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What are the typical (first generation) antipsychotics and their generic names?
- Chlorpromazine (thorazine/CPZ)
- Fluphenazine (Prolixin)
- Perphenazine (Trilafon)
- Haloperidol (Haldol)
- Loxapine (Loxitane)
- Thiothixene (Navane)
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What are the atypical (second generation) antipsychotics and their generic names?
- Clozapine (Clozaril)
- Risperidone (Risperdal)
- Olanzepine (Zyprexa)
- Quetiapine (Seroquel)
- Paliperidone (Invega)
- Lurasidone (Latuda)
- Ziprasidone HCL (Geodon)
- Aripiprazole (Abilify) [Technically 3rd generation]
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What are the characteristics of chlorpromazine (thorazine/CPZ)?
- First anti-psychotic on the market
- Strong sedative effect
- Decreases BP, decreasing energy
- Moderate EPSE risk
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What are the characteristics of Fluphenazine (prolixin)?
- Low sedative effect
- Neutral action on BP
- Strong risk of EPSE
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What are the characteristics of Perphenazine (Trilafon)?
- Low sedative effect
- Neutral action on BP
- Strong risk of EPSE
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What are the characteristics of Haloperidol (Haldol)?
- Used mainly in emergency situations, acutely
- Butyrophenone: most widely used in this class
- Metabolized in the liver
- PO, IV, IM, PRN, scheduled, long-acting
- More likely to have anticholinergic effects
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What are the characteristics of Loxapine (Loxitane)?
- Dibenzoxazepine
- Moderately sedating
- Strong risk of EPSE
- Hypotension common
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What are the characteristics of Thiothixene (Navane)?
- Thioxanthene
- Low sedation and hypotension
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What does the 5150 emergency cocktail include, and what are the intended effects of each drug?
- 5 mg Haldol, ↓ psychosis
- 1 mg Ativan, ↓ anxiety, ↓ muscle tension
- 50 mg Benadryl, ↓ sleep
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What is NMS?
- Neuroleptic Malignant Syndrome
- Potentially fatal
- Symptoms: muscle rigidity, sudden high fever (up to 105* even!), altered LOC, fluctuations in BP (take it more than once), tachycardia, dysrhythmias, seizures, rhabdomyolysis (breaking down of muscles), ARF (acute renal failure), respiratory failure, coma, death.
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How do you treat NMS?
- Immediately stop the antipsychotic medication.
- IV fluids to hydrate
- Hypothermia blankets
- Administration of antipyretics, benzodiazepines, muscle relaxants
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What are the side effects of first generation anti-psychotic drugs?
- Drowsiness
- Extrapyramidal symptoms (EPS)
- Orthostatic Hypotension
- Dry mouth (anticholinergic effects)
- Confusion
- Dystonia
- Hallucinations
- ↑ HR
- Urinary retention
- Constipation
- Hyperpyrexia
- HTN
- Tardive Dyskinesia
- Akathisia
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How do you help reduce drowsiness from first generation anti-psychotic medications?
Get the patient eating, drinking, and on a regular sleep cycle.
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How do you treat dystonia from first generation anti-psychotics?
- Anticholinergic meds
- IM diphenhydramine (Benadryl)
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What do you do when a patient develops tardive dyskinesia from their antipsychotic meds?
Stop the medication and get them started on a different, less symptomatic med.
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How do you treat akathisia from antipsychotic meds?
- Bring the med dose down slowly to reduce the side effect
- Beta blockers (propanolol)
- Benzodiazepines
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What are the adverse considerations for typical antipsychotic meds?
- High doses and long term use can cause agranulocytosis.
- Strong photo-sensitivity
- Pruritis
- Lowers seizure threshold
- Sedative effect increased with use of alcohol, benzodiazepines, narcotics, hypnotics
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What do you do when a patient develops agranulocytosis?
- Take labs (WBCs)
- Monitor for infection
- Stop their anti-psychotic med
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What important interventions should you do when dealing with a patient having adverse reactions to a typical antipsychotic?
- Do not leave the patient
- Put them on their back when taking them down, not on their stomach
- Educate them about the side effects of the medication
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What are the metabolic considerations for typical antipsychotics?
- Highly protein bound
- Metabolized in the liver and excreted in the urine
- Metabolites can cause urine to turn pinkish/brown, which is harmless
- Document urine color change
- Take labs before, during and after administration to monitor for toxicity
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When do you expect to see improvement after administration of anti-psychotic meds and when do they reach their full therapeutic effect?
- Some improvement in 7-10 days
- Full therapeutic effect in 3-6 weeks
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Why is there a high non-compliance rate for anti-psychotic meds?
- Anosognosia
- Not thinking clearly in psychotic state
- Side effects
- Most people do not want to be forced to take drugs
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What is the most common expected side effect of typical antipsychotic meds?
Pseudoparkinsonisms
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When do extrapyramidal symptoms usually show up?
5-30 days after starting anti-psychotic meds
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What are the common anticholinergics?
- Benztropine (Cogentin)
- Trihexyphenidyl HCl (Artane)
- Diphenhydramine (Benadryl)
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What are the common side effects of anticholinergic meds?
- Dry mouth
- Constipation
- Blurred vision
- Fever
- Hot/dry skin
- Sexual dysfunction
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What are other side effects of anticholinergic meds?
- Decreased production of sweat, saliva and secretions
- Decreased gut motility
- Urinary retention
- Eczema
- Increased esophageal reflux
- Cardiac infarction
- May increase absorption of neuroleptic drugs, resulting in higher plasma levels
- Increases hepatic enzymes
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What are the symptoms of anticholinergic toxicity?
- Confused state/delirium
- Flushed, dry skin
- Fever
- Tachycardia
- Arrhythmias
- Rapid breathing
- Widely dilated pupils
- Urinary retention
- Constipation
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What are the special considerations for Ziprasidone HCl (Geodon)?
- It is limited to people without heart conditions and are younger.
- Check EKG regularly
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What are the common side effects for atypical antipsychotic meds?
Weight gain, metabolic complications, metabolic syndrome (diabetes, hyperlipidemia, coronary artery disease)
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What medication is most likely to cause weight gain and metabolic syndrome?
Olanzepine (Zyprexa)
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What are the nursing implications for a patient taking atypical anti-psychotic medications?
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How does cigarette smoking affect anti-psychotic drug use?
Increases metabolism, affecting half-life.
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What important patient teaching points should a patient taking atypical anti-psychotics consider?
- Lab work q 3 months
- Wear a medical ID band
- Avoid direct sunlight
- Quit smoking
- Orthostatic hypotension
- Caution use of alcohol, narcotics, OTC meds
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What are the different types of anxiolytics?
- Benzodiazepines
- Azapirones
- Metathizanone
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What are the benzodiazepines?
- Lorazepam (Ativan)
- Clonazepam (Klonopin)
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What is the trade name for Buspirone and what type of drug is it?
- BuSpar
- Azapirone anxiolytic
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What is the trade name for Chlormezanone and what type of drug is it?
- Trancopal
- Metathizanone anxiolytic
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What other type of drug is used as an antianxiety besides anxiolytics?
- Antidepressants:
- SSRIs (escitalopram (Lexapro))
- SNRIs (venlafaxine (Effexor))
- NaSSA: (mirtazapine (Remeron))
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What is the important patient teaching for anxiolytics?
- Benzos are short term and PRN due to dependence
- Wean off drug
- Best taken at night
- Available as tablet or disintegrating tablet
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What are the common side effects of anxiolytics?
- Sedation
- Lightheadedness
- Ataxia
- Decreased cognitive fxn
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What are the withdrawal symptoms for anxiolytics?
- Irritation
- Insomnia
- Tremors
- Nausea
- Sweating
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What is the important drug-drug interaction for MAOIs?
- It can be fatal if used with an antipsychotic
- Need a 14 day lapse before starting
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What drugs do you want to caution a patient when taking antipsychotics and anxiolytics, and why?
- Digoxin (potentiates)
- Warfarin (potentiates)
- Diazepam (potentiates)
- Increased risk of bleeding with ASA/NSAIDS
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What drugs, when taken concurrently with antipsychotics and anxiolytics, increases the risk for serotonin syndrome?
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