Podcast
Questions and Answers
What is the difference in drug-acquisition costs between atypical and typical antipsychotics?
What is the difference in drug-acquisition costs between atypical and typical antipsychotics?
What is a concern regarding atypical antipsychotics?
What is a concern regarding atypical antipsychotics?
Which side effect is more likely with low-potency agents?
Which side effect is more likely with low-potency agents?
What is a characteristic of sedation as a side effect?
What is a characteristic of sedation as a side effect?
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Which patients should receive a high-potency agent?
Which patients should receive a high-potency agent?
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What is a manifestation of EPS?
What is a manifestation of EPS?
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What is the best option for treating akathisia?
What is the best option for treating akathisia?
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What may play a role in reducing akathisia symptoms?
What may play a role in reducing akathisia symptoms?
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What blocks prolactin secretion?
What blocks prolactin secretion?
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What is a common side effect of low-potency antipsychotics?
What is a common side effect of low-potency antipsychotics?
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What is a characteristic of Second-Generation Antipsychotics (SGAs)?
What is a characteristic of Second-Generation Antipsychotics (SGAs)?
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What is a side effect of dopamine blockers?
What is a side effect of dopamine blockers?
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What is a characteristic of high-potency FGAs?
What is a characteristic of high-potency FGAs?
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What is the first atypical antipsychotic?
What is the first atypical antipsychotic?
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What is a common side effect of antipsychotics in men?
What is a common side effect of antipsychotics in men?
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What is a characteristic of SGAs?
What is a characteristic of SGAs?
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What is the recommended period for tapering and discontinuing the first antipsychotic when switching to another?
What is the recommended period for tapering and discontinuing the first antipsychotic when switching to another?
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What is a key factor in selecting an antipsychotic medication?
What is a key factor in selecting an antipsychotic medication?
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What is the primary route of administration for antipsychotic medications during the acute phase?
What is the primary route of administration for antipsychotic medications during the acute phase?
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What is a key consideration in dosing antipsychotic medications?
What is a key consideration in dosing antipsychotic medications?
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What is the primary difference between typical and atypical antipsychotic agents?
What is the primary difference between typical and atypical antipsychotic agents?
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What is a major influence on safe and effective antipsychotic selections?
What is a major influence on safe and effective antipsychotic selections?
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What is the primary goal of titration in antipsychotic therapy?
What is the primary goal of titration in antipsychotic therapy?
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What is a key consideration in selecting an antipsychotic medication in terms of pharmacokinetics?
What is a key consideration in selecting an antipsychotic medication in terms of pharmacokinetics?
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What is the primary goal of treatment?
What is the primary goal of treatment?
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What is performed before treatment?
What is performed before treatment?
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What is a benefit of nonpharmacologic interventions?
What is a benefit of nonpharmacologic interventions?
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What is the first-line agent for treating schizophrenia?
What is the first-line agent for treating schizophrenia?
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What is the difference between first-generation and second-generation antipsychotics?
What is the difference between first-generation and second-generation antipsychotics?
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What is the goal during the first 7 days of treatment?
What is the goal during the first 7 days of treatment?
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What is the dose range for first-episode psychosis?
What is the dose range for first-episode psychosis?
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What is done during initial therapy?
What is done during initial therapy?
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What side effect is cariprazine associated with, particularly at initiation and with dose increases?
What side effect is cariprazine associated with, particularly at initiation and with dose increases?
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What is the incidence of weight gain with cariprazine over 6 weeks?
What is the incidence of weight gain with cariprazine over 6 weeks?
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What is a common side effect of iloperidone?
What is a common side effect of iloperidone?
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What is lurasidone associated with?
What is lurasidone associated with?
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What is the maximal daily dose of lurasidone?
What is the maximal daily dose of lurasidone?
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What is a common side effect of olanzapine?
What is a common side effect of olanzapine?
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What is olanzapine similar to in terms of structure and pharmacologic profile?
What is olanzapine similar to in terms of structure and pharmacologic profile?
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What condition is olanzapine associated with, along with clozapine?
What condition is olanzapine associated with, along with clozapine?
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Study Notes
Goals of Treatment
- Alleviate target symptoms, avoid side effects, improve psychosocial functioning and productivity, achieve compliance with the prescribed regimen, and involve the patient in treatment planning.
Diagnosis
- Perform a mental status examination, physical and neurologic examination, complete family and social history, psychiatric diagnostic interview, and laboratory workup (CBC, electrolytes, hepatic function, renal function, ECG, fasting serum glucose, serum lipids, thyroid function, and urine drug screen) before treatment.
Nonpharmacologic Interventions
- Often combined with drug treatment and can provide additional benefits in relapse prevention, improved coping skills, better social functioning, and ability to function more independently.
- Should be started as early as possible, even during the management of an acute episode.
Antipsychotics
First-Generation Antipsychotics (FGAs)
- Include older antipsychotics, such as phenothiazines.
- Examples: chlorpromazine.
Second-Generation Antipsychotics (SGAs)
- Also called atypical antipsychotics.
- Include newer agents, starting with clozapine.
- Adverse effect profile is more heterogeneous and differs from that of FGAs.
Initial Therapy
- Goals during the first 7 days: decreased agitation, hostility, anxiety, and aggression, and normalization of sleep and eating.
- Dose range for first-episode psychosis is about 50% of that for chronically ill patients.
Maintenance Therapy
- Titrate over the first few days to an average effective dose.
- When switching from one antipsychotic to another, taper and discontinue the first over 1 to 2 weeks while initiating and tapering up the second antipsychotic.
Selection of an Antipsychotic
- Based on factors such as prior experience (efficacy and side effects), medical comorbidities, ease of attaining a therapeutic dose, available dosage forms, medication adherence history, long-term treatment planning, and formulary or cost considerations.
Efficacy
- Antipsychotics have consistently been found to be superior to placebo in treatment trials of patients with schizophrenia.
- Typical antipsychotic agents are believed to be equally effective when used in equivalent doses.
Dosage Forms
- During the acute phase, pharmacotherapy is administered orally (as capsules, tablets, or liquid concentrate) or intramuscularly (IM), depending on the patient's willingness to take medication, the risk of imminent harm, and dosage-form availability.
Pharmacokinetics and Drug Interactions
- Dosing considerations have a major influence on safe and effective antipsychotic selections.
- Factors include the number of times a day a medication needs to be administered, the difference between a starting dose and a "target" therapeutic dose (titration required), and the risk for drug–drug interactions.
Pharmacoeconomic Considerations
- Drug-acquisition costs for atypical antipsychotics can be 100-fold higher than typical antipsychotics, and concerns have been raised about the cost of atypical antipsychotics and whether their theoretical advantages over typical agents are worth their increased cost in the management of schizophrenia.
Adverse Effects
- Potential risks for adverse events such as EPS, anticholinergic side effects, cardiovascular effects, metabolic effects, and hyperprolactinemia.
- Factors influencing adverse effect profiles include:
- Sedation: More likely with low-potency agents.
- Anticholinergic effects: Dry mouth, constipation, blurred vision, and urinary hesitancy.
- Orthostatic hypotension (OH): Low-potency agents block the α-adrenergic receptor, which can cause OH.
- EPS: Four main manifestations – Parkinsonism, dystonia, akathisia, and tardive dyskinesia.
- Weight gain: Up to 40% of patients, with low-potency agents having a higher risk.
- Sexual dysfunction: Erectile dysfunction, loss of libido, and anorgasmia may occur in men and women.
First-Generation Antipsychotics (FGAs)
- Can be categorized according to chemical class or potency as antagonists at the dopamine D2 receptors.
- Potency at D2 receptors can be split into low and high potency.
Second-Generation Antipsychotics (SGAs)
- Developed to reduce EPS adverse effects and tardive dyskinesia and to improve efficacy.
- Share at least three characteristics: lower risk of EPS, reduced risk of tardive dyskinesia, and ability to block serotonin-2 receptors.
Clozapine (Clozaril)
- The first "atypical" antipsychotic.
- Associated with dose-related OH, particularly at initiation and with dose increases.
Cariprazine (Vraylar)
- Limited studies suggest a low rate of weight gain (1%–8% incidence).
- Additional adverse drug reactions include GI symptoms, somnolence, dizziness, parkinsonism (13%–21%), and seizures.
Iloperidone (Fanapt)
- Appears to have a lower risk of metabolic effects.
- Has a higher risk of orthostasis but a lower risk of EPS, anticholinergic symptoms, and sedation.
- Short- and long-term studies have also shown an association with QTc prolongation similar to that of haloperidol and ziprasidone.
Lurasidone (Latuda)
- Has a low risk of metabolic and cardiac effects.
- Dose-related EPS may occur.
- Recommended starting dose for moderate and severe renal impairment and when used with a moderate CYP3A4 inhibitor is 20 mg, and the maximal dose is 80 mg.
Olanzapine (Zyprexa)
- Structurally similar to clozapine and has a similar pharmacologic profile.
- Associated with extreme sedation and delirium.
- Carries a high risk of diabetes, similar to clozapine.
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Description
This quiz covers the goals of treatment in psychiatry, including alleviating symptoms, improving functioning, and involving patients in treatment planning. It also discusses the importance of pre-treatment examinations and laboratory workups.
