Schizophrenia

What generation of antipsychotics is better at treating negative symtpoms

2nd gen is better for negative symptoms, but both mainly treat postitive symptoms

List first gen antipsychotics (typical)

chlorpromazine

fluphenazine

haloperidol

loxapine

perphenazine

pimozide

thioridazine

thiothixene

trifluoperazine

What sceond gen antipsychotics are partial D2 agonists

Aripiprazole

Brexipiprazole

Cariprazine

Second gen anipshycotics

clozapine (Clozaril®)

risperidone (Risperdal®)

paliperidone (Invega®)

olanzapine (Zyprexa®)

quetiapine (Seroquel®)

ziprasidone (Geodon®)

*aripiprazole (Abilify®)

asenapine (Saphris®)

iloperidone (Fanapt®)

lurasidone (Latuda®)

*brexpiprazole (Rexulti™)

*cariprazine (Vraylar™)

*lumateperone (Caplyta™)

†pimavanserin (Nuplazid®)

List antipsychotics that are available in long-acting injectable (LAI) formulation

Fluphenazine, heloperidol, airpipirazole, olanzapine, paliperidone, resperidonen

What SGA is not orally bioavailable?

Asenapine

What is the most effective antipsychotic

Clozapine is the most effective (can reduce suicidality), but only used in treatment resistant schizo due to many complications

Schizphrenia treatment algorithm

1) SGA

2) Switch SGA ot FGA

3)CLozapine

4)Combo/adjunct therapies

Acute therapy goals for treating schizophrenia

Prevent hospitalization

↓ severity of psychotic thoughts and behaviors (reduce to manageable / functional level)

Alter course of illness

Minimize adverse effects of treatment

long term goals of treating schizophrenia

Minimize symptoms and related functional impairments

Promote recovery (optimize functioning and QOL)

Slow neurodegeneration

Prevent relapses

Reduce significant psychosocial and health consequences

Prevent mortality and morbidity

Shared adverse effects of antipsychotics

Sedation

Orthostatic hypotension

Anticholinergic effects

QT prolongation

Extrapyramidal symptoms (EPS)

Tardive dyskinesia

Metabolic effects

Hyperprolactinemia

Neuroleptic malignant syndrome

3 EPS

Akathisia

Parkinsonism

Dystonias

Akathisia def

Feeling of inner restlessness “crawling out of yout skin”

How to minimize Akathisia

Decrease dose, change med, use Beta-adrenergic blocker or benzodiazepine

Parkinsonism def

Symptoms of patkinsons

How to minimize Parkinsonism

decrease dose, change med, add anticholinergic agent

Dystonias def

Acute muscle spasms

How to minimize dystonias

discontinue antipsychotics, add anticholinergic agent

Tardive dyskinesia

Irreversible involuntary movements

Ex: blinking, lip smacking,

How to minimize tardive dyskinesia

MONITOR AND PREVENTION

Lowest effective dose for shortest duration

Administer AIMS (abnormal involuntary movement scale)

How to treat Tardive dyskinesia

Discontinue problematic agents

Switch from FGA to SGA or lower risk among SGAs

VMAT2 inhibitors —> Tetrabenzine, valbenzine , Deutetrabenzine

Neuroleptic malignant sundrome

Rare, but high mortality rate

fever, mental status changes, autotnomic dysfunction, rigidity

Treatment for Neuroleptic malignant sundrome

discontinue med

inpatient care

What SGA has the highest risk for QT prolongation

Ziprasidone

Who is at hgihest risk for QT prolongation?

Over 70

Hypokalemia or hypomagnesmia

Family history of sidden death

Cardiac abnormality histpry

Using other QT prolongation meds

How to monitor risk of QT prolongation?

ECG

Metabolic changes in SGA

Weight gain

Lipid increase

INcrease glucos e

FGA associated with ________ SGA associated with metabolic side effects

Movement side effects

Baseline & at 3 month then annually metabolic parameters

Weight/BMI

Blood pressure

Fasting plasma glucose/A1C

Lipids

How often should you check weight?

Monthly then quarterly later

How to prevent metabolic changes

Diet, nutrition

Select antipsychotic with lower metabolic risk

Maybe add metformin

Treatmeant of metabolic changes

Switch to antipsychotic with lower metabolic risk

How do antipsychotics affects prolactin

Hyperproloactinemia

How to manage hyperprolactinemia

Switch ti antipsychotuic with less potetial to elevate prolactin (lower D2 blocking)

What antipsychotics are most likely to cause metabolic changes?

Clozapine

Olanzapine

What antipsychotics are least likely to cause metabolic changes?

Ziprasidone

Aripiprazole

Lumateperone

What antipsychotics are most likely to cause sedation?

Clozapine

Olanzapine

Quetiapine

What antipsychotics are least likely to cause sedation?

Aripiprazole

Lumateperone

What antipsychotics are most likely to cause EPS?

FGAs

Paliperidone

Risperidone

Lurasidone

FGAs

What antipsychotics are least likely to cause EPS?

Clozapine

Quetiapine

Iloperidone

Lumateperone

What antipsychotics are most likely to cause prolactin elevation?

Risperidone

paliperidone

FGAs

What antipsychotics are least likely to cause prolactin elevation?

Clozapine

Aripiprazole

Cariprazine

Lumateperone

QUetiapine

Lurasidone

Brexipiprazole

What antipsychotics are most likely to cause orthostatic hypotension?

Iloperidone

Clozapine

What antipsychotics are least likely to cause orthostatic hypotension?

Aripiprazole

Brexipiprazole

Cariprazine

Lumateperone

Lurasidone

What antipsychotics are most likely to cause anticholinergic effects ?

Clozapine

What antipsychotics are least likely to cause anticholinergic effects ?

Asenapiine, Paliperidone

Ziprasidone

Lurasidone

Aripirazole

Brexiipraxole

Lumateperone

Risperidone

Iloperidone

Clozapine Adverse effects

Agranulocytosis

Seizure risk

Drooling

Urinary incontinence

Respiratory depression

Risks of antipsychotics in pediatrics

Trend of increasing prescription of antipsychotics for disruptive behaviors

Children are particularly susceptible to hyperprolactinemia and metabolic effects of antipsychotic

Reccommendations of antipyschotics in pediatrics

Only use for specific indication and with clearly documented goals

Regular monitoring of metabolic parameters

Risk of antipyschotics in geriatrics

Black box warning: "Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death"

Causes of death varied, but the most common were cardiovascular or cerebrovascular in nature

Reccommendations of antipyschotics in geriatrics

Avoid antipsychotic use for treating psychosis secondary to dementia if possible

Identify barriers to medication taking in patients with severe and persistent mental illness (SPMI)

Lack of efficiacy, side effects, costly, complex regimen, challenges accessing medication, cognitive impairment, cultural barriers, stigma, perceive cured, poor therapeutic alliance, poor insight

Estimate time to benefit once an antipsychotic medication is started for schizophrenia

2 weeks, an continued imprivement after that

Explain expected duration of treatment and risk of relapse to a patient starting an antipsychotic for schizophrenia

risk of relaose is higheat 3 months following discontinuation

Continue for 12 months following remission

Describe why and how antipsychotic should be tapered if the decision is made to discontinue

High risk of relapse

What antipsychotics have split daily dosing

Ziprasidone

Asenapine

iloperidone

What antipsyhcotics should be taken with food

Ziprasidone

Lurasidone

Lumaterepone