Antipsychotics
Antipsychotics
Antipsychotics
Antipsychotics (AKA
neuroleptics)
Divided into 3 groups: 1) typical (1st
generation), 2) atypical (2nd
generation), and 3) novel (3rd
generation)
2nd & 3rd generation are
characterized by improved response
of negative symptoms, less harmful
effects on cognition & fewer
extrapyramidal effects
Goals of Therapy
Overall goal of treatment is to return control to
the individual.
Antipsychotic meds are used to decrease
psychotic signs and symptoms, including
hallucinations, delusions and feelings of paranoia.
These drugs are very potent & overmedication
places control of individual in the hands of the
clinician.
Goal of returning control to the individual is
achieved through monitoring specific psychotic
symptoms and improvement in the clients ability
to provide self-care.
Medication Forms
Most troubling symptom is lack of insight,
client who believes he is not sick will have little
motivation to take any medication.
Liquid most antipsychotics are available as
liquids
Injectable
Acute Situations - Immediate-release
injectable forms of medications are available
for emergencies; A one-time IM injection
can be rapidly effective for clients who pose
a danger to themselves and others
Older Adults
2nd generation
Antipsychotics
Clozapine (Clozaril), risperidone
(Risperdal), olanzapine (Zyprexa),
quetiapine (Seroquel), ziprasidone
(Geodon), paliperidone (Invega),
asenapine (Saphris), lurasidone (Latuda)
2nd generation
Antipsychotics, cont.
Clozapine
Clinical Use and Efficacy
Gradual titration essential b/c of
hypotension, tachycardia & sedation
Risk of agranulocytosis
Clozapine Protocol
Institute therapy only if WBC above
3500/mm3 and ANC = 2000/mm3 or
higher
Monitor WBC weekly
If counts normal for 6 months,
monitor level every 2 weeks
If counts normal for 1 year, monitor
level every 4 weeks
Risperidone (Risperdal)
High-potency drug - well absorbed w/
or
w/o food
Dose-related EPS usually seen @ > 6
mg/d; other side effects include
anxiety, rhinitis, somnolence,
tachycardia & weight gain
Olanzapine (Zyprexa)
Medium-potency drug
Mild EPS, particularly akathisia; other
side effects include postural
hypotension, dizziness, constipation
& substantial weight gain
Quetiapine (Seroquel)
Low-potency drug; serum half-life is 7
hours
Few EPSEs nor increased serum
prolactin
Side effects include postural
hypotension, somnolence, dizziness,
weight gain, tachycardia
Ziprasidone (Geodon)
Tx of psychotic disorders, as well as
bipolar mania
Affinity for dopamine, serotonin,
noradrenergic & histaminic receptors
Less weight gain than others
Paliperidone (Invega)
Metabolite of risperidone for tx of
schizophrenia. Blocks dopamine type
2, serotonin type 2, and alpha 2
adrenergic receptors.
Extended-Release Tablets, Decanoate
IM
Asenapine (Saphris)
Tx of schizophrenia & acute mania,
mixed episodes
Dosed sublingually, poorly absorbed if
swallowed
Side effects: anticholinergic &
cardiac effects, weight gain
Possible gynecomastia, galactorrhea,
amenorrhea, and low libido due to
increased prolactin levels
Latuda - lurasidone
Indication: schizophrenia
Must be taken with food
No controlled studies for longer than
six weeks
Side effect profile similar to other 2nd
& 3rd antipsychotics
3rd generation
Antipsychotics
aripiprazole (Abilify)
Mode of Action partial
dopamine/serotonin agonist
Clinical Use and Efficacy Less
weight gain than 2nd generation
antipsychotics. As w/ other 2nd
generation decreased EPS.
Neuroleptic Malignant
Syndrome (NMS)
Medical emergency rare abnormal
reaction to neuroleptics and result of
dopamine blockade
Can occur at any stage of treatment,
but more likely to occur early
Potentially fatal complications: MI,
hepatic failure, disseminating
intravascular coagulation (DIC), and
pulmonary edema
(NMS), cont.
Characterized by muscular rigidity,
hyperthermia, altered consciousness &
autonomic dysfunction
Increased creatinine, increased leukocytes
Treatment Stop medication!
Hydration & cooling of patient
IV admin. of muscle relaxant, dopaminergic
drugs (bromocriptine [Parlodel] and
amantadine [Symmetrel]) &
anticholinergics have been used
Extrapyramidal Side-effects
(EPSEs)
Movement-related effects caused by
the dopamine blockade of
medications, esp., but not limited to
antipsychotics
A major reason for non-adherence
EPSEs present as acute dystonia,
neuroleptic induced
pseudoparkinsonism, akathisia, and
tardive dyskinesia.
Anticholinergic drugs
Promptly effective for relieving EPSEs.
Mild presentations may be treated with
oral drugs and severe presentations
will benefit from rapid onset of IM or IV
treatment. Benztropine (Cogentin) 1mg
IM/IV (may be increased incrementally
up to 6 mg) and diphenhydramine
(Benadryl) 50-100 mg IM/IV used most
often. Continue 1-3 days.
Extrapyramidal Side-effects
(EPSEs)
Akathisia most common occurs
with many drugs (see drug guide)
Motor restlessness, feelings of inner
restlessness, pacing, foot-tapping
and rocking. Irritability and/or
inability to sit still and/or lie down.
(similar to S&S of Restless Leg
Syndrome)
Akathisia
Differentiating between akathisia and
psychomotor agitation/irritability of
worsening psychosis is difficult
Mistaking akathisia for psychomotor
agitation could result in increasing
dosage thus worsening akathisia
If severe, patients at risk for suicide
Acute Dystonias
Spontaneous, painful muscle spasm
Blepharospasm (eye closing)
Torticollis (neck muscle contraction - 'twisting'
side to side)
Oculogyric crisis (severe upward deviation of
the eyeballs)
Opisthotonos (severe dorsal arching of the
neck and back)
Laryngospasm can result in dysphagia
(difficult swallowing)
Neuroleptic-Induced
Pseudoparkinsonism
Dopamine & acetylcholine exist in
balance in brain
Dopamine blockade results in
cholinergic predominance leading to
symptoms similar to those seen in
patients w/ Parkinsons Disease
Neuroleptic-Induced
Pseudoparkinsonism, cont.
Tremors
Bradykinesia/akinesia (slowness, absence of
movement)
Cogwheel rigidity (slow, regular muscular
jerks)
Postural instability, hunched posturing,
shuffling gait
Masked facies (loss of mobility in facial
muscles)
Hypersalivation & drooling
Tardive Dyskinesia
Late occurring, abnormal movements
that may occur anywhere on body, but
usually oral, buccal, lingual &
masticatory movements (tongue
writhing, lip pursing, smacking, facial
grimaces.)
May also occur on arm, finger, leg, feet
and truncal movements
Potentially irreversible