an acute schizophrenia episode present?
-delusions
-hallucinations
What are the residual symptoms of schizophrenia?
-suspiciousness
-poor anxiety management
-diminished judgement, insight, motivation, self-care
How does long-term schizophrenia present?
acute exacerbations separated by partial remission
Possible etiology of schizophrenia: excessive activation of CNS receptors for _____________
dopamine
Possible etiology of schizophrenia: insufficient activation of CNS receptors for _____________
glutamate
What receptors do 1st gen antipsychotics (typical) block?
dopamine
What receptors do 2nd gen antipsychotics (atypical) block?
serotonin (a little bit of dopamine)
Are 1st gen antipsychotics used for positive or negative symptoms of schizophrenia?
positive
Are 2nd gen antipsychotics used for positive or negative symptoms of schizophrenia?
negative
What are some possible complications of 1st gen antipsychotics?
movement disorders:
-extrapyramidal symptoms
-neuroleptic malignant syndrome (NMS)
-increase prolactin
Do 2nd gen antipsychotics have the same effects as 1st gen?
no - less EPS, less NMS, no change in prolactin
What are inappropriate off-label uses of atypicals?
-controlling agitated nursing home residents
-sleep aid
How are 1st gen (typical) antipsychotics classified?
potency (low, medium, high)
What is the 1st gen low potency prototype?
Chlorpromazine
What is the 1st gen high potency prototype?
Haloperidol (Haldol)
Do antipsychotics block dopamine 1 or 2 receptors?
2
Where do antipsychotics act?
mesolimbic area of the brain
What causes adverse effects from antipsychotics?
blocking dopamine, ACh, serotonin, histamine, norepi
What are extrapyramidal symptoms (EPS)?
-acute dystonia
-oculogyric crisis
-akathisia
-parkinsonism
Are EPS symptoms reversible?
yes with anticholinergic meds (benztropine and procyclidine)
What can EPS symptoms progress to?
tardive dyskinesia (is irreversible)
What are the symptoms of tardive dyskinesia?
-choreoathetoid movements of tongue and face
-lip-smacking, fly-catching
-slow, worm-like movement of tongue
-involuntary limb movement
What is neuroleptic malignant syndrome (NMS)?
a rare but serious adverse effect that causes rigidity, high fever, sweating, autonomic instability, dysrhythmias, BP fluctuations, altered LoC, seizures, coma
Does NMS have a slow or fast onset?
slow
How does NMS present on labs?
-elevated creatine kinase
-elevated creatine phosphokinase
-elevated transaminases
-leukocytosis
How can death result from NMS?
-respiratory failure
-CV collapse
-dysrhythmias
How is NMS treated?
-supportive measures
-drugs
-withdrawal of antipsychotics
What drugs are used for NMS?
dantrolene and bromocriptine
What are ALL the AE of antipsychotics?
-extrapyramidal symptoms
-tardive dyskinesia
-neuroleptic malignant syndrome
-dry mouth
-blurred vision
-photophobia
-urinary hesitancy
-constipation
-tachycardia
-orthostatic hypotension (A1 blockade)
-sedation
-gynecomastia
-sexual dysfunction
-increased prolactin levels
-seizures
-agranulocytosis
-dysrhythmias (prolonged QT interval)
-dementia
-sunburn
-menstrual irregularities
Agranulocytosis is uncommon in ____ gen drugs?
1st
What kind of drugs do antipsychotics interact with?
-anticholinergics (↑ effect)
-CNS depressants (↑ effect)
-levodopa and dopamine agonists (counteract effects)
Sudden stoppage of antipsychotics can…
-cause some SE (restlessness, insomnia, headache, GI, sweating)
What family is Haloperidol?
Butyrophenone family
Is Haloperidol low, moderate, or high potency?
high
What is Haloperidol used for?
schizophrenia and acute psychosis
Haloperidol is the preferred drug for…
Tourette’s syndrome
What are the adverse effects of Haloperidol?
-extrapyramidal reactions
-neuroendocrine effects
-dysrhythmias (prolonged QT interval)
How is Haloperidol administered?
-depot injection
-short-acting injection
-oral
What potency is fluphenazine?
high
What family is fluphenazine?
piperazine subclass of phenothiazines
What are the adverse effects of fluphenazine, flupenthixol, and zuclopenthixol?
-early EPS
-acute dystonia
-parkinsonism
-akathisia
-sedation
-orthostatic hypotension
-anticholinergic effects
-gynecomastia
-galactorrhea (milk production)
-menstrual irregularities
How are fluphenazine and flupenthixol administered?
depot injection and oral tablet
What is the potency of flupenthixol?
high
What class is flupenthixol?
thioxanthine
What is the potency of zuclopenthixol?
high
What family is zuclopenthixol?
thioxanthine
What is a unique use for zuclopenthixol?
acute psychosis and psychotic agitation
What level of potency is chlorpromazine?
low-potency
What is chlorpromazine used for?
-schizophrenia
-schizoaffective disorder
-manic phase of bipolar disorder
-antiemetic
-hiccup relief
What are the adverse effects of chlorpromazine?
-sedation
-orthostatic hypotension
-anticholinergic effects
How is chlorpromazine administered?
PO, IM, or IV
How do ATYPICAL (2nd gen.) antipsychotics differ from typical antipsychotics?
-less risk of tardive dyskinesia
-do not increase prolactin levels (as much)
-less NMS
-work better on POSITIVE symptoms of schizophrenia
Aytpical antipsychotics have an increased risk of…
-weight gain
-diabetes
-dyslipidemia
-metabolic syndrome
Which receptors do atypical antipsychotics block?
mainly dopamine 2 and serotonin (5-HT 2A) receptors, also histamine, alpha, muscarinic (ACh), norepinephrine
What is responsible for improved efficacy and safety of atypical antipsychotics?
differences in MOA of serotonin receptors
What gen is clozapine?
2nd gen
What receptors does clozapine block?
-dopamine
-serotonin
-histamine
-ACh
-NE
-alpha
What special cases are clozapine used for?
-treatment resistant schizophrenia that is not responsive to other drugs
-Parkinson’s disease related psychosis
How is clozapine transported in blood?
95% plasma protein bound
How is clozapine metabolized and excreted?
-hepatic
-urine and feces
What are the adverse effects of clozapine?
-agranulocytosis (really low neutrophil count)
-seizures
-diabetes
-dyslipidemia
-weight gain (!!!)
-myocarditis
-constipation
-hyper salivation
-EPS (rare)
What is used for hypersalivation treatment?
ATROPINE
What should the nurse monitor for with patients taking clozapine?
-WBC and neutrophil count weekly for 26 weeks
-if WBC levels are stable monitor count every 2-4 weeks
How is clozapine administered?
orally
What is special about the dosing of clozapine?
a test dose should be administered once then increased until therapeutic
What are the DI’s of clozapine?
-smoking
-drugs that suppress bone marrow function
-anticancer drugs
-phenytoin and rifampin can lower
-ketoconazole and erythromycin can raise
What generation is risperidone?
2nd. gen (atypical)
Increasing the dose of risperidone increases…
receptor binding (dopamine)
How is risperidone metabolized?
-hepatic
-active metabolite
What are the AE’s of risperidone?
-EPS (high doses)
-endocrine effects
-dizziness
-agitation
-anticholinergic
How is risperidone administered?
-orally
-IM
Paliperidone is the active metabolite of _____________
risperidone
How is paliperidone (invega) administered?
-orally
-depot shot (invega sustenna and invega trinza)
For Invega Sustenna (Paliperidone) where is the shot administered?
-deltoid (initial dose)
-gluteal (maintenance dose)
When is Invega Trinza (Paliperidone) used?
-after invega sustenna is used for at least 4 months
How often is invega trinza administered?
every 3 months
How is the IS dose converted to the IT dose?
3.5x multiplier
How does the nurse prepare an Invega Sustenna injection?
shake vigorously for minimum of 10 seconds
What needle gauge is used for Invega sustenna if the patient weighs less than 200 pounds?
1 inch 23 gauge
What needle gauge is used for Invega sustenna if the patient weighs more than 200 pounds or if giving gluteal injection?
1.5 inch 22 gauge
How is Invega Trinza administered?
IM
What kind of antipsychotic is Olanzapine?
atypical (2nd gen)
What are the adverse effects of Olanzapine?
-low risk of EPS
-high risk of metabolic effects
-akathisia (restlessness)
-increased BP
What kind of antipsychotic is Ziprasidone?
Atypical (2nd gen)
What is Ziprasidone used for?
schizophrenia and acute bipolar mania
What receptors does Ziprasidone block?
-D2
-5-HT2
-H1
What are the adverse effects of Ziprasidone?
-somnolence
-orthostatic hypotension
-rash
-EPS
-weight gain
-increased QT interval
How is Ziprasidone administered?
oral capsules with food
What class of antipsychotic is Quetiapine (seroquel)?
atypical (2nd gen)
What is Quetiapine used for?
-schizophrenia
-major depression
-acute episodes in bipolar disorder
-SLEEP (off label)
What are the adverse effects of Quetiapine?
-metabolic effects
-cataracts
-prolonged QT interval
-low EPS
-somnolence
-hypotension
How is Quetiapine administered?
orally
What kind of antipsychotic is Aripiprazole?
atypical (2nd gen)
Ariprprazole is a _________ system stabilizer meaning…
Dopamine, it ensures just the right amount of dopamine is released (also works on 5-HT1A and 5-HT2A)
What is Ariprprazole used for?
-schizophrenia
-autism
What are the adverse effects of Aripiprazole?
-headache
-agitation
-nervousness
-anxiety
-insomnia
-N&V
-dizziness
-somnolence
-weight gain
-risk of impulsive behaviour (gambling, hypersexuality, suicide)
Does aripiprazole affect prolactin?
no
What does aripiprazole interact with?
-barbiturates
-carbamazepine
-phenytoin
-rifampin
-ketoconazole
-itraconazole
-fluconazole
-erythromycin
-quinidine
-fluoxetine
-paroxetine
How is aripiprazole administered?
orally or IM
What class is asenapine?
atypical
Where does asenapine act?
D2, 5-HT2A, and their subtypes
What are the AE of asenapine?
-drowsiness
-hypotension
-prolonged QT interval
-EPS
-mouth numbness
-LESS ANTICHOLINERGIC
How is asenapine administered?
sublingually
Brexpiprazole is a partial agonist at ________ and _____ and an antagonist at _______
5-HT1A and D2; 5-HT2A
Who shouldn’t take Brexpiprazole?
-renal and hepatic impairment
-poor CYP2D6 metabolizers
-risk for impulsive behaviour
-dehydration
-elderly clients with dementia
What should the nurse monitor for in patients taking Brexpiprazole?
suicidal ideation
What are the side effects of Brexpiprazole?
-constipation
-weight gain
-dizziness
-akathisia
-increased prolactin
-QT prolongation
How is Brexpiprazole administered?
orally
Lurasidone is used for schizophrenia in people older than _____
14
What receptors does Lurasidone block?
5-HT2 and D2
Who can’t take Lurasidone?
-renal and hepatic impairment
-cardiac impairment
-elderly clients
What are the side effects of Lurasidone?
-weight gain
-dizziness
-EPS
-sedation
-increased prolactin
How is Lurasidone administered?
orally with FOOD (not grapefruit juice)
What are Depot preparations?
-long-acting injections used for long-term maintenance
What vital signs should be monitored after depot injection?
BP, pulse, respirations
What are key points for depot injections?
-SLOW admin
-don’t MASSAGE
-protect from LIGHT
-use in 15 MINS
Most typicals and atypicals are equally effective except ________ which is more effective than the rest.
clozapine
Do typicals or atypicals cost more?
atypicals
Typicals have a high risk of ____
EPS
Atypicals have a high risk of __________ effects
metabolic
