Psychotic disorder med

PURPOSE OF SECOND- AND THIRD-GENERATION ANTIPSYCHOTIC AGENTS

  • The primary mechanism of action is blocking serotonin and dopamine receptors.
  • They also block receptors for norepinephrine, histamine, and acetylcholine.
  • These medications can function as both agonists and antagonists in the dopamine system.

THERAPEUTIC USES

  • Schizophrenia Spectrum Disorders: Addressing both negative and positive manifestations.
  • Psychotic Episodes Induced by Levodopa Therapy: Treating disorders associated with increased dopamine.
  • Control Disorders: Managing symptoms effectively.

FORMULATIONS

  • Olanzapine:
    • Available as tablets, short-acting injectable, and orally disintegrating tablets.
  • Quetiapine:
    • Available in tablets and extended-release tablets.
  • Ziprasidone:
    • Available as capsules and short-acting injectable.
  • Clozapine:
    • Available as tablets, quick-dissolving tablets, oral solution, and IM depot preparations.
  • Aripiprazole: (Third-generation antipsychotic)
    • Available as tablets (including orally disintegrating), oral solution, and sustained-release injectable.

COMPLICATIONS AND ADVERSE EFFECTS

1. Olanzapine

  • Complications:
    • Low risk of extrapyramidal symptoms (EPS)
    • High risk for diabetes mellitus, weight gain, dyslipidemia, and leukopenia.
    • Other possible effects: sedation, orthostatic hypotension.

2. Quetiapine

  • Complications:
    • Low risk of EPS.
    • Moderate risk for diabetes mellitus, weight gain, dyslipidemia, cataracts.
    • Other effects: sedation, orthostatic hypotension, and anticholinergic effects.
    • Eye exams are recommended every 6 months.

3. Ziprasidone

  • Complications:
    • Low risk of EPS and diabetes mellitus.
    • Other effects: sedation, orthostatic hypotension, anticholinergic effects, rash.
    • ECG changes can lead to torsades de pointes due to QT prolongation.

4. Clozapine

  • Advantages:
    • Relief from both positive and negative manifestations of schizophrenia.
    • Improvement in neurocognitive deficits such as poor memory.
    • Reduction in anxiety and suicidal behaviors.
    • Fewer or no EPS, including tardive dyskinesia (TD).
    • Less relapse due to lower cholinergic blockade.
  • Complications:
    • High risk of weight gain, diabetes mellitus, dyslipidemia, and agranulocytosis.
    • Baseline WBC counts and weekly monitoring recommended.
    • Other adverse effects: sedation, hypersalivation, orthostatic hypotension, anticholinergic effects.
    • Pregnancy Risk Category B.

5. Aripiprazole

  • Complications:
    • Common adverse effects: sedation, headache, anxiety, insomnia, gastrointestinal distress.

6. Lurasidone

  • Complications:
    • Common effects include sedation, akathisia (a movement disorder), parkinsonism, agitation, and anxiety.
    • Low risk for diabetes, weight gain, dyslipidemia, and does not cause anticholinergic effects.
    • Pregnancy Risk Category B.

7. Paliperidone

  • Complications:
    • High risk for diabetes mellitus, weight gain, dyslipidemia.
    • Other adverse effects: prolonged QT interval, hypotension, mild EPS.

8. Iloperidone

  • Complications:
    • Common adverse effects: dry mouth, sedation, fatigue, nasal congestion.
    • Significant risk for weight gain and prolonged QT interval; orthostatic hypotension may occur.
    • Low risk for diabetes and dyslipidemia; advise caution with titration schedule.

NURSING ACTIONS AND CLIENT EDUCATION

General Recommendations

  • Diabetes Monitoring:
    • Baseline fasting blood glucose should be obtained and monitored throughout treatment.
  • Weight Management:
    • Encourage a low-calorie diet and regular exercise, advising clients to monitor their weight.
  • Cardiovascular Health Education:
    • Monitor cholesterol and triglycerides regularly due to increased risks of hypercholesterolemia and hypertension.
  • Orthostatic Hypotension:
    • Monitor blood pressure and heart rate; advise clients to change positions slowly to prevent dizziness.
  • Anticholinergic Effects Management:
    • Monitor and advise clients on coping strategies for symptoms like dry mouth (sipping fluids, sugarless gum).
  • Awareness of EPS:
    • Use AIMS data collection tool for screening EPS and educate clients on recognizing symptoms.

Contraindications/Precautions

  • Pregnancy Risk:
    • Clozapine and lurasidone only to be used when benefits outweigh risks to the fetus.
    • Risperidone safety is not established for pregnancy.
  • Lactation Precautions:
    • Some medications are contraindicated or should only be used if benefits outweigh risks during breastfeeding.
  • Dementia Patients Warning:
    • All atypical antipsychotic medications can increase the risk of death in dementia patients due to cerebrovascular accidents or infections.

INTERACTIONS

Risk Factors

  • Immunosuppressive Medications:
    • Clozapine may intensify immune suppression if combined with anticancer medications.
  • CNS Depressant Effects:
    • Alcohol, opioids, and antihistamines increase sedation risks.
    • Advise avoidance of such substances and caution during hazardous activities.
  • Levodopa Interaction:
    • Levodopa may counteract antipsychotic effects; concurrent use should be avoided.

NURSING ADMINISTRATION NOTES

  • Administer medications PO or via depot routes.
  • Anticipate a delay in therapeutic effect (weeks for stabilization).
  • Establish a titration schedule and ensure adherence to the regimen for long-acting injectables.
  • Monitor clients carefully post-injection to address any immediate adverse reactions.

EVALUATING MEDICATION EFFECTIVENESS

  • Improvement can be observed through:
    • Reduction or absence of both positive and negative manifestations of psychosis (e.g., reduction in hallucinations, delusions, agitation).
    • Enhancements in daily living activities and social interactions.
    • Better sleeping and eating habits.