Snapshot A 19-year-old male is brought into the ED by his parents. The patient recently started college and was living in the dorms. He struggled with school and friends and had some issues with his roommate so he moved back home. His parents have noticed that he has become more reclusive and often stays in his room alone. He no longer cares for himself, and has not showered in over a month. The patient is often seen talking to himself, and when his parents ask him what he is doing he says, "It's classified information." Overview 2 classes login to view 7 more bullets Targets login to view 5 more bullets Typical Antipsychotics Overview Typical Antipsychotics High Potency Antipsychotics (in Descending Order) Advantages Disadvantages Unique Features Haloperidol Fluphenazine Perphenazine Fewer side effects of sedation and hypotension High association with extrapyramidal symptoms Able to use as long-acting depot injections Can be given IM in acute situations Chlorpromazine Lower frequency of extrapyramidal side effects Greater incidence of anticholinergic side-effects, hypotension, sedation Corneal deposits Thioridazine Lower frequency of extrapyramidal side effects Greater incidence of anticholinergic side-effects, hypotension, sedation Retinal deposits QT prolongation Typical Antipsychotics Overview login to view 5 more bullets Drugs ("haloperidol + -azines") login to view 7 more bullets Clinical use login to view 6 more bullets Toxicity login to view 38 more bullets Extrapyramidal Side Effects of High Potency D2 Blockers (Haloperidol, Fluphenazine, Perphenazine) 3 Hours: Acute Dystonia 3 Days - Weeks: Bradykinesia (Pseudo-Parkinsonism) 3 Months: Akathisia 3 Years: Tardive Dyskinesia Emergency: Neuroleptic Malignant Syndrome Muscle spams (neck, eye, diffuse) Trouble swallowing Symptoms of Parkinson's disease: tremors, bradykinesia, rigidity Sustained feeling of motion/restlessness Uncontrollable repetitive, stereotypical writhing movements, usually of the tongue High fever Muscle rigidity Unstable vitals Increased CK, K+, and WBC's NOTE: You can always decrease the dose or switch to a different antipsychotic – choose the drug with the side-effect profile that the patient can tolerate. Treatment of Side Effects 3 Hours: Acute Dystonia 3 Days - Weeks: Bradykinesia (Pseudo-Parkinsonism) 3 Months: Akathisia 3 Years: Tardive Dyskinesia Emergency: Neuroleptic Malignant Syndrome Anticholinergic medications:(benztropine, diphenhydramine, trihexyphenidyl) Anticholinergic medications:(benztropine, diphenhydramine, trihexyphenidyl) β-blockers Benzodiazepines Stop high potency D2 blockers Switch to atypicals Stop antipsychotic IV fluids Cooling Dantrolene Atypical Antipsychotics - Overview Atypical Antipsychotics Medication Unique features and side effects Risperidone High potency Usually first line Hyperprolactinemia Weight gain Olanzapine Severe weight gain Very sedating Ziprasidone Minimal to no weight gain Increased QTc Quetiapine Low potency Sedating Weight gain Useful in bipolar depression and augmentation of major depression therapy Lurasidone Minimal weight gain Useful in biploar depression Clozapine Weight gain Most effective anti-psychotic Decreased suicide risk Agranulocytosis Myocarditis Sialorrhea Orthostatic hypotension Increased seizures Aripiprazole D2 partial agonist Augmentation of major depression therapy Atypical Antipsychotics Drugs login to view 6 more bullets Mechanism login to view 1 more bullet Clinical use login to view 8 more bullets Toxicity login to view 12 more bullets