Antipsychotic Medications
1. Antipsychotic Medications
A. Typical - the “old” ones primarily block dopamine from the receptors and have
serious side effects. They only effect the “positive symptoms” of schizophrenia.
B. Atypical – the “new” medications effect dopamine and serotonin. Also, they have
a much better side effect profile and decrease the “positive” and “negative”
symptoms. They are very expensive.
2. Typical antipsychotics:
A. High Potency - 1 to 20 mgm-High EPS, low anticholinergic side effects
1. Haldol (haloperidol)
2. Prolixin (fluphenazine): both these meds come in PO, IM and Depot IM
B. In-betweens - 4-20 mgm
1. Stelazine (trifluoperazine)
2. Trilaphon (perphenazine)
3. Navane (thiothixene)
4. Loxitane (loxapine)
5. Moban (molindone)
C. Low Potency - 50 to 1000 mgm
1. Thorazine (chlorpromazine)
2. Mellaril (thioridazine)
3. Serentil (mesoridazine)
3. Atypical Antipsychotics: less EPS side effects, decrease BOTH positive and negative
symptoms
A.
B.
C.
D.
E.
F.
Clozaril - 300 mgm (clozapine)
Risperdal - 6-12 mgm (risperidone)
Zyprexa - 10 mgm (olanzapine)
Seroquel - .150-300 mgm (quetiapine)
Geodon – 20- 80 mem BID (ziprasidone)
Abilify (Aripiprazole)
4. Antiparkinsonian Agents
A.
B.
C.
D.
Cogentin 1-2 mgm (benztropine)
Artane 1-2 mgm (trihexyphenidyl)
Benadryl 50 mgm (diphenhydramine)
Symmetrel 100 mgm (amantidine)
5. Side Effects of Typical Antipsychotics
A. Drowsiness: common during the first few days of treatment; usually disappears in
one to two weeks. Clients should avoid alcohol and medications such as
antihistamines and sleeping aids.
B. Extrapyramidal side affects (EPS):
1. Dystonias: usually occur during the first 5 days of treatment, almost never
after the first 3 months of treatment. They can occur after each injection of IM
medication. Risk factors include high potency agents, large doses, and
parental (IM or IV) route of administration. These affects are readily
reversible with intramuscular injections of diphenhydramine (Benadryl), or
benztropine (Cogentin). Oral antiparkinson agents may need to be continued
for a few weeks to prevent recurrence of the reaction. Clients will often times
refer to these reactions as “drug allergies” or “seizures”. These however are
not allergic or epileptogenic in nature, and do not preclude continued use of
the agent. These reactions include spasms of the:
eye-oculogyric crisis
neck-torticollis
back-retrocollis/opisthotonus
tongue-glossospasm
or other muscles
2. Pseudoparkinsonism: Due to an imbalance of acetylcholine and dopamine in
the basal ganglia, similar to idiopathic Parkinson’s disease except in
pseudoparkinsonism this effect is reversible. Treatment consists of reducing
the dose, changing to a different agent, or using oral antiparkinson agents such
as benztropine (Cogentin), trihexyphenidyl (Artane), diphenhydramine
(Benadryl), biperiden (Akineton), or amantidine (Symmetrel). Symptoms
include: decrease movements (bradykinesia, akinesia), muscle rigidity
(cogwheel and lead pipe), resting hand tremor, drooling, mask-like face, and
shuffling gait.
3. Akathisia: can’t remain still, constantly pacing. Clients may describe this
effect as a feeling of inner restlessness. This effect can easily be confused with
anxiety and agitation. Differences between akathisia and anxiety/agitation
improves with increases in antipsychotic doses, and vice-versa; and the client
can usually control anxiety/agitation for a period of time whereas the client
cannot typically control akathisia. This effect can be treated by changing to a
different agent, reducing the dose if possible, or by the use of an antiparkinson
agent or benzodiazepine.
4. Tardive Dyskinesia: symptoms consist of involuntary lip and tongue
movements, and writhing movements (choreoathetoid) of the arms and legs.
Movements disappear during sleep. Risk factors include increased age, long
duration of therapy, use of high potency agents, and large doses. There is no
effective treatment for tardive dyskinesia. Reducing the dose of the
antipsychotic agent and addition of an antiparkinson agent result in worsening
of the symptoms.
C. Anticholinergic side affects: tolerance usually develops to these side affects over
1-2 months.
– dry month - use of ice chips, sugarless gum, or sugarless sour candy may be
helpful
– blurred vision - reading in well lighted areas and varying the distance of the
material being read may be helpful
– constipation - exercise, drinking plenty of fluids daily, and increasing the
amount of bulk food (bran, salads) intake may relieve this effect. Chronic
problems may require short term use of topical nasal decongestant.
– increase in heart rate
– ejaculation inhibition - most common with mellaril
D. Cardiovascular side effects: most common with low potency agents.
– postural hypotension (dizziness or fainting) - commonly occurs with sudden
changes in position e.g. laying or sitting to standing position, or in hot
temperatures such as hot showers, saunas, and summer heat. Clients should be
told to change positions slowly, and use good judgement in extreme heat.
– arrhythmias/palpitations (changes in heart rhythm)
E. Miscellaneous side effects:
– skin rash: usually 2 to 8 weeks after initiation of treatment
– photosensitivity: severe sunburn, most common with Thorazine. Clients should
be instructed to wear hats, and long sleeve clothing until the effects from the
sun are determined for that client. A sunscreen is also useful. A Sun Protection
Factor (SPF) number 15 sunscreen is best. Good choices are Presun 15, and
Solbar 15 plus.
Rare side effects
– Neuroleptic Malignant Syndrome
– agranulocytosis
– jaundice
– lowered seizure threshold
– galactorrhea, gynecomastia
– menstrual irregulations
– body temperature alterations
– pigmentary retinopathy
– increase in blood sugar
– weight gain
Neuroleptic Malignant Syndrome
1.
Predisposing factors; Youth, male; High-potency neuroleptic, client
who is pharmacologically naïve.
2.
Four Cardinal Symptoms
a. Febrility: usually the first symptom
b. Lead pipe rigidity
c. Automatic instability; tachycardia
d. LOC Changes
Lab results will include elevated CPK
3.
Medical emergency; DC all meds. May resume meds after crisis.
Syndrome is very RARE. Resume medication with an atypical
antipsychotic after CPK has returned to normal.
Atypical Antipsychotic Medications
A. Clozaril
1. Atypical antipsychotic
2. Decreases negative symptoms of schizophrenia
3. No Extrapyramidal symptoms (EPS)
4. May decrease symptoms of tardive dyskinesia
5. Affects both dopamine and serotonin
6. Side effects: drowsiness and drooling
7. Very costly $9,000 per year.
8. Side effects:
a. Agranulocytosis, weekly blood draws
b. Sedation, excessive salivation, dizziness, seizures
c. Hyperglycemia/weight gain, NIDDM
B. Risperidone
1. Medication is costly - $400 for 1 month supply
2. Atypical; effects serotonin and dopamine
3. 1st line; affects both positive and negative symptoms
4. Can cause EPS, but lower incidence
5. Side effects: CNS insomnia, drowsiness (most common), agitation,
headache, anxiety – Orthostatic hypotension – Hyperglycemia
6. GI: constipation, nausea, vomiting and dyspepsia
7. High potency - 8 mgm per day in 2 doses
8. Available in long lasting IM form (2 weeks)
C. Olanzapine / Zyprexa
1. 1st line drug: Positive and negative symptoms
2. High potency: 10 mgm a day - up to 20
3.
4.
5.
6.
7.
Side effects: Drowsiness, constipation, dry mouth, headache. Rare
EPS, NMS
Affects both serotonin and dopamine
Weight gain long term/Hyperglycemia/NIDDM
Drug is costly - 10 mgm per day for 30 days is $250
Available in short acting IM form
D. Seroquel (Quetiapine)
1. Atypical antipsychotic, low potency
2. Effective for positive and negative symptoms
3. EPS profile same as placebo
4. No increase in prolactin levels
5. Sexual dysfunction problems are rare
6. Side effects: somnolence and hypotension
7. Doses: effective at 150 mgm to 750 mgm per day
8. Average: 300 mgm; 100 in AM-200 in PM
9. Titrate doses: begin at 50 mgm per day
E. Ziprasidone
1. Geodon/Atypical Antipsychotic – Antagonizes Dopamine and
Serotonin
2. Low EPS
3. No increase in prolactin levels
4. Side effects: somnolence in short term and insomnia in long term use
5. Weight gain neutral
6. Big issue: prolongs the QT interval
7.
Contraindiciated for clients with cardiac pathology or prone to
electrolyte imbalance
8. Monitor serum potassium and magnesium
9. Starting dose of 80 mgm per day in 2 doses
10. Can go to 160 mgm
11. Available in short acting IM form
F. Aripiprazole / Abilify
1. Atypical antipsychotic, affects both dopamine and serotonin,
antagonizing some receptors and serving as a partial agonist for others
2. Decrease in the EPS side effects and minimal weight gain, minimal
sedation, no problems with QT interval
3. Side effects: headache, anxiety, insomnia, somnolence, occasional
stomach upset
4. Dosage: 10 to 15 mgm daily can go up to 30