Anti-Psychotics Part II Flashcards by Joshua Borkosky

What is the mechanism of action of atypical anti-psychotics and how is this clinically relevant?

Antagonize serotonin-2A –> makes them better at treating negative symptoms

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T/F: Atypical anti-psychotics increase depression.

False: The serotonin-2A receptor has no impact on depression

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In addition to psychosis, what is the other indication for atypical anti-psychotics?

Bi-polar manic phase –> insomnia, risky behavior, grandiosity, etc.

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What common medication can trip a manic episode in bi-polar patients?

SSRIs or other antidepressants

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What are the disadvantages of atypical anti-psychotics?

Weight gain, even more than typical anti-psychotics
Acceleration of development of DM
Hyperlipidemia –> increase cardiovascular morbidity and mortality in patients older than 65
Cost

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What are the advantages of atypical anti-psychotics?

Less risk of EPS
Treats negative symptoms
Available in a variety of dosage forms (helps with adherence)

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List groups of atypical antipsychotics that are “related”.

Risperidone and Paliperidone
Olanzapine, Quetiapine, and Clozapine
Aripiprazole and Brexiprazole

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What are the effects of quetiapine at various doses?

Low dose: hypnotic (great for insomnia)
Medium dose: antidepressant
High dose: anti-psychotic

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What are the main advantages and disadvantages of quetiapine?

Adv: very low risk of EPS and hyperprolactinemia
Disadv: causes weight gain

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What was the first atypical anti-psychotic?

Clozapine

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T/F: Clozapine is commonly used. State why or why not.

False: Used last line because it has 5 black box warnings

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What are the black box warnings associated with clozapine?

Agranulocytosis (monitor WBC count)
Orthostatic hypotension
Seizures
Increased mortality in elderly with dementia related psychosis
Myocarditis/cardiomyopathy

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What is the advantage of utilizing olanzapine?

It is structurally similar to clozapine but it has no black box warnings

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What is the major disadvantage of olanzapine?

Significant weight gain –> decreases adherence

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What are the primary advantages and disadvantages of risperidone?

Adv: less weight gain
Disadv: significant hyperprolactinemia (must monitor prolactin level)

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What S/S result from hyperprolactinemia?

Galactorrhea, sexual dysfunction, bone density changes

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What are the indications for use of risperidone?

Schizophrenia in adults and adolescents
Acute bipolar mania
Behavioral disturbances in autistic children

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What is the difference between paliperidone and risperidone?

Same effects –> paliperidone is an active metabolite of risperidone

When would you prescribe paliperidone over risperidone?

If the patient could not tolerate risperidone, they may be able to take paliperidone since it is an active metabolite of risperidone.

What are the advantages of lurasidone?

Less sedating and low metabolic risk (less weight gain, hyperlipidemia, etc.)

How is lurasidone administered?

Taken with a 500 calorie meal to increase absorption

What is the advantage of ziprasidone?

Low risk of metabolic effects

What are the advantages and disadvantages of aripiprazole?

Adv: low risk of: weight gain, hyperprolactinemia, sedation, and dyslipidemia
Disadv: high cost

T/F: Aripiprazole is a commonly used atypical anti-psychotic.

True –> one of the cleanest anti-psychotics

What is an additional use of aripiprazole in addition to its use as an anti-psychotic?

Added to an SSRI/SNRI for severe depression

What effect will administration of anti-psychotic medications have on Parkinson's Disease?

Worsen Parkinson's because anti-psychotics decrease dopamine

What drug can be given for psychosis in a Parkinson's patient and why?

Pimavanserin --> modulates hallucinations and delusions without antagonizing dopamine

What is the primary indication for administration of Lithium?

Mood stabilizer in bi-polar disorder

If Lithium is not used for bi-polar disorder, what other class of medications is likely used?

Anti-psychotics

Describe and state the dose range of Lithium and state what affect this has on patient management.

It has a narrow therapeutic window --> 0.4 - 1.0 mmol/L. | Monitor serum Li weekly until stabilized.

What affect will most diuretics have on serum lithium levels?

Lithium has an inverse relationship with Na. Diuretics waste Na causing lithium levels to rise.

When are therapeutic effects seen after lithium administration is started?

2-3 weeks after the drug is started

What are the AEs of Lithium?

Fine tremor, polyuria, polydipsia, hypothyroidism, weight gain, metallic taste, rash

What is the hallmark sign of lithium toxicity?

Coarse tremor

What serum lab must be monitored in patients on lithium and why?

TSH --> monitor for elevation of TSH as indication of hypothyroidism

Name an anti-epileptic medication that has an off label use for agitation.

Valproic acid --> not first line for agitation

What are the AEs of valproic acid?

Alopecia, weight gain, sedation

What serum levels must be monitored in patients taking valproic acid?

Serum valproic acid, LFTs, ammonia if hepatic encephalopathy is suspected

Describe the dosing availability of valproic acid.

Available in many dosage forms --> PO tablets, capsules, oral syrup, IV, etc.

What are the concerns of using second generation anti-psychotics in patients over 65 years of age?

Increased morbidity and mortality from cardiovascular events | Increased rates of metabolic syndrome --> dyslipidemia, development of DM, etc.

Describe the use of anti-psychotic medications in pregnancy.

Can't use anti-psychotics in the third trimester - should try to avoid throughout pregnancy

List some drugs that sound like anti-psychotics but are not anti-psychotics.

Brand name Zyrtec (antihistamine) sounds like Zyprexa Clonazepam (BZD) sounds like Clozapine All the PPIs sound like Aripiprazole

Name all the drugs approved by the FDA for treatment of tardive dyskinesia.

Only one --> valbenazine

What is the mechanism of action of valbenazine?

Vesicular Monoamine Transporter-2 (VMAT-2) inhibitor