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What is the acute dosing for ziprasidone IM?
10-20 mg IM q2-4 hours. max 40 mg/day
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What is the acute dosing for olanzapine IM?
2.5-10 mg IM; repeat again in 2 hours, then 4 hours for each dose after that. Max of 30 mg/day.
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What is the acute dosing for aripiprazole?
5.25-9.75 mg IM q 2 hours prn. Max 30 mg/day
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Typical antipsychotics MOA.
Block D2 receptors
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What is a low potency typical antipsychotic?
High potency?
chlorpromazine
haloperidol
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How frequently are atypicals dosed initially? When are they usually taken?
BID - QID
In the evening if possible - (sedating)
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Atypical antipsychotics MOA.
- 5HT/DA antagonists
- Effective for positive AND negative symptoms
- Little increase in prolactin
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What is the biggest risk of clozaril and how to you monitor it?
- Agranulocytosis
- Weekly to monthly monitoring of CBC
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What might happen in the first few hours of a patient who received IM zyprexa relprevv?
Delirium
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How and in what dose is asenapine taken?
- 5 mg sublinual BID (~35% bioavailability)
- Max 20 mg/day
- Weight gain similar to risperidone
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How often do you receive aripiprazole injection (Abilify Maintena)?
Monthly
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What are the initial and maintenance doses for Iloperidone (Fanapt)?
- Initial: 1 mg po BID
- Maintenance: 6-12 mg BID
- Max: 24 mg/day
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Who shouldn't take iloperidone?
Hepatic impairment pts (little data available)
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This atypical has a lower risk for weight gain and somnolence. It has a low risk of akathisia, and dose related tachycardia.
Iloperidone
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How should lurasidone (Latuda) be taken?
- Inital: 40mg/day
- Maintenance: 80 mg/day
- Take with food (>350 calories)
- Weight neutral/weight loss
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Extrapyramidal symptoms are much more common with typical antipsychotics. Name a few of these symtpoms.
- Acute dystonia
- Pseudoparkinsonism
- Akathisia
- Tardive dyskinesia
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How would you counteract acute dystonia? (2 ways)
- Diphenhydramine 25-50 mg IM
- Benztropine 1-2 mg IM
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How would you counteract akathisia? (2 ways)
- Propranolol 20-30 mg TID, increased to 120 mg/day
- Benzodiazepines
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What class of medication would you use to treat pseudoparkinsonism?
Anticholinergics (benztropine, trihexyphenidyl, diphenhydramine, amantadine)
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How long does it usually take for pseudoparkinsonism to manifest after starting therapy and who would most likely be affected?
- 1-3 months after therapy started
- Increased risk with pts over 40, females, and higher doses
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What scale is used to assess tardive dyskinesia?
AIMS (Abnormal Involuntary Movement Scale)
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This antipsychotic has very low rates of tardive dyskinesia and may be indicated in pts who experience TD from other medications, usually typical antipsychotics.
Clozapine
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How would you treat neuroleptic malignant syndrome?
- D/C antipsychotic
- Use bromocriptine, dantrolene, or amantadine
- Supportive care
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(High/Low) potency antipsychotics are more commonly associated with orthostatic hypotension?
Low potency
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Which med has the highest risk of QTc prolongation?
- Thioridazine
- (higher risk with electrolyte imbalance)
- D/C if QT interval > 500 msec
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Which atypicals have the fewest amount of metabolic side effects?
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What should you be cautious of in patients taking lamotrigine concomitantly with valproate?
Stevens-Johnson Syndrome
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Lamotrigine does not affect hepatic metabolic enzymes so there is a low potential for interactions. BUT lamotrigine may be _____ or _____. One agent that typically does this is _____.
- Inhibited/induced
- Valproate
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What is the starting dose and eventual maintenance dose for lamotrigine?
How long does it take to titrate up?
- 25 mg po qd (qod if pt is on VPA)
- Titrate up to 200 mg qd over 6 weeks
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Who should receive carbamazepine (CBZ)?
Pts who are intolerant or refractory to lithium; rapid cyclers or mixed states
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Why should you not combine CBZ with clozapine?
Bone marrow suppression
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