Definition of dystonias
Prolonged contraction of muscles during drug initiation, including painful muscle spasms
Definition of akathisia
restlessness with anxiety and inability to remain still
Definition of parkinsonism
looks similar to parkinson disease, with tremors, abnormal gait and bradykinesia
Definition of tardive dyskinesias
abnormal facial movements, primarily in the tongue or mouth
Definition of dyskinesias
abnormal movements, more common with dopamine replacement for parkinson disease
What is schizophrenia
chronic, severe and disabling thought disorder
Common symptoms of schizophrenia
hallucinations, delusions, disorganized thinking/behavior
Definition of hallucinations
sensing something that is not present, such as imaginary voices
Definition of delusions
a belief about something real that is not true, such as imagining that your family (which is real) wishes to hurt you (delusion)
Definition of disorganized thinking/behavior
inability to focus attention and communicate organized thoughts
How is schizophrenia diagnosed
based on behavior which includes both negative and positive signs and symptoms
Schizophrenia pathophysiology
includes altered brain structure and chemistry, primarily involving dopamine, serotonin and glutamate
Negative signs and symptoms
loss of interest in everyday activities, lack of emotion (apathy), inability to plan or carry out activities, poor hygiene, social withdrawal, loss of motivation (avolition), lack of speech (alogia)
Positive signs and symptoms
hallucinations (auditory, visual, somatic), delusions, disorganized thinking/behavior, difficulty paying attention
Medications that can cause psychotic symptoms
anticholinergics, dextromethorphan, dopamine agonists, interferons, stimulants, systemic steroids, illicit/recreational substances, cannabis
Antipsychotics primarily block
dopamine receptors (newer antipsychotics also block serotonin and other receptors)
Decreasing dopamine activity helps control psychosis but
negatively affects dopamine pathways involved in focus, attention and movement
What class of medications are used first-line due to a lower incidence of EPS
second generation antipsychotics (SGAs)
Benefits of long-acting injections
eliminate the need for daily oral tablets or capsules. They are given IM
Benefits of orally disintegrating tablets (ODTs)
useful with dysphagia (difficulty swallowing) and prevents cheeking
Benefits of oral solutions/suspension
useful with children and people with a feeding tube
Benefits of acute IM injections
provide "stat" relief to calm down an agitated, psychotic patient
IM antipsychotic are often mixed with
other drugs in "cocktail" such as BZDs (anxiolytic/sedative effects) and anticholinergics (to reduce dystonia)
Why should olanzapine and BZDs not be given together
due to risk of excessive sedation and breathing difficulty
How do first generation antipsychotics work
mainly by blocking dopamine (D2) receptors with minimal serotonin receptor blockade
Low potency FGAs
chlorpromazine and thioridazine
Mild potency FGAs
loxapine and perphenazine
High potency FGAs
haloperidol, fluphenazine, thiothixene, trifluoperazine
Brand name of haloperidol
Haldol
Treatment/prophylaxis for dystonia
anticholinergics (benztropine), diphenhydramine
Treatment for akathisia
BZDs and propranolol
Treatment for tardive dyskinesia
stop the drug and replace with an SGA with low risk of EPS
MOA of SGAs
block dopamine (D2) and serotonin (5-HT2A) receptors
Which SGAs are D2 and 5-HT1A partial agonist
aripiprazole, brexpiprazole and cariprazine
Abilify Maintena is a
IM suspension given monthly
Brand name of clozapine
Clozaril
When can clozapine be prescribed
only if failed to respond to 2 standard AP treatments or had significant ADRs
Brand name for lurasidone
Latuda
Brand name for olanzapine
Zyprexa
Brand name for paliperidone
Invega
Brand name for risperidone
Risperdal
Brand name for ziprasidone
Geodon
Paliperidone is the active metabolite of
risperidone
Brand name for cariprazine
Vraylar
Brand name for asenapine
Saphris
Invega Sustenna is a
IM injection given monthly
Invega Trinza is a
IM injections given every 3 months
Invega Hafyera is a
IM injection, given every 6 months
Which risperidone is an IM injection given every 2 weeks
Risperdal Consta
SGA metabolic side effects
weight gain, increased cholesterol, increased triglycerides, increased blood glucose
Clozapine boxed warnings
agranulocytosis, seizures, myocarditis
Antipsychotics used for acute psychosis (STAT)
haloperidol (sometimes in combination with lorazepam and diphenhydramine), ziprasidone and olanzapine
What medication is used for psychosis in parkinson disease
Nuplazid
Generic name of Nuplazid
pimavanserin
Asenapine sublingual can cause
tongue numbness
MOA of Nuplazid
inverse agonist and antagonist at 5-HT2A receptors
First medication approved for tardive dyskinesia
Valbenazine
Brand name of valbenazine
Ingrezza
MOA of Ingrezza
reversibly inhibits vesicular monoamine transporter 2 (VMAT2) which is a transporter that regulates monoamine uptake from the cytoplasm to the synaptic vesicle for storage and release
Brand name and indication for deutetrabenazine
Austedo for tardive dyskinesia
What can occur with all antipsychotics
Neuroleptic malignant syndrome (NMS) - rare but highly lethal
Signs of NMS
hyperthermia, extrema muscle rigidity, mental status changes, tachycardia, tachypnea and blood pressure changes
Treatment for NMS
stop the antipsychotic and provide supportive care (relax muscles with BZDs, dantrolene or bromocriptine