Schizophrenia/Psychosis Flashcards
1
Q
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
A
2
Q
Extrapyramidal side effects: include ___________
A
Dystonias:
Akathisia:
Parkinsonism:
Tardive dyskinesias (TD):
Dyskinesias:
3
Q
Dystonias:
A
painful muscle contractions
-
4
Q
Akathisia:
A
restlessness, inability to remain still.
-
5
Q
Parkinsonism:
A
6
Q
Tardive dyskinesias (TD):
A
repetitive, involuntary movements (such as, grimacing and eye blinking)
-
7
Q
Dyskinesias:
A
abnormal movements
-
8
Q
Schizophrenia is ___________
A
- a chronic, severe mental illness and disabling thought disorder that occurs in ~1% of all societies regardless of class, color, religion or culture.
- it has the highest rate of suicide of the psych conditions
- a person loses much of the ability to think clearly, manage emotions, make decisions and relate to others
9
Q
-
-
A
Disorganized thinking/behavior: inability to focus attention and communicate organized thoughts.
Delusions: a belief about something real that is not true, such as imaging that your family (which is real) wishes to hurt you (delusion)
Hallucinations: sensing something that is not present, such as imaginary voices.
10
Q
Diagnosis of Schizophrenia:
- is NOT based on lab tests/results but on _____1______, which includes both ____2___ and ______3_____.
A
1) behavior
2) negative signs & symptoms
3) positive signs & symptoms
11
Q
The ___________________ sets the diagnostic criteria for psychiatric conditions.
A
DSM-5
12
Q
Schizophrenia’s pathophysiology is _________1_____ and includes altered brain structure and chemistry, primarily involving ______2______, ____3_____and ____4___
With Schizophrenia, we see increased levels of __________ which causes the ___________ symptoms
A
1) multifactorial
2) dopamine
3) serotonin
4) glutamine
dopamine
positive
13
Q
Increased dopamine levels, and can have changes in
A
glutamate levels
14
Q
-
-
-
A
Hallucinations: Sensing something that is not present, such as imaginary voices
Delusions: a belief about something real that is not true, such as imagining that your family (which is real) wishes to hurt you (delusion)
- “take something that is actually there and misinterpret what it actually represents.”
Disorganized thinking/behavior: inability to focus attention and communicate organized thoughts.
Difficulty paying attention
15
Q
-
-
-
A
Lack of speech (alogia)
Loss of motivation (avolition)
Social withdrawal
Lack of emotion (apathy)
Poor hygiene
Loss of interest in everyday activities (anhedonia)
Inability to plan or carry out activities.
16
Q
antipsychotics can effectively treat ______________.
antipsychotics primarily block ___________________.
A
positive signs & symptoms
dopamine receptors. (Newer antipsychotics also block serotonin)
The negative symptoms (lack of motivation, cognitive and functional impairment) are more difficult to treat.
17
Q
Decreasing dopamine activity helps control ______1____, but negatively affects dopamine pathways involved in _____2_______
A
1) psychosis
2) focus, attention and movement
18
Q
Parkinson medications increase _____1____ in the brain, which relieves the ___2___ symptoms.
Having increased ______3____ can trigger hallucinations or delusions.
A
1) dopamine
2) motor
3) dopamine
19
Q
Medications/Recreational drugs that can cause Psychotic symptoms:
-
-
-
-
-
-
-
-
-
-
A
Anticholinergics (centrally-acting, high doses)
Dextromethorphan
Dopamine or dopamine agonists - (Requip, Mirapex, Sinemet)
Interferons
Stimulants, especially if already at risk (includes amphetamines)
Systemic steroids (typically with a lack of sleep - ICU psychosis)
*Illicit/recreational substances
Bath Salts
Cannabis
Cocaine
Meth
PCP - phencyclidine
LSD - Lysergic acid diethylamide
20
Q
Currently ____________________ are used first line due to a lower incidence of extrapyramidal symptoms.
A
(SGA) second generation antipsychotics
21
Q
(FGA) First Generation Antipsychotics have a high incidence of extrapyramidal symptoms, including painful:
–
–
A
dystonias (muscle contractions)
dyskinesias (abnormal movements)
tardive dyskinesias (repetitive, involuntary movements, such as grimacing and eye blinking)
akathisia (restlessness, inability to remain still)
22
Q
______________can be irreversible; the drug causing ____ should be discontinued.
A
tardive dyskinesia (TD)
TD
23
Q
Adherence to antipsychotics is _________, primarily due to lack of insight (inability of the patient to recognize the illness).
Formulations are used to increase adherence and help when dysphagia (difficulty swallowing) is present.
A
poor
24
Q
Which antipsychotics come as a long-acting injection? and what are there frequencies?
what is the benefit with this dosing form?
A
Haldol Decanoate (every 4 weeks)
Risperdal Consta (every 2 weeks)
Invega Sustenna (every 4 weeks), Invega Trinza (every 3 months)
Abilify Maintena (every 4 weeks), others
eliminate the need for daily oral tablets or capsules.
25
which antipsychotics are available as an ODT?
what is the benefit with this dosing form?
- Abilify Discmelt
- Clozapine Fazaclo
- Risperdal M-tab
- Zyprexa Zydis
- Saphris (sublingual)
are useful with dysphagia (difficulty swallowing) and prevents cheeking (when tablets are hidden inside the cheek and spit out later)
ODTs dissolve quickly in the mouth, also cause less nausea
26
Which antipsychotics come as an oral solution/suspension?
what is the benefit with this dosing form?
are useful for children and people with a feeding tube
27
which antipsychotics come as an acute FAST-Acting IM injection?
what is the benefit with this dosing form?
- Haloperidol
- Fluphenazine
- Zyprexa
- Geodon
provide "stat" relief to calm down an agitated, psychotic patient for their own safety and the safety of others.
28
olanzapine AND _____________ SHOULD NOT be given together (in an injection) due to risk of excess sedation and breathing difficulty.
benzodiazepines
29
IM antipsychotics are often mixed with other drugs (in cocktails) such as benzodiazepines for anxiolytic/sedative effects, and __________ to reduce ______
anticholinergics
dystonias
30
Haldol cocktail contains:
haloperidol
lorazepam
diphenhydramine
31
Boxed Warning for Antipsychotics:
--- 1
All Antipsychotics also carry a warning for _____2_____
1) Are NOT indicated for Agitation control in elderly patients with dementia-related psychosis! There is an increased risk of mortality when used for this purpose, mostly due to cardiovascular conditions (heart failure, sudden death) and infection.
2) falls
32
Several antipsychotics also carry a warning for an increased risk of ________ in patients with dementia
stroke
33
First Generation Antipsychotics (FGAs): work mainly by ______1_____.
Many of the (FGA) are in the _____1_______ class; they can be easily recognized because their names end in "azine".
1) blocking dopamine-2 receptors (D2-receptors) with minimum serotonin (5-HT2A) receptor blockade.
"dopamine antagonists"
2) phenothiazine
34
Highest QT prolongation:
Higher risk TdP with Low potassium and magnesium.
Thioridazine (highest QT risk) > Haloperidol > Ziprasidone (lower risk than Haldol)
35
First Generation Antipsychotics:
-
-
-
-
-
-
-
-
-
Chlorpromazine LOW potency
Thioridazine LOW potency
Loxapine (Adasuve) MID potency
Perphenazine MID potency
Haloperidol (Haldol) HIGH potency
Fluphenazine HIGH potency
Thiothixene HIGH potency
Trifluoperazine HIGH potency
36
First Generation Antipsychotics (FGA):
High Potency FGAs, such as haloperidol, are associated with a HIGH RISK OF EPS EFFECTS, a moderate risk of sedation and a lower risk of orthostatic hypotension, tachycardia, and anticholinergic effects compared to low-potency FGAs.
First Generation Antipsychotics (FGA):
In contrast,
Low potency FGAs are associated with a LOWER RISK OF EPS EFFECTS, a high degree of sedation and a HIGH risk of cardiovascular effects (orthostatic hypotension, tachycardia) and anticholinergic effects.
37
When we talk about EPS, this includes 3 things:
-
-
-
1) dyskinesia's = abnormal movements
2) dystonic
- anyone can have dystonic reactions when taking antipsychotics
- younger adults at higher risk, usually antipsychotic is given with a centrally acting anticholinergic like benztropine or Benadryl to prophylaxis dystonic reactions
3) tardive dyskinesia's
- big deal with FGAs and risperidone and paliperidone SGA
- anyone can get TD when taking antipsychotics, risk is higher in elderly
- common symptom in TD: buckle lip smacking, weird movements with tongue
- discontinue offending agent, the longer the patient has TD symptoms the more likely it can become irreversible
38
39
Important Adverse Effects of First-Generation Antipsychotics:
40
Chlorpromazine (Thorazine)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms:
Dosing: 300-1000mg/day
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
41
Thioridazine (Mellaril)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonist), with minimal serotonin (5-HT2A receptor)
Dosage forms:
Dosing: 300-800mg/day, divided doses
Max dose:
Boxed Warnings:
-** elderly patients with dementia-related psychosis: increased risk of death from antipsychotics
-** QT Prolongation**
Warnings:
*Cardiovascular effects: *QT prolongation, *orthostasis/falls, *tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increased EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*(NMS) Neuroleptic Malignant Syndrome; use may be associated with NMS; monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
- sedation, dizziness, anticholinergic effects, increased prolactin
- EPS: can give anticholinergic (benztropine, diphenhydramine) to limit/avoid painful dystonic reactions
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation and decreased risk for EPS.
HIGHER potency drugs have decreased sedation and increased risk for EPS.
Drug-Drug/Food interactions:
42
Loxapine (Loxitane & Adasuve - inhaler)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms:
Dosing: 30-100mg/day, divided doses
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Adasuve-inhalation powder for acute agitation, can have dysgeusia- (bad, bitter, or metallic taste in the mouth)
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
43
Perphenazine (Trilafon)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms:
Dosing: 8-64mg/day, divided doses
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
44
Haldol
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Haloperidol
Class: First Generation Antipsychotic, butyrophenone
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms: tablet, injection
Dosing:
Oral (tablet, solution): start 0.5-2mg BIT-TID, up to 30mg/day
IV: usually 5-10mg
Decanoate (monthly): IM only; for conversion from PO, use 10-20x the PO dose.
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
45
Fluphenazine (Prolixin & Permitil)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms: tablet, elixir, injection
Dosing: 6-12mg/day, divided doses
*Decanoate (every 2 weeks): IM only
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
46
Thiothixene (Navane)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms:
Dosing: 15-60mg/day, divided doses
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
47
Trifluoperazine (Stelazine)
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Class: First Generation Antipsychotic
Indications: Schizophrenia, Psychosis
MOA: drug works mainly by blocking dopamine-2 receptors (DA-2 receptor antagonists), with minimal serotonin (5-HT2A) receptor
Dosage forms:
Dosing: 15-50mg/day, divided doses
Max dose:
Boxed Warnings:
*- Elderly patients with dementia-related psychosis: increase risk of death from antipsychotics
Contraindications:
Warnings:
*- Cardiovascular effects: QT prolongation (especially with Thioridazine, Haloperidol, Chlorpromazine), *orthostasis/falls, tachycardia
*Anticholinergic effects: constipation, xerostomia, blurred vision, urinary retention
*CNS depression
*Extrapyramidal symptoms (EPS): including Parkinsonism, dystonic reactions, akathisia, tardive dyskinesia (increase EPS with injections)
*Hyperprolactinemia: infertility, oligomenorrhea/amenorrhea (less or no menstrual periods), galactorrhea (abnormal breast discharge), erectile dysfunction/ decreased libido
*Neuroleptic Malignant Syndrome (NMS): monitor for mental status changes, fever, muscle rigidity, autonomic instability
Side Effects:
* sedation, dizziness, anticholinergic effects, increase prolactin production
Monitoring:
Pearls/Notes:
LOWER potency drugs have increased sedation & decreased risk of EPS.
HIGHER potency drugs have decreased sedation & increased risk of EPS.
-*ALL Antipsychotics are sedating and can cause EPS*
Drug-Drug/Food interactions:
48
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA has the lowest risk of (EPS) Extrapyramidal side effects AND is preferred in patients with Parkinson's disease who require antipsychotics?
Quetiapine, drug of choice and is preferred in those who have psychosis associated with Parkinson's disease.
49
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA has the lowest risk of (EPS) Extrapyramidal side effects?
Clozapine, has the lowest risk of EPS, but is reserved last line for patients who have run out of other options with nothing else working.
50
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA has the highest risk of QT prolongation?
Ziprasidone
51
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA can increase Prolactin Production?
risPeridone
paliPeridone
52
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA have a lower metabolic risk of worsening metabolic issues, having minimal effect?
aripiprazole
asenapine
lurasidone
ziprasidone
53
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA have a higher risk of worsening metabolic issues (increase in weight, blood glucose, lipids)?
quetiapine
olanzapine
KO'd
54
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA has a risk for hematological effects?
clozapine (agranulocytosis/neutropenia)
55
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which SGA require higher doses if the patient smokes, due to the reduced levels from smoking? smoking is an inducer
olanzapine
clozapine
56
Important Adverse Effects of Second-Generation Antipsychotics (SGAs):
Which antipsychotic has a higher risk of seizures and should be avoided with concurrent drugs that lower the seizure threshold?
clozapine
57
Antipsychotic Drug Interactions:
Monitor for increased risk of respiratory depression and hypotension when administered with benzodiazepines.
Avoid other dopamine blocking agents such as metoclopramide (Reglan), as EPS and TD risk may be increased.
There is a warning specifically not to mix olanzapine with benzodiazepines, increased risk of respiratory depression.
Metoclopramide, is a renally excreted drug. It is used to propel food forward. Speeding up peristalsis. Usually dosed 10mg QID.
58
High Prolactin levels can cause:
-
-
-
-
-
- stimulates lactation during pregnancy/enlarges mammary glands
- galactorrhea
- decreases sex hormones
- amenorrhea
- sexual dysfunction
59
ALL antipsychotics can prolong the QT interval. Some are considered higher risk than others.
1) The SGA that are high risk of prolonging the QT interval include:
2) The FGA that are high risk of prolonging the QT interval include:
1) Ziprasidone (highest risk)
2) Thioridazine (has a Boxed warning), Haloperidol, Chlorpromazine = THC FGAs
60
Abilify
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aripiprazole
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis, also approved for irritability with autism and Tourette disorder
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: tablet, ODT, IM suspension
Dosing:
tablet: 10-30mg PO every morning
Abilify Maintena: IM suspension, given monthly
Aristada- IM suspension, give every 4-8 weeks
Max dose:
Contraindications:
Warnings:
Side Effects:
* akathisia, *activating or sedating, headache, anxiety, confusion
- *Lower risk for weight gain and lower metabolic risk, some QT prolongation, EPS (in children)
Monitoring:
Pearls/Notes:
ODT: useful for patients not adherent to daily treatment, PO treatment or swallowing difficulties.
Drug-Drug/Food interactions:
61
Aristada
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
aripiprazole
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis, also approved for irritability with autism and Tourette disorder
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: tablet, ODT, IM suspension
Dosing:
Aristada- IM suspension, give every 4-8 weeks
Max dose:
Contraindications:
Warnings:
Side Effects:
* akathisia, *activating or sedating, headache, anxiety, confusion
- Lower risk for weight gain, some QT prolongation, EPS (in children)
Monitoring:
Pearls/Notes:
- Aristada: frequency dependent on dose
Drug-Drug/Food interactions:
62
Rexulti
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
brexpiprazole
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: tablet
Dosing: 2-4mg daily
Max dose:
Contraindications:
Warnings:
Side Effects:
dyspepsia, diarrhea, akathisia
- weight gain
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
63
Saphris
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
asenapine
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: *sublingual tablet
Dosing:
10-20mg/day, divided BID
No Food/Drink for 10 minutes after dose
Max dose:
Contraindications:
Severe hepatic impairment
Warnings:
Side Effects:
somnolence, tongue numbness (with sublingual tablet), EPS, QT prolongation
Monitoring:
Pearls/Notes:
place tablet under the tongue and allow it to dissolve completely. Do NOT eat or drink for 10 minutes after taking this medication. Your tongue may feel numb afterwards.
Drug-Drug/Food interactions:
64
Secuado
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
asenapine
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: patch
Dosing: 3.8-7.6 mg applied daily
Max dose:
Contraindications:
severe hepatic impairment
Warnings:
Side Effects:
somnolence, EPS, QT prolongation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
65
Clozaril
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
clozapine
Class: Second Generation Antipsychotic
Indications: Last line for Schizophrenia.
** Clozapine is very effective and has decreased risk of EPS & TD, but used no sooner than 3rd-line due to the severe side effect potential.
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: tablet, suspension (Versacloz)
Dosing: 300-900mg/day, divided (start at 12.5mg and titrate;
medication should be titrated off since abrupt discontinuation can cause seizures.
**Boxed Warnings:
1) - **Significant risk of potentially life-threatening neutropenia/agranulocytosis (*REMS program*). Severe Neutropenia ANC > 1500 REQUIRED to start! Discontinue if ANC < 1000.
2) - **Can cause Myocarditis & Cardiomyopathy: Discontinue if suspected
3) - **Can cause Seizures (dose-related): start no higher that 12.5mg once or twice daily, titrate slowly, using divided doses; Use with caution in patients at seizure risk (seizure history, head trauma, alcoholism, or taking medications which lower seizure threshold).
Contraindications:
Warnings:
Side Effects:
** agranulocytosis, seizures, constipation, somnolence, metabolic syndrome (increases weight, blood glucose, lipids), sialorrhea (hypersalivation), hypotension
Monitoring:
**REMS: prescribers and pharmacies must be certified and patients must be enrolled with the Clozapine REMS.
** To start treatment, baseline ANC must be > or = to 1500/mm3.
**- Monitor ANC every week for 6 months, then every 2 weeks for 6 months, then every month for life. Stop therapy if ANC < 1000/mm3.
Pearls/Notes:
-** Is very Effective and has Decreased risk of EPS/TD, BUT used no sooner than 3rd-line due to severe side effect potential (metabolic effects, neutropenia) "have to have FAILED 2 other antipsychotics"
-** smoking reduces drug levels
-doesn't cause movement disorders
Drug-Drug/Food interactions:
66
Versacloz
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
clozapine
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
67
Zyprexa
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
olanzapine
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: 10-20mg QDHS *(take at bedtime)
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
68
Zyprexa Zydis ODT
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
olanzapine
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: ODT
Dosing: 10-20mg QDHS
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
69
Zyprexa Relprevv
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
olanzapine injection
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: injection
Dosing:
Relprevv inj suspension lasts 2-4 weeks; restricted use.
Boxed Warning:
**Zyprexa Relprevv: sedation (including coma) and delirium (including agitation, anxiety, confusion, disorientation) have been observed following injection; must be administered in a registered healthcare facility and patients are monitored for 3 hours post-injection (Zyprexa Relprevv REMS program requirement) **
Warnings:
Side Effects:
*Somnolence, *metabolic syndrome (increased weight, blood glucose, lipids), orthostasis.
Monitoring:
Pearls/Notes:
**Smoking reduces drug levels
Drug-Drug/Food interactions:
70
Seroquel
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
quetiapine, quetiapine ER (Seroquel XR)
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: 400-800mg/day, divided BID or XR is QDHS
IR- take with/without regard to food
XR- take without food or 300kcal max
Max dose:
Warnings:
Side Effects:
*somnolence, *metabolic syndrome (increased weight, blood glucose, lipids), orthostasis, possible ocular effects (cataracts)
**Low EPS risk- often used for psychosis in Parkinsons disease**
Monitoring:
Pearls/Notes:
XR- take at night without food or with a light meal (< or = 300kcal)
Drug-Drug/Food interactions:
71
Latuda
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
lurasidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: 40-160mg/day, divided
*Take with at least 350kcal of Food*
Max dose:
Contraindications:
** Use with strong CYP3A4 inducers and inhibitors**
Warnings:
Side Effects:
**somnolence, EPS (dystonias), nausea**
**Risk of metabolic syndrome, BUT lower risk than other SGAs - minimal effect on weight, lipid and blood glucose**
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
72
Invega
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects: "P"
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
paliperidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: tablet, IM injection
Dosing:
PO: 3-12mg daily
CrCl < 50mL/min: 3mg daily
CrCl < 10mL/min: Not recommended
**OROS delivery enables once daily dosing- do NOT break or crush**
Contraindications:
Warnings:
Side Effects: in
** Increased prolactin - sexual dysfunction, galactorrhea (milk production unrelated to pregnancy or lactation), irregular/missed periods
**EPS, especially at higher doses**
* tachycardia, QT prolongation*
*Metabolic Syndrome (increased weight, blood glucose, lipids)
Monitoring:
Pearls/Notes:
**Ghost tablet in the stool
Drug-Drug/Food interactions:
73
Invega Sustenna --------
Invega Trinza-----------TRI
Invega Hafyera---------HAF
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects: "P"
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
paliperidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing:
Sustenna- IM injection given monthly
Trinza-- IM injection given every 3 months (Start only after receiving Sustenna for 4 months)
Hafyera-- IM injection given every 6 months (Start only after receiving Sustenna for 4 months AND Trinza for 1 month)
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
74
Risperdal
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects: P
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
risperidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms: tablet, IM injection, SC injection
Dosing:
PO: 2-16mg/day, divided
Risperidal Consta: IM injection- give every 2 weeks, 25-50mg.
Perseris: SubQ injection, given monthly.
Side Effects:
**Increased Prolactin - sexual dysfunction, galactorrhea, irregular/missed periods
EPS, especially at higher doses
**Metabolic Syndrome (increased weight, blood glucose, lipids)
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
75
Perseris
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
risperidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
76
Geodon
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
ziprasidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: *Take with food*
40-160mg/day, divided BID
Acute injection: Geodon IM 10mg Q2H or 20mg Q4H
Max dose: acute injection: 40mg/day IM
Contraindications:
** QT prolongation- DO NOT USE with QT risk*
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
77
Vraylar
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
cariprazine
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: 1.5-6mg daily
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
78
Fanapt
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
iloperidone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: 12-24mg/day, divided
titrate slowly due to orthostasis/dizziness
Max dose:
Contraindications:
Warnings:
Side Effects:
QT prolongation
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
79
Caplyta
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
lumateperone
Class: Second-Generation Antipsychotic
Indications: Schizophrenia/Psychosis,
MOA: drug works by blocking dopamine-2 receptors (D2 receptor antagonist) and serotonin receptors (5-HT2A receptor antagonist).
Dosage forms:
Dosing: 42mg daily
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
80
Symbyax
olanzapine + fluoxetine
81
Lybalvi
olanzapine + samidorphan
-treatment of schizophrenia and bipolar disorder
82
anhedonia:
lack of interest or pleasure
83
avolition:
lack of motivation
84
alogia:
a cause to speak less in response to others.
85
Drug Treatment:
Side-effect profiles play an important role in selecting Initial treatment for schizophrenia.
86
Which second generation antipsychotics require a REMS program?
clozapine
Zyprexa Relprevv injection
87
Which first generation antipsychotic has a boxed warning for QT Prolongation?
Would want to discontinue with a QT > _________
Thioridazine (Mellaril),
500ms
88
Patient Counseling: with antipsychotics
Contact your healthcare provider right away if you experience uncontrollable movements of the mouth, tongue, cheeks, jaw, arms or legs. - regards TD Tardive Dyskinesia
Contact your healthcare provider immediately and seek immediate medical attention if you experience fever, sweating, severe muscle stiffness (rigidity) and confusion. - regards NMS Neuroleptic Malignant Syndrome- is a medical emergency when it happens, muscles freeze up.
Use caution when driving, operating machinery, or performing other hazardous activities. This drug can cause dizziness confusion and drowsiness. - regards CNS depression effects
89
(TD) Tardive dyskinesia is a complication that can occur with dopamine receptor blockade, as with antipsychotics.
Symptoms can be irreversible:
- uncontrollable movements in the tongue, face, trunk, and extremities and can interfere with walking, talking, and breathing.
- Stop the drug
90
(NMS) Neuroleptic Malignant Syndrome:
NMS is rare BUT is highly lethal. It occurs most commonly with FGAs and is due to ____________.
The majority of cases occur within __________ of starting treatment or immediately following high doses of injectables given alongside multiple oral doses. Occasionally, patients develop NMS even after years of antipsychotic use.
NMS is a _____________, as the intense muscle contractions can lead to acute renal injury (due to rhabdomyolysis from the destruction of muscle tissue), suffocation and death.
D2 blockade
2 weeks
medical emergency
91
(NMS) Neuroleptic Malignant Syndrome:
Signs/Symptoms
-
-
-
-
-
-Hyperthermia (high fever, with profuse sweating)
- extreme Muscle Rigidity **(called "lead pipe" rigidity)**, which can lead to respiratory failure
- mental status changes
- tachycardia, tachypnea and blood pressure changes
Lab Results:
increased Creatine Phosphokinase & WBCs
92
(NMS) Neuroleptic Malignant Syndrome:
Treatment:
-
-
-
-
- taper off the antipsychotic quickly
- provide supportive care: cardiorespiratory and hemodynamic support and control of electrolyte balance
- Cool the patient down: cooling bed, antipyretics, cooled IV fluids
- Muscle relaxation with benzodiazepines or *dantrolene *(Ryanodex, Dantrium, Revonto)
93
Choosing an Antipsychotic: What to consider for Tx
- Previous response to medication. Did it work?
-Side effect profile. Any risks or contraindications with this medication for this specific patient?
- Before considering a medication a treatment failure, an adequate dose for 4-6 weeks is recommended
