Psy Newton 2
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- How is injectable fluphenazine dosed?
- 12.5mg q2 weeks oil for every 10mg the pt was getting
- How is injectable haloperidol dosed?
- 150mg qmonth oil divided: 20x oral dose with 100mg max first dose, balance in 3-7 days
- How is injectable risperidone dosed?
- 25-50mg q2weeks suspension
- When is an oral risperidone needed after injection?
- 3 weeks
- When should APs be dosed?
- qHS b/c of sedation
- How to monitor EPS?
- baseline AIMS then every 6 months at least
- Side effects of AP not mentioned by Phipps?
- skin reactions, impaired heat regulation
- Most common pts for EPS?
- <30 and male
- Prophylaxis for EPS?
- benztropine 2mg bid
- Acute Tx for EPS?
-
benztropine 1-2mg IM or PO
or Benadryl 25-50mg IM or PO
or Valium 5mg IV - Tx for akathisia
-
switch to atypical or lower the dose;
acute benztropine 1mg bid
or propranolol 20mg qid
or lorazepam 0.5mg tid - Tx for parkinsonism
-
decrease dose or switch to atypical
benztropine 1-2mg bid
amantadine - Risk factors for tardive dyskinesia
-
>6 months tx
elderly
female
pts with affective/organic brain disorders - Tx for tardive dyskinesia
- Vitamin E 800-1200 IU/day
- Sx of Neuroleptic Malignant Syndrome
- altered mental state, lead pipe rigidity, hyperthermia, increased CPK and WBC, autonomic instability
- Tx for NMS
- fluids & electrolytes, symptomatic tx for BP and fever
- MOA of clozapine
- 5HT2 and D4 block, some D1, weak D2
- What condition must be met before starting clozapine?
- WBC >3500
- ADR of clozapine and monitoring?
- agranulosytosis: weekly WBC for 6 months, then q2 weeks; stop clozapine if WBC <2000 or granuloctyes <1000
- Dosing of clozapine
- Start 12.5mg/day and increase by 25mg/week to 600mg; increased seizure risk >600mg but max dose 900mg
- Other ADRs of clozapine?
- orthostasis & tachycardia, sedation, weight gain, PE if history, carditis
- Desired clozapine levels?
- 250-350 ng/mL
- What increases plasma clozapine?
- fluvoxamine, cimetidine, erythromycin
- What decreases plasma clozapine?
- smoking, phenytoin, carbamazepine, phenobarbital
- Dosing of risperidone?
- 4-6mg/day, only atypical if <6mg
- ADRs of risperidone?
- dizziness, postural hypotension, headache, anxiety, weight, anticholinergic effects
- DDI with risperidone?
- SSRIs with caution
- Other receptor effects of risperidone?
- NE antagonist, histamine antagonist
- Comparison of olanzapine to clozapine?
- similar efficacy but olanzapine has greater effect on negative sx
- Dosing?
- Start 10mg (unless elderly then 2.5mg)
- ADRs of olanzapine?
- weight gain, sedation, dizziness, dry mouth, constipation, elevated LFTs without hepatotoxicity
- ADRs of quetiapine?
- sedation, orthostasis, weight gain, headache, reversible LFT elevation...NOT anticholinergic
- Monitoring of quetiapine?
- eye exams baseline and q6months - risk of cataracts?
- Dosing of quetiapine?
- Start 25mg tid; range 150-800mg
- MOA of ziprasidone?
- 5HT2/D2 antagonist, NE reuptake block
- Dosing of ziprasidone?
- start 20-40mg bid; 80-160mg/day
- ADRs of ziprasidone?
- nausea, hypotension, sedation, non-dose related QT prolongation...NO weight gain
- CI for ziprasidone?
- cardiac disease
- Risk factors for QT prolongation with ziprasidone?
-
cardiac disease
hypothyroidism
low serum K or Mg
substance abuse - Medications that increase QT prolongation with ziprasidone?
- quinidine, TCAs, low potency neuroleptics
- MOA of aripiprazole?
- partial agonist of D2 & HT1-a, antagonist of HT2-a
- Dosing for aripiprazole?
- 5-30mg in the morning, start 10-15mg/day
- ADRs of aripiprazole?
- headache, insomnia, anxiety, nausea, akathisia
- Atypical with longest half-life?
- aripiprazole
- Problems with thioridazine?
-
significant QT increase, renal pigmentation at doses >800mg/day, CI with paroxetine, fluvoxamine, propranolol, or fluoxetine
use only for pts who fail - Steps for tx resistance
-
assess trial
adjust dose & interactions
switch atypicals
adjuncts: risperidone or olanzapine with clozapine
add lithium, antidepressant, buspirone, glutamate agonists - How do APs cause diabetes?
- altered apolipoprotein fx, insulin receptor resistance, altered glucose transport & metabolism, altered lipid metabolism, abnormal interleukin-6
- Which atypicals have least incidence of diabetes?
- aripiprazole & ziprasidone
- Which receptors increase appetite?
- 5HT2-a & -c, H1
- Worst two atypicals for weight gain?
- clozapine & olanzapine
-
Atypical monitoring other than baseline:
Hx
Weight
Waist
BP
FBG
Lipids -
q1yr
qmonth x3mos
q1yr
in 3mos then 1yr
in 3mos then 5yrs - Higher risk for diabetes?
-
atypical schizophrenia
obesity
lack of exercise
African American
Hispanic
Native American - Which atypicals cause increased TG?
- olanzapine, clozapine
- Tx for new diagnosis or failure on typicals?
- olanzapine, quetiapine, risperidone
- ADRs with aripiprazole injection?
- headache, nausea, dizziness, somnolence
- ADRs with aripiprazole oral?
- headache, anxiety, insomnia, nausea
- Black box warning on all atypicals?
- elderly pts with dementia at increased risk of death
- What is paliperidone?
- active metabolite of risperidone
- Dose of paliperidone?
- 6mg qAM
- ADRs of paliperidone?
- QT prolongation, cardiac, renal and hepatic side effects