Mid-Ohio Psychological Services, Inc. Staff Training: Psychopharmacology Daniel DiSalvo, CNP...

Mid-Ohio Psychological Services, Inc. Staff Training:

Psychopharmacology

Daniel DiSalvo, CNPFebruary 8, 2008

Outline Welcome, Introduction & Lunch Content

Pharmacodynamics/kinetics & Basic Principles Antidepressants

MAOIs, TCAs SSRIs SNRIs Other

Mood Stabilizers Antipsychotics

Discussion Question & Answer Conclusion

Psychopharmacology The study of the effects of drugs

on affect, mood, cognition and behavior and the use of drugs to treat disorders of the central nervous system where it is the expressed intent to alter mood, thought or behavior.

The Concept of Chemical Imbalance

NT in deficit in excess

acetylcholine memory impairment/delirium aggression/depression

dopamine dementia/depression psychosis/anxiety/ confusion/aggression

serotonin depression/impulsivity/anxiety anxiety

norepinephrine depression/anxiety/dementia anxiety/aggression

GABA anxiety/impulsivity cognitive/motor slowing

glutamate cognitive slowing/dementia seizures/neuronal

degeneration

The Basis of Psychopharmacology

Correcting the chemical imbalance – either increasing or decreasing activity of that

NT. For disorders associated with

hypofunctioning:1. Stimulate NT release2. Use chemical (drug) that mimics NT3. Block metabolic inactivation of NT4. Block reuptake For disorders associated with

hyperfunctioning:1. Inhibit or reduce NT release2. Block target receptors

Antidepressants >8 different pharmacological MOAs >2 dozen ADs Most block monoamine reuptake Some block alpha-2 receptors Others might work on the enzyme MAO Some have direct actions on only one

monoamine NT system, while others work on multiple monoamine NT systems

The immediate pharmacological actions of all ADs eventually have the effect of boosting the levels of monoamine NTs

Why Does It Take So Long?

Down Regulation: no matter what their initial actions on receptors and enzymes, ADs eventually cause a desensitization of key NT receptors in a time course consistent with the delayed onset of AD action of these drugs.

Delayed actions of ADs may not only explain the delay in onset of therapeutic action of ADs; they may also explain why some patients fail to respond to ADs, as…

It is possible that in such patients the initial pharmacological actions are not translated into the required delayed pharmacologic and genetic actions.

Function Pharmacokinetics: How the body acts on the drug. Pharmacodynamics: How the drug acts on the body,

especially the brain. Drug is absorbed and delivered through the gut wall to

the liver to be biotransformed so that it can be excreted.

CYP450: enzyme in the gut wall or liver converts the drug substrate into a biotransformed product in the bloodstream.

After the passing through the gut wall and liver, the drug will exist partly as unchanged drug and partly as biotransformed drug.

CYP450 Systems

1A2Substrates of this enzyme:clomipramineimipramine

Biggie for ADs

fluvoxamine inhibits

2D65-10% of Caucasians are poor metabolizers

Several SSRIs are inhibitors (paroxetine, fluoxetine – most)

2C920% of Japanese and Chinese persons

3-5% of Caucasians

2C19Inhibitors: bupropion, fluphenazine, sertraline

Inducers:carbamazepine, ethanol, phenytoin, St. Johns’ wort

3A4Some BDZs are substrates

Some ADs are inhibitors (nefazodone)

Mood stabilizers

Classical ADs: MAOIs & TCAs

MAOIs – the very first! 1950s, 1960s Anti-TB drug Great for panic and social phobia Used to stop ‘em…dead! Subtypes: A (depression – 5-HT, NE),

B (anti-neurodegenerative - Parkinson’s) Hypertensive crisis

MAOI Diet Cheese pizza, sour cream, yogurt, and all cheeses except

cream and cottage Beef and chicken livers, unrefrigerated fermented

sausage, summer sausage, bologna, salami, pepperoni, tofu, pickled fish/herring, lox caviar, dried salted herring/other smoked fish

Broad bean pods, fava beans, Italian green beans, snow pea pods, sauerkraut, avocados

Chocolate cake, cookies, ice cream, pudding, chocolate candy

Chianti, sherry, red, burgundy, ale, beer, vermouth, Reisling, liqueurs

Salad dressings with cheese or MSG Brewer’s yeast/yeast extract (e.g., some soups, sauces,

gravies), MSG, meat tenderizers , soy sauce.

MAOI Medication Interactions Sympathomimetics General anesthetics Local or spinal anesthetics w/ epi (e.g., Novocaine) OTC cough, cold and sinus w/ sympathos (e.g.,

Actifed, Sudafed, Contact, Dristan, Afrin, NyQuil, Dimetapp, Triaminic, etc.)

Demerol and other narcotics containing codeine, morphine, hydrocodone (e.g., Percocet, Percodan)

Cocaine Macrolantin Other ADs

MAOIs-ADrug Form Generic Daily

DoseMax Price

(qd dose)

Marplan

10mg tab

No 30mg 60mg $2.45

Nardil 15mgtab

No 60mg 90mg $2.64

Parnate

10mgtab

No 40mg 60mg $3.94

MAOIs-B & RIMAs Selegiline – parkinsonism…

Emsam (selegiline): greater affinity for B, but works on both at AD doses

6/9/12mg transdermal/qd – no restrictions at 6

RIMAs not available in US Manerix – few dietary restrictions

Pharmacological Actions - MAOIs

Readily absorbed through GI Peak plasma in 2hr. T ½ is 2-3hr. Irreversibly inactivate MAOs – i

dose can last for 2w.

Therapeutic Indications –MAOIs

Depression, esp. that associated with mood reactivity, extreme sensitivity to interpersonal loss or rejection, prominent anergia, hyperphagia, hypersomnia (atypical features)

Also great for panic, PTSD, AN, BN, SP and pain syndromes.

Refractory Panic (high) OCD (none) GAD (moderate) BDD (moderate)

Precautions & Adverse Reactions – MAOIs

Orthostasis, insomnia, weight gain, edema, sexual dysfunction

(divide dose, increase fluids/salt, support stockings, take in a.m., add sleep agent, or…switch)

HTN crisis w/o tyramine (Parnate) – avoid Taper and wait for >2w w/ a switch

Paresthesias, myoclonus, muscle pains Pyridoxine 50-150mg/d

Less cardiotoxic, epileptogenic compared to TCAs Caution, though, w/ renal, CV and hyperthyroidism May alter dosage of a hypoglycemic agent Associated w/ induction of mania in pts. in depressed

phase of BPAD I and triggering psychotic decompensation in scz

Contraindicated in pregnancy/nursing

Precautions & Adverse Reactions – MAOIs OD: agitation coma w/

hyperthermia, HTN, tachypnea, tachycardia, dilated pupils and hyperreflexia, involuntary movements (face, jaw) Asymptomatic 1-6hrs. acidify urine, dialyze Multi-drug (esp. 5-HT) – increase effects

Precautions & Adverse Reactions – MAOIs Labs:

DM meds (hypoglycemia) minimal, false elevation of TFTs Periodic LFTs

TCAs Wide range: MDD, Panic, GAD, PTSD, OCD, EDs, Pain

Syndrome Yet, very toxic and we have alternatives Significant FPE Peak plasma 2-8hrs T ½ 10-70hrs 2D6: (Is) quinidine, cimetidine, fluoxetine, sertraline,

paroxetine, phenothiazines, carbamazepine, some antiarrhymics (propafenone, flecainide)

Block reuptake of NE, 5-HT Competitive antagonists of muscarinic acetylcholine,

H1, alpha-1, -2 Use if cannot tolerate anxiety/GI upset (SSRIs)

TCAs – Approved / Off-Label Uses

MDD: induce mania in susceptible pts. (compared to bupropion, SSRIs)

Panic: imipramine, yet anxiogenic, so start low, go slow GAD: doxepin, imipramine OCD: clomipramine (2-4w…4-5m) and depressed pts.

w/ marked obsessive features EDs: imipramine, desipramine, clomipramine Pain: any Enuresis: imipramine Peptic ulcer: doxepin Others: narcolepsy, nightmare d/o, PTSD, sometimes

for ADHD, sleepwalking, separation anxiety, sleep terrors, premature ejaculation, movement d/os

Precautions & Adverse Reactions – TCAs

Anticholinergic, sedation, orthostasis, seizure, conduction abnormalities, weight gain

Can induce mania (over SSRIs, bupropion) May exacerbate psychotic d/os Confusion, delirium

Tachycardia, flattened T waves, prolonged QTc intervals, depressed ST segments

Don’t use w/ cardiac pts., unless other agents have failed (monitor)

Sore throat in initial stages – monitor Transient increase in LFTs vs. hepatitis

Drug Interactions – TCAs MAOIs Antihypertensives

Esimil, Ismelin (block reuptake) propranolol, clonidine (also block) Aldomet + TCA = agitation

DA blockers perphenazine = doubling of plasma [ ] of both products (add to anticholinergic SE

profile, too) Sympathomimetics

Serious CV effects CNS depressants

Opioids, EtOH, anxiolytics, hypnotics, OTC cold remedies Oral contraceptives

BCPs may decrease TCA plasma [ ] through the induction of hepatic enzymes Diamox, ASA, cimetidine, thiazide diuretics, fluoxetine, sodium bicarbonate =

increase, while ascorbic acid, ammonium chloride, barbiturates, cigarette smoking, carbamazepine, chloral hydrate, lithium decrease levels

TCA Labs Can get levels, though

Should be clinically driven

TCA Dosages / Clinical Guidelines

DRUG TABLET (mg) CAPSULES PARENTERAL (mg/mL)

SOLUTION (mg/mL)

imipramine 10, 25, 50 75, 100, 125, 150

12.5

desipramine 10, 25, 50, 75, 100, 150

25, 50

trimipramine 25, 50, 100

amitriptyline 10, 25, 50, 75, 100, 150

10

nortriptyline 10, 25, 50, 75 10/5

protriptyline 5, 10

amoxapine 25, 50, 100, 150

doxepin 10, 25, 50, 75, 100, 150

10

maprotiline 25, 50, 75

clomipramine 25, 50, 75

Clinical Guidelines of TCAs Prior to tx: PE, CBC w/ diff, lytes, LFTs, EKG (esp. women >40,

men >30)

Contraindicated in pts. w/ a QTc >450msc

Consider using newer agents 1st, esp. if pt. has an interfering medical dx

In kids, elderly – avoid, but if need to use, EKG should be monitored frequently

Those w/ chronic pain might be sensitive to initial dosing, but may benefit later

Taper to avoid cholinergic rebound syndrome

Dosing & Levels – TCAsDrug Usual Adult Dosage Range

(mg/d)Therapeutic Plasma [ ](mcg/mL)

Tofranil 150-300 150-300

Norpramin 150-300 150-300

Surmontil 150-300 ?

Elavil 150-300 100-250

Pamelor 50-150 50-150

Vivactil 15-60 75-250

Asendin 150-400 ?

Sinequan 150-300 100-250

Ludiomil 150-230 150-300

Anafranil 130-250 ?

TCAs & OD Serious, can easily be fatal NRF, <1w quantity for those at risk amoxapine – most fatal OD Sx:

agitation, delirium, convulsions, hyperreflexia, bowel/bladder paralysis, dysregulation of BP, T and mydriasis…coma, respiratory depression

cardiac arrhythmias may not be correctable, and are at risk for up to 4d s/p OD d/t long T ½

SSRIS(the ones we know and love)

fluoxetine – 1987

Rapidly eclipsed the MAOIs/TCAs

Don’t necessarily work better, but are safer and have a less (different) SE profile

Subtle differences between compounds: T 1/2 , potency for reuptake inhibition and affinity for some other receptors

Overall, less effects on adrenergic, histaminergic and cholinergic

Pharmacologic Actions – SSRIs Selectively block the reuptake of 5-HT presynaptically Slightly different pharmacokinetic profiles, as each drug is

structurally different from the others Many are highly protein bound Varying T ½ - 24hr to several days

fluoxetine (active metabolite) = 7-15d citalopram = 1.5d sertraline / paroxetine = 1d

All are well absorbed and not generally affected by food administration except for sertraline (level may be increased w/ food)

No correlation between T ½ and time to onset All eliminated in urine as active metabolites citalopram / escitalopram – more selective for 5-HT receptor

blockade

Indications For / Off-Label Use

of SSRIs MDD – acute, single, recurrent, prevention, etc. DD, PD OCD (may need more, take longer) GAD, SP, PTSD AN, BN (APA recommends use for persistent depression after pt.’s gained wt.) BDD PMDD Children

Repetitive-type abnormalities, e.g., autism, ADHD (as adjunct), MR/DD, chronic enuresis

Other complex behavioral d/os Obesity (high dose fluoxetine) Binge eating (sertraline) Substance abuse Decrease aggressive behaviors – impulsivity / uncontrolled anger in all ages

Migraine / cluster HAs Diabetic neuropathy, facial pain, fibrositis, arthritis, RLS

Pharmacokinetic Profiles – SSRIs

Drug Time to Peak Plasma [ ]

T ½ T ½ metabolite

Time to Steady State (days)

Plasma-Protein Binding (%)

fluoxetine 6-8h 4-6d 4-16d 28-35 95

fluvoxamine

3-8h 15h -- 5-7 80

paroxetine 5-6h 21h -- 5-10 95

sertraline 4.5-8.5h 26h 62-104h 5-7 95

escitalopram

3-5h 30h 50-60h 10 90

citalopram 4h 35h 3h 7 80

Basics – SSRIs

Drug Generic/Supply Dose/Day Price Index ($ cost of dose/d)

Prozac Y/Soln, Tabs, Delayed Cap

60mg 1.10

Zoloft Y/Soln, Tabs 100mg 3.02 (brand)

Paxil Y/Soln, Tabs 40mg 2.97

Luvox Y/Tabs 200mg 5.25

Lexapro N/Soln, Tabs 20 2.65

Celexa Y/Soln, Tabs 40 2.65

Precautions & Adverse Reactions – SSRIs

¾ of pts. experience no SEs ¼ have SEs in first 2w, usually subside 10-15% are unable to tolerate

Sexual dysfunction: 50-80%, might not go away… Decrease dose; switch (bupropion, nefazodone); add

(bupropion) GI: sertraline, fluvoxamine, citalopram

N, V, D, anorexia, dyspepsia – transient? Weight gain: initially lose, but 1/3 will gain

(>20lbs.); paroxetine (d/t anticholinergic SE) HAs: 18-20% (fluoxetine – most); alternately,

SSRIs are wonderful for tension HAs/migraines


CNS Anxiety: fluoxetine (most), but then tx it Insomnia/sedation: ¼ have insomnia (fluoxetine – take in

a.m.); sertraline = fluvoxamine; citalopram/paroxetine – sedation

Tx w/ trazodone, BDZ, other off-labels Nightmares: small amount of pts. (resolves) Seizures: 0.1 - 0.2% of all pts. txd w/ SSRIs (comparable to

other ADs/placebo) EPS:

Tremor 5-10% TD (exceptionally rare) Pts. w/ well-controlled Parkinson’s – acute worsening of their motor

symptoms Bruxism (buspirone) Most common w/ fluoxetine


Anticholinergic: paroxetine (mild)

opposite of S.L.U.D. Dry mouth (up to 20%) Dose-dependent

Hematologic: Can decrease plt. function = bruisability paroxetine, fluoxetine (reversible neutropenia – rare, usually if concurrent

w/ clozapine)

Electrolyte / Glucose: Hypoglycemia (rare – DM pts. need to be careful) Hyponatremia/ADH release (also rare) – if diuresing/H2O deprived

Endocrine / Allergic: Decrease prolactin/galactorrhea (breast changes may take several months

to correct) Various rash types – 4% (d/c)


5-HT Syndrome: SSRI + MAOI or SSRI + L-tryptophan or SSRI + lithium = can raise 5-HT

concentrations to toxic levels, causing cascade of: D Restlessness Extreme agitation Hyperreflexia Autonomic instability Myoclonus Seizures Hyperthermia Uncontrollable shivering, rigidity Delirium Coma Status epilepticus CV collapse Death


5-HT Syndrome Tx: D/C offender Supportive care Nitro Cyproheptadine Methysergide Cooling blankets Chlorpromazine Dantrolene Benzodiazpines Anticonvulsants Mechanical vents Paralyzing agents


SSRI W/D: Abrupt discontinuation, esp. w/ a

shorter T ½ (paroxetine, fluvoxamine) After 6w; ends by 3w

dizziness, weakness, N, HA, rebound depression, anxiety, insomnia, poor concentration, UR Sx, paresthesias, migraine-like Sx

Tx: don’t abruptly stop; use fluoxetine

SSRIs & Labs None

SNRIs “3rd Generation” ADs 5-HT, NE – equal affinity

duloxetine, venlafaxine, mirtazapine Differences among the three:

mirtazapine – antagonist of central presynaptic alpha2-adrenergic receptors; potent antagonist of H1

venlafaxine – a little faster onset w/ rapid dose increase; great for severe MDD w/ melancholy; 1st non-bdz drug (other than buspirone) to be approved for GAD

duloxetine – compared w/ venlafaxine, it has a greater effect on 5-HT reuptake in vitro; approved for diabetic neuropathic pain

Other ADs bupropion (DA, NE) – late 80’s

augmentation, SEs, off-label, etc. be careful w/ OD and EDs – sz d/o

trazodone structurally related to nefazodone, structurally unrelated to SSRIs,

TCAs, MAOIs active metabolite is mCPP (5-HT2c agonist), is especially sedating

(off-label use), blocking H1 priapism (1:6000; surgical intervention in 33%)

nefazodone mixed 5-HT antagonist/reuptake inhibitor great for anxiety less sedation, hypotension than TCAs, trazodone

atomoxetine (NOT approved for depression) – NRI; could use off-label

Special Considerations in the Selection of an AD

Gender: women have less gastric acid / slower

emptying = slower GI absorption volume distribution = more adiposity than

lean muscle H2O retention associated w/ menses =

affects volume distribution, too PO contraceptives can alter hepatic

metabolism (TCAs)


Ethnicity: AAs slow metabolizers compared to Europeans

d/t metabolic enzyme expression AAs have higher plasma levels per dose of AD

(demonstrated most w/ TCAs) Asians are slower to metabolize nortriptyline than

other groups Minorities were less likely than

nonminorities to be offered AD treatment, independent of dx (study of CMHCs’ prescribing practices in Westchester County, NY)


Age: Elderly? Steady-state [ ] are minimally affected by

age (except paroxetine) Remember: start low, go slow

Comorbidities: Renal – dose adjustment (except fluoxetine,

sertraline) Liver – can increase levels of TCAs (monitor); give

lower doses of SSRIs; don’t use nefazodone Pregnant Women and Nursing Mothers:

Risks vs. benefits Generally safe, but be careful of w/d for neonate

Mood Stabilizers Agents that are geared at affecting

one phase of illness w/o worsening any other phase(s)

3 families: lithium anticonvulsants atypicals

Lithium 1970 Used the longest, quite frequently and is excellent

for mania, maintenance – all phases Yet non-response rate can be as high as 40% Narrow TI Structurally simple = Li+ MOA: unclear if NTs are involved, like they are in

depression tx; occurs intracellularly w/ second-messenger systems

A monocovalent cation – a direct competitior of Mg+ @ regulatory enzyme, IMPase = reduces intracellular Ca+/protein kinase C activation

Lithium lithium carbonate, Lithobid, Eskalith CR =

immediate and extended (better tolerated, convenience)

Peak plasma 1-4h T ½ 18-36h Rapid, complete absorption Low protein binding No first-pass effect 95% drug excretion by kidneys Can remit mania in many cases, but clinically

an antiepileptic or atypical is also used

Lithium – Labs / Pre-Treatment Testing

CBC Lytes KFTs TFTs EKG Pregnancy

Check level q3-6mos, as well as associated labs/EKG

Normal range: 0.5-1.5mEq/L

Lithium 150mg, 300mg, 600mg cap

$15.54, $17.77, $42.30 (#100)

Eskalith CR 450mg cap $81.97 (#180)

Adverse Effects – Lithium Narrow TI

Prolonged exposure to >2.0mEq/L: CNS impairment, renal collapse, coma, permanent brain injury, death

Tox s/s: tremor, confusion, ataxia, N, V, D, tinnitus, blurred vision, HA, dizziness.

Common SEs: N, V, D, tremor, polydipsia, polyuria, weight gain, hypothyroidism (reversible), fatigue

Drug Interactions – Lithium Increase levels

ACE Is Alprazolam Antipsychotics Fluoxetine Ibuprofen Indomethacin Naprosyn NSAIDs Some antibiotics Aldactone Thiazide diuretics

Decrease levels Caffeine Carbonic

anhydrase Is Dilor Laxatives Osmotic diuretics Atenolol Theophylline

Lithium & Pregnancy No!…? 1st trimester = Ebstein’s anomaly (1:2000) However, discuss the risk and benefit Be very clear in initial interview about

risks, as a female pt. might be well into her 1st trimester…

Retrospective studies have shown to use aggressive pharmacotherapy in the immediate PPP (90% of bipolar I females are at risk for relapse in first 2mos of PP)

Depakote / Depakene Acts at Na channels, at steps in GABA

metabolism, and on the activity of histone deacetylase

-Kote “coats” Available in IR, ER Rapid absorption, reaching peak plasma in 2-4h Bioavailability unaffected by food, though

absorption may be delayed Rapid distribution and high (90%) plasma protein

binding T ½ 9-16h

Depakote / DepakeneUses / Indications

Bipolar I d/o Acute, maintenance, prophylaxis

SCZ (off-label) IED, kleptomania, other behavioral

dyscontrol syndromes Physical aggression, restlessness, agitation Also off-label for anxiety d/os such as panic,

PTSD, OCD, BN MDD EtOH, sedative/hypnotic w/d; cocaine detox Borderline PD

Depakote / Depakene – Pre-Treatment / Labs

CBC w/ diff., LFTs, check levels and associated labs q3-6mos

Level: 50-100mcg/mL, but be clinically-driven

Check for bleeding and bruisability

Depakote / DepakenePreparations

Depakene: 250mg caps, #100, $207.01

Depakote: 125mg tab, #180, $110.29; also available in 250mg and 500mg tabs, and in ER (which does not affect timing of lab, but affects timing of dose)

Depakote / Depakene Common SEs:

Alopecia GI upset Sedation Tremor Weight gain

Rare SEs: Acute pancreatitis Anemia Ataxia Bone marrow suppression Breast enlargement Dermatitis Diplopia, dizziness Edema Hepatotoxicity Irregular menses Leukopenia Nystagmus Parotid gland swelling Stevens-Johnson syndrome Thrombocytopenia

Depakote / DepakeneDrug Interactions

2D6 metabolism Can increase phenobarb, phenytoin,

TCAs, Retrovir, diazepam Can decrease lamotrigine,

carbamazepine DVP levels can be increased by ASA,

highly protein-bound drugs DVP levels can be decreased by

carbamazepine, Rifampin, mefloquine

Depakote / Depakene & Pregnancy / Nursing

Do not give to pregnant or nursing pts. Associated w/ neural tube defects

(e.g., spina bifida) in 1-2% of all women during 1st trimester

This risk can be reduced if FA (1-4mg/d) is taken 90d prior to and throughout gestation

Antipsychotics Rapidly expanding! Atypicals over conventionals, w/ birth of

clozapine Newer agents have less EPS, TD, cognitive

impairment, and improvement in negative Sx

Nonconventionals are used for other d/os, not just psychosis

Atypicals: Clozaril, Zyprexa, Seroquel, Risperdal, Geodon,

Abilify

Pharmacology – Atypicals All have affinity for DA, but vary in potency 5-HT2a > D2 (different SE profile compared to

conventionals) Attracted to alpha1/2-adrenergic, muscarinic

acetylcholine, H1 as well Antagonize DA, 5-HT2a Rapidly absorbed from GI tract w/ extensive FPM Highly lipophilic – cross BBB Primarily metabolized by 2D6, 1A2, 3A4 & 2C19 Average T ½ is 20-24h, except for aripiprazole: 95h Parenteral form: olanzapine, aripiprazole, ziprasidone

as IR and risperidone as decanoate

Indications for Use – Antipsychotics

SCZ, Schizoaffective d/o Acute manic/mixed episodes – bipolar MDD w/ psychosis Delusional d/o Delirium Dementia MR Developmental d/o (e.g., autism) Huntington’s Tourette’s Substance-induced psychotic d/o (stimulants, PCP,

levodopa, steroids)

Preparations / Dosage – Antipsychotic

Risperdal (mg tabs 0.25, 0.5, 1, 2, 3, 4; soln; M-tabs;

RisConsta): 2-8mg/d Geodon (mg caps 20, 40, 60, 80; soln): 80-200mg/d Clozaril (mg tabs 25, 100): 25-600mg/d Zyprexa (mg tabs 2.5, 5, 7.5, 10, 15, 20; Zydis; soln):

5-30mg/d Seroquel (mg tabs 25, 50, 100, 200, 300, 400): 150-

800mg/d Abilify (mg tabs 5, 10, 15, 20, 30; soln): 10-30mg/d

Drug Selection & Initiation of Treatment – Antipsychotics

Tests: height, weight, waist circum., BMI; interview about personal and family h/o diabetes or lipid dysregulation

Obtain FBS, lipid panel Is this psychotic episode consistent w/ SCZ? Have affective syndromes such as mania and depression with psychotic

features been ruled out? Is this the patient’s first episode? Previous AP exposure – efficacy and tolerability profiles? H/O EPS or TD? H/O NMS? What Sx are current predominant: + or -? H/O noncompliance/depot exposure? If AP trials have failed, were the doses/duration of tx adequate? Etc.

Side Effect Profile of SGAs

aripiprazole

clozapine risperidone

olanzapine

quetiapine ziprasidone

EPS + 0 ++ + 0 +

TD + 0 ++ + 0 +

NMS ? + + + ? +

Prolactin 0 - + 0 +++ 0 - + 0 0 - +

QTc 0 0 + 0 + ++

Hypotension + +++ + ++ ++ +

Anticholinergic 0 +++ 0 ++ + 0

Hepatic + +++ + ++ + +

Agranulocytosis 0 ++ 0 0 0 0

Sedation + +++ + ++ +++ +

Seizure 0 - + +++ 0 0 - + 0 - + 0 - +

Side Effect Profile of SGAs

S eroq ue lG e od on

R isp e rd a lA b ili fy

M on ito rfo r

M eta bo licS yn d ro m e!

W e ig h t G a inT ie rs

C lozar ilZ ypre xa

Case Study 32yo MWF who’s escorted to the clinic by her BF. Pt.’s been

c/o, and partner corroborates, that she’s been feeling quite sad lately, cannot get out of bed, has been w/ regular crying spells, is sleepless, has felt hopeless and believes she’d be better off dead. She adds that she has no health insurance and is 13w pregnant. You observe that she is nearly morbidly obese. She is not sure, but she’s been so sad that she thinks she’s been hearing her name being called and hears occasional, indecipherable whispers. She’s w/ severe GI discomfort, associated w/ her pregnancy, as well as sedation, probably within the context of both pregnancy and mood. The BF’s asking for a medication to help the pt., and the pt. is very willing to try a product.

What thoughts come to mind as far as a product for this pt.?

Discussion

Divide into small groups to process this case.

Questions, Comments, Concerns?

Thank you for your time, interest and participation.

Daniel DiSalvo614-519-4880

Mid-Ohio Psychological Services, Inc. Staff Training: Psychopharmacology Daniel DiSalvo, CNP...

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