1. Mental Health Nursing: Pharmacology: Antipsychotic Medications C. Calzolari 2016

2. Antipsychotic Medications Antipsychotic medications treat the s/s of psychotic illnesses such as schizophrenia, manic and delusional disorders. These drugs do not cure psychotic illnesses: they are effective in managing symptoms as long as the patient takes them consistently. There are many adverse side effects with this class of medication. 2 categories:  Typical (First Generation) Antipsychotics (Neuroleptics)  Atypical (Second Generation) Antipsychotics (Neuroleptics)

3. Typical Antipsychotic Medications Phenothiazines Phenothiazine –Type Drugs Non phenothiazine Drugs

4. What is Phenothiazine? Phenothiazine is an organic compound. Its derivatives are used as antipsychotics. They also have antiemetic properties. They control the symptoms by blocking the transmission of dopamine. They have strong sedative properties.

5. Side Effects of Phenothiazine Derivatives Anticholinergic effects Sedation Hypotension Sexual Dysfunction Agranulocytosis Neuroleptic Malignant Syndrome (rare) Photosensitivity Extrapyramidal symptoms (EPS)

6. EXTRA… WHAT?!?! Extrapyramidal symptoms (EPS) include:  Dystonia  Akathisia  Parkinsonism  Tardive Dyskinesia

7. Anticholinergic Effects Typical symptoms include dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and decreased sweating. Other symptoms that affect the CNS are: impaired concentration, confusion, attention deficit, and memory impairment.

8. Neuroleptic Malignant Syndrome The combination of hyperthermia, rigidity, and autonomic dysregulation that can occur as a rare but serious complication of the use of antipsychotic drugs. Diaphoresis Dysphagia Tremor Incontinence Delirium progressing to coma Labile blood pressure Pallor Dyspnea Psychomotor agitation Rigidity Hyperthermia Tachycardia Shuffling gait

9. FDA WARNING In April 2005, FDA has alerted healthcare professionals that both typical and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia –related psychosis. Antipsychotics are not indicated for the treatment of dementia-related psychosis.

10. Black Box Warnings Patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk for death, as shown in short-term controlled trials; deaths in these trials appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature This drug is not approved for treatment of patients with dementia-related psychosis

11. Phenothiazines Phenothiazine –Type Drugs Thorazine (chlorpromazine)- introduced in 1954. Permitil, Prolixin (fluphenazine) Serentil (mesoridazine besylate) Phenazine, Trilafon (perphenazine) Prozine, Sparine (promazine) Mellaril (thioridazine) Stelazine (triflouperazine)

12. Phenothiazines Phenothiazine –Type Drugs Thorazine is the oldest antipsychotic drug approved by the FDA in 1954. Prolixin can cause photosensitivity. Mellaril is not to be taken if a person has irregular EKGs and is on CVS drugs. This drug is not used as a first line medicine. All drugs in the phenothiazine family should be used with caution for patients with cardiovascular, liver or renal disease. These drugs are not to be used along with CNS depressants (this includes ETOH).

13. Non-phenothiazine Drugs Taractan (chloroprothixene) Haldol (haloperidol) Loxitane (loxapine succinate) Moban (molindone HCL) Orap (pimozide) Navane (thiothixene)

14. Non-phenothiazine Drugs 3 rd category of TYPICAL antipsychotics This class of drugs was introduced with the hope that there would be less side effects. Unfortunately, the side effects of nonphenothiazines are identical to those of phenothiazines. They may have less sedative effects and less anti- cholinergic effects, BUT there is a higher incidence of EPS symptoms. Orap is used for Tourette’s disorder.

15. Atypical Antipsychotic Medications 2 nd generation of antipsychotics Clozaril (clozapine) –1st introduced in 1990. Abilify (aripiprazole) Zyprexa (olanzapine) Seroquel (quetiapine fumarate) Risperdal (risperidone) Geodon (ziprasidone)

16. Atypical Antipsychotic Medications Although the claims are that this class of antipsychotics cause less side effects, there are still significant ones to be aware of:  Neuroleptic Malignant Syndrome  Tardive Dyskinesia – can be irreversible  Significant weight gain  Altered temperature regulation  Orthostatic hypotension  Increased glucose levels  CVA in the elderly  High cholesterol and triglyceride levels  Myocarditis and agranulocytosis with Clorazil  Irregular heart rhythms with Geodon

17. Increased Prolactin Levels Seen with Typical and some atypical (esp. Risperdal) antipsychotics. Clinical manifestations of prolactin levels:  Menstrual irregularities  Sexual dysfunction  Tender breasts  OP  Weight Gain

18. Other Side Effects: Sedation Orthostatic Hypotension Weight Gain

19. Patient Education These drugs have many interactions with other drugs. Instruct the patient to keep a list of all prescription and non-prescription drugs, including herbs, supplements, teas, etc. Many of these drugs require frequent blood tests and MD visits. These drugs do not cure the disease. The patient must continue taking them even if they feel better. Teach patient how to recognize symptoms of EPS and NMS.

20. Patient Education The patient must inform the physician before undergoing any procedure or surgery that involves CNS depressants. The patient should not consume ETOH or street drugs while taking these medications. Monitor caffeine use. Teach patient to avoid extreme temperatures. Teach the patient how to avoid orthostatic hypotension.