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Update on Antipsychotics and Mood Stabilizers
David S. Rad, M.D.Medical Director, Crisis Resolution Unit
Harbor-UCLA Medical CenterAssistant Clinical Professor, UCLA
Overview
• Antipsychotics– Typicals
– Atypicals
– New Atypicals
– Long Acting Injectable
• Mood Stabilizers– Antipsychotics
– Lithium
– Anticonvulsants (seizure medications)
Medication Decision
• Prior treatment response
• Family treatment response history
• Side effects and current physical health
• Target symptomatology
Antipsychotics
• Also known as:
– Neuroleptic
– Major Tranquilizers
• Used in treatment of other conditions
– Mood disorders
• All current antipsychotic medications share dopamine blocking property
• Have other effects, however
Side effects of Antipsychotics
• Weight gain
• Metabolic changes
• Menstrual abnormalities
• Galactorhea- milk production
• Sexual Side effects:
– Anorgasmia, Lack of libido, impotence
Side Effects Continued
• Extrapyramidal Side Effects (EPS):
– Neuroleptic-Induced Parkinsonism
– Neuroleptic-Induced Acute Dystonia
– Neuroleptic-Induced Acute Akathisia
• Neuroleptic-Induced Tardive Dyskinesia
• Neuroleptic Malignant Syndrome
First Generation Antipsychotics
• Also known as:
– typical and conventional antipsychotics
• More frequent movement disorders
• Some have cardiac side effects
• Less frequent wt gain and metabolic changes
First Generation Continued
DRUG Dose (mg)
• Haldol 2• Prolixin 2• Navane 5• Trilifon 8• Stelazine 15• Moban 25• Loxipine 25• Serentil 50• Mellaril 95• Thorizine 100
Decanoate Formulation
• Lipid (fat) soluble
• More consistent concentration
• Prolixin (Fluphenazine) Decanoate
– Every 2-3 weeks
• Haldol (Haloperidol) Decanoate
– Every 3-4 Weeks
• Oral medications are still needed for the first 3-4 injections
Atypcial Antipsychotics
• Also known as:
– Second generation
• Less movement disorder side effects
• Some cause significant weight gain and metabolic changes
Clozapine (Clozaril)
• First atypical antipsychotic
• Reserved for treatment resistant Schizophrenia– May help with negative symptoms
• Significant side effects:– Agranulocytosis (bone marrow suppression)
• Weekly blood monitoring for first 6 months
• Every other week 6mo-1yr
• Every four weeks following 1yr
– Seizures
– Cardiac
Old Atypicals
• Risperidone (Risperdal) 1-6mg
• Olanzapine (Zyprexa) 5-20mg
• Qeutiapine (Seroquel) 50-600mg
• Ziprasidone (Geodon) 40-160mg
• Aripiprazole (Abilify) 5-30mg
• Paliparidone (Invega) 6-12mg
New Atypicals
• Iloperidone (Fanapt):
– 12-24mg twice a day
– Low incidence of EPS and sedation
– Intermediate risk of wt gain and diabetes
– Significant hypotension
• 1mg titration required
New Atypicals
• Asenapine (Saphris)– Sublingual formulation
• No food 20mins before and after
– 10-20mg twice a day
– Side effects:• Numbing of tongue
• Hypotension
• Sedation
• Wt gain
• Lower risk of diabetes
New Atypicals
• Lurasidone (Latuda):
– 40-80mg a day with food
– Low incidence of hypotension and sedation
– Intermediate EPS
– Good diabetes and wt gain profile
Long-Acting Injectable (LAI)
• Risperidone Microspheres (Risperdal Consta)
– IM every 2 weeks
– 25, 37.5 and 50mg injections
• Paliperidone (Invega Sustenna)
– Two loading doses separated by a week, then monthly
– 39, 78, 117, 156 and 234 mg injections
Long Acting Injectable
• Olanzapine pamoate (Zyprexa Relprevv)– 150, 210, 300 and 405 mg injections
– No requirement for overlap with oral
– Biweekly injections recommended
– Higher incidence of post injection syndrome requires extended observation following injection
• Aripiprazole (Abilify Sustenna)– 300 and 400 mg injections
– Monthly dosing
Mood Stabilizers
• Atypical antipsychotics
• Lithium
• Anticonvulsants (Seizure medications)
Atypical Antipsychotic
• RPD, OLP, QTP, ARP, ZPD, and asenapine(ASEN) are indicated in mania
• OLP + FOT, QTP work in bipolar depression
• OLP, APR, QTP, ZPR prevent relapse rates, and appear separate from the antipsychotic effects
• No antipsychotic has been proven to not be useful in bipolar disorder
Lithium
• Lithobid, Eskalith CR (450mg)• First mood stabilizer used• Dosed 600 – 2,700 mg
– Therapeutic level = 0.5 – 1.2
• Excreted by the kidneys• Side effects:
– Can affect thyroid and kidney function• Lab monitoring
– GI, urinary, skin and hair– Contraindicated in pregnancy
Valproic Acid
• Valproate, Depakote, Depakene
• 750 – 2,500mg– Blood level 50-125
• Side effects:– Can affect liver functioning
• Requires monitoring
– Sedation, wt gain, hair loss
– Polycystic ovarian syndrome
– Contraindicated with liver or pancreatic disease, and pregnancy
Carbamazepine
• Tegretol, Carbatrol,Equetro
• 400-1,200 mg/day
• Side effects:– Sedation, dizziness and GI symptoms are common
– Rare lethal rash
– Bone marrow suppression
– Long term use can affect liver, kidney and thyroid
– Contraindicated in pregnancy and can lower serum level of oral contraceptive
Lamotrigine
• Lamictal
• Works better for depression phase of Bipolar Disorder
• Most rashes are benign
• Low incidence of potentially lethal rash– Steven-Johnson syndrome
– Facial, eyes and mouth involvement
– Fever, sore throat, body pain
– Requires slow titration
Oxcarbazeine
• Trileptal
• 1,200 – 2,400 mg/day
• Side effects:
– Sedation, dizziness and GI
– Rash
– Sodium depletion