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Natural Products Fish Oils o ADHD o Depression o Triglycerides o Psychosis Do not recommend cod liver oil due to risk of vitamin A toxicity
Medications that can cause psychotic symptoms Amphetamines Methamphetamine Cannabis Cocaine Phencyclidine Lysergic acid diethylamide (LSD) and other hallucinogenics Anticholinergics (centrally-acting, high doses) Dopamine or dopamine agonists used for Parkinsons disease
o Requip, Mirapex, Sinemet Interferons Steroids (typically with lack of sleep ICU psychosis) Stimulants including ADHD drugs, modafinil
Pharmacotherapy
Patient should have an adequate trial period of 4-6 weeks to determine response. Second generation Antipsychotics are typically used first, however some patients still need first generation antipsychotics. ODTs contain phenyllanine o Do not dispense to pts with PKU
Long Acting Injections Haloperidol Haldol(1st) o Decanoate Once a MONTH Risperidone Risperidal o Consta Every 2 WEEKS Paliperidone o Invega Susteena Once a MONTH Orally disintegrating Tablets Clozapine - Clozaril Olanzapine - Zyprexa Risperidone - Risperidal Asenapine - Saphris Acute IM Injections May be mixed with a Benzodiazepine Zispiradone Geodon Haloperiodol Haldal Olanzapine - Zyprexa
More in elderly females o Dystonias Prolonged muscle contractions More in younger males Can use benedryl or benztropine as prophylaxis therapy o Akathisia Consistent urges to move o Dyskinesias Abnormal movements Moderate risk of sedation Low risk of orthostatic hypotension, tachycardia and anticholinergic effects Moderate risk of weight gain Low risk of metabolic effects High risk of sexual side effects Cardiovasular complications o QT prolongation (Thioridazine) is associated with highest o Orthostasis
Low-potency FGAs are associated with: Lower risk of EPS High degree of sedation High risk of orthostatic hypotension and tachycardia High risk of anticholinergic effects Moderate risk of weight gain Low risk of metabolic effects High risk of sexual side effects Chlorpromazine (lower potency) Thioridazine - Mellaril Black Box Warning o QT Prolongation Loxapine Perphenazine Fluphenazine Available in 2-week deconoate (Prolixin) Haloperidol Haldol (higher potency) Class - Butyrophenone Also used for tics and vocal outbursts due to Tourette syndrome Formulations o Tab o Solution o IV o Deconoate (monthly), o IM (only for conversion from PO) Use 10-20x the oral dose
Trifluoperazine Thiothixene
2 week injection o Side effects o EPS High Risk o Prolactin o Sexual dysfunction o Orthostasis o Weight gain, increased lipids, and glucose o QT prolongation Quetiapine Seroquel, Seroquel XR o Take once daily at night o Must have eye exam for cataracts at beginning of therapy o Drug of choice for pts with Parkinsons o Seroquel XR Taken at night without food or light meal o Side Effects Sedation Orthostasis Weight gain Increased lipids, and glucose o Low risk of EPS Ziprasidone Geodon o Available in acute injection o Watch for QT Prolongation o Contraindicated with QT risk o No metabolic issues Aripiprazole Abilify o Also 5HT1a partial agonist o IM injection and ODT o No metabolic issues or QT risk o Side effects o Anxiety o Insomnia o Constipation o Least Sedating Paliperidone Invega o Active metabolite of Risperidone o Available in OROS delivery system o Invega Sustenna o Long acting Monthly injection o Side Effects o Increased Prolactin o High risk of EPS o Tachycardia, Headache, Sedation, Anxity o Prolongs QT interval
o Metabolic issues Ilooperidone Fanapt o Prolongs QT interval o Must titrate slowly Asenapine Saphris o Only Sublingual formulation o No food/drink for 10 min after dose o Side effects o Somnolence o Tongue/mouth numbness o EPS o Prolonged QT interval Lurasidone Latuda o Side effects o QT risk o Metabolic issues Agents that cause QT prolongation/Arrhythmias Ziprasidone - Geodon Risperidone - Rispiradal Paliperione - Invega Iloperidone Asenapine - Saphris Lurasidone - Latuda Thioridizine (BBW) SGAs are associated with: Weight gain and metabolic effects( lipids, glucose levels) o Clozapine - Clozaril o Olanzapine Zyprexa (highest Risk) o Quetiapine - Seroquel o Risperidone - Risperidal o paliperidone - Invega Agents that increase Prolactin levels Can cause galactorrhea, gynecomastia, osteoporosis, irregular periods. Risperidone - Risperidal Paliperidone - Invega Agents with increased risks of Tardive Diskenisia Risperidone - Risperidal Paliperidone - Invega Lowest risk: o Quetiapine Seroquel
DOC for Parkinson Disease o Clozapine - Clozaril Risperidone is the only generic currently available SGA MOA Primarily dopamine receptor blockers. o All First Generation Antipsychotics All SGAs block Dopamine2 and Serotonin2a receptors. o Aripiprazole is a Dopamine and serotonin1a and partial agonist and serotonin2a antagonist Black Box Warning Increased risk of mortality in elderly patients with dementia-related psychosis, primarily due to an increased risk of stroke