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46 Cards in this Set

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low - potency FGA
chlorpromazine
thioridazine

mORE LIKELY TO cause:

sedation, orthostatic hypotension, anticholingergic side effects, weight gain.
thioridazine
dose-related QTc interval
Intermediate-potency FGA
- Loxapine (Loxitane)
- Perphenazine (Trilafon)

Moderate anticholingergic activity, sedation, EPS.
High Potency FGAs

- Require higher dose of antiparkinsian agents.
Haloperidol (Haldol)
Fluphenazine (Prolixin)
Thiothixene (Navane)
Trifluoperazine (Stelazine)
Haloperidol (Haldol)
Fluphenazine (Prolixin)
- depot DECANOTE injections.
- Haldol q4w (po x 10)
- Prolixin q2w (po x 1.2)

- More likely to cause EPS ....
Candidates for Depot Injections
1. History of non-compliance
2. Need for long-term tx.
3. Good response to oral formulation
4. Decreased drug absorption
5. patient refused oral medication but is willing to take I.M.
FGA moa:
D2 Antagonists in ALL four pathways, varying degrees of toerh receptor antagonism at muscarnic, alpha, histamic)
SGA: "ATYPICALS"
Moa
First line (except clozapine)
1. D2 and 5HT2A receptor antagonist effects
A. 5HT2A reverses blockade at NIGROSTRIATAL pathway --> reducing EPS.
B. 5HT2A antagonizes DA activity in the MESOCORTICAL pathway -> improve cognitive and negative symptoms.
Atypicals less than:
1. less EPS
2. less TD
3. less hyperprolactinmia
4. improvement in negative sx and cog.
5. metabolic complications
Metabolic complications:
1. weight gain
2. hyperlipidemia
3. hyperglycemia
4. lipid abnormalities
5. high b.p.
Aripiprazole (Abilify)
Partial D2 Agonist:
- Hypodopaminergic -> agonist at mesocorticol, nigrostriatal, tuberoinfundibular.
- Hyperdopaminergic -> antagonist (mesolimbic)
Aripiprazole A.E.:
LESS METABOLIC COMPLICATIONS compared to other SGA.

1. Akathisia
2. Asthenia
3. n/v
4. constipation
5. anxiety
6. insomnia
7. dose related sedation
Should you adjust the dose?
No need to adjust dose for renal or hepatic impairment --> but requied with CYP2D6 inhibitors
-> required with CYP3A4 inducers.
Clozapine:
MOA
- low D2 blockade
- high 5HT2A blockade.

- MAX DOSE : 900MG/DAY
BLACK BOX WARNING FOR clozapine
1. Agranulocytosis (1%)
2. Seizures (5%)
3. Myocarditis
4. Other adverse respiratory and cardiovascular effects.
5. Increased MORTALITY in elderly pts w/ dementia-related psychosis.
What are the monitoring parameters for CLOZAPINE and frequency?
WBC at least 3500 / mm3
ANC at least 2000/ mm3

Frequency?
QW for 6 mo
Q2w for 6 mo
Q4W forever
What are the adverse effects of Clozapine?
- syncope, dizziness, n/v, hypotension, drowziness, seizures, profuse salivation, agranulocytosis.
- metabolic sx.
What is clozapine used for?
- treatment-refractory cases.

HIGHLY effective low incidence of EPS/TD.
What are the A.E. of Olanzapine (Zyprexa)?
A.E.:
- DOSE-DEPENDENT SOMNOLENCE AND EPS.
- Agitation, dizziness, orthostasis.
- Weight gain, hyperglycemia,
lipid abnormalities

TRY TO AVOID IN OBESE PATIENTS.
Are there any dosage requirement for Zyprexa?
- No dosage adjustments for zyprexa
Are there any other uses for zyprexa?
- bipolar depression with fluoxetine.
Quetiapine:
(Seroquel and Seroquel XR)
A.E.
1. SEDATION
2. HA
3. Xerostomia
4. Constipation
5. Hypotension
6. Dizziness
7. LOW RISK OF EPS ->
Dose adjustments for quetiapine:
- need adjustments done for HEPATIC INSUFFICIENCY.
Quetiapine is aslo approved for:
1. Parkinson's Disease
- Lowest D2 binding and rapid disassociation from D2 receptor
2. Bipolar depression
Black box warning for quetiapine
Adults and children with MDD for worsening of their condition and/or emerging suicidal ideation and behavior. (suicidal)
What was risperdone also approved for?
- Adolescent 13 to 17 with schizophrenia.
What are the A.E. of Risperodone?
1. Dose dependent EPS (> 6mg/day or elderly > 2 mg/day)
2. Hyperprolactinemia
3. Hypotension, dizziness, somnolence
4. Less...but have weight gain.
What dosage adjustment do you need for Risperidone?
1. Dose should be REDUCED for renal, hepatic, and geriatric.
2. LONG ACTING INJECTABLE ONLY:(Consta)
-> overlap oral and I.M. for 3 weeks after 1st injection.
What is the active metabolite of Risperidone and what should you watch out for?
Paliperidone ER (INVEGA)
- OROS oral delivery
- CrCl 50 - 79 = 6 mg/day
- CrCl 10 - 49 = 3 mg/day
What a.e. of paliperidone should you watch out for?
QTc interval prolongation.
Ziprasidone (Geodon) What other MOA should be added?
- Inhibits serotonin and NE reuptake...should not be used depression.

- TAKE WITH FOOD.
What are some adverse effects of Geodon?
LESS METABOLIC COMPLICATIONS.

1. Rare QTc interval
2. Rash,
3. Somnolence
4. Constipation
5. Dizziness
6. Nausea
What should patients watch out for with Geodon?
Avoid in pt with QTc interval >450msec.

No dosage adjustment with P.O. but yes with I.M. (Cyclodextrin can accumulate renally.
What drugs available in oral solution?
Abilify
Risperdal
in IM inj.
- Geodon
- Abilify
- Zyprexa
- Risperdal (long acting)
ODT
- Fazaclo
- abilify DISCMELT
- Risperdal
- zyprexa
What are the other major sideeffects with SGA antipsychotics?
1. Increased Mortality in Elderly Patents with Dementia related psychosis.

-- NO ATYPICAL IS APPROVED FOR THis.

2. Hyperglycemia and DM.
- monitor regularly

3. CV A.E. in elderly patients with Dementia - Related Psychosis:
--> Use antipsychotics ONLY for psychotic sx.
What other labs values should be monitored for SGA?
1. Personal/Family History (1st)
2. Weight (BMI)= Baseline, 12wks, quarterly.
3. Waist Circumference = bas,12wks,1yr.
4. B.P.= Baseline, 12 wks,1yr.
5. Fastin plasma glucose = base, 12wks, 1yr.
6. Fasting lipid profile = base, 12wks, 5yrs.
Psychosis.
Presense of delusion or hallicinations with the ABSENCE of insight into their pathological nature.
Delusions
Fixed falso befiefs not based in reality or consistent with the pts religion or culture.
Ex. Bizarre, Grandiose, Jealousy, Persecutory, Somatic.
Hallucinations: Feeling something is not there.
False sensory impressions or perception that occur in the absence of external simuli:
auditory, visual, olfactory, gustatory, tactile...continous or intermittent.
Schizophrenia
a devastating, chronic though disoder in which pts are unable to develop interpersonal relationships or function in society on a daily basis.
Nigrostriatal Pathway causes many EPS and TD? What are the different EPS, SX, and how do you treat each?
1. Dystonia:
Types;
A. Trimus: clenched jaw
B. Tongue protusion
C. Oculogyric Crisis: fixed upward gaze
D. Torticollis: twisting
movement of the neck.

Treatment:
I.V. and I.M. Anticholingerics or Benzo
Pseudoparkinsonism
2. Pseudoparkison:
Rigidity, akinesia, bradykinesia, stooped posture, shuffling gait, tremr.

tx:
Anticholingers:
Amantadine
Akathisia
sense of subjective restlessness:
--> pacing, shuffling, or tapping feet.

Tx of akathisia:
1. beta-blockers and benzo, or switch to SGA.
Tardive Dyskinesia
Hyperkinetic movement Disorder:
- Facial and tongue movements
(constant chewing, tongue protrusions, facial grimacing)
- Limb movement: quick, jerky or choreiform

test with AIM

tx: prevention
- which to CLOZAPINE (SEVERE)
- SGA for mild to mod.