pocket psiquiatry guide[1]

7/30/2019 Pocket Psiquiatry Guide[1]

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ACP Formulary

and Pocket Guide To

Psychopharmacology

Virg

Volu

200


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The Office of Health and Quality Care in the VirginiaDepartment of Mental Health, Mental Retardationand Substance Abuse Services (DMHMRSAS or

Department) is pleased to present the publication of thefirst Formulary Pocket Guide (FPG) for the AfterCarePharmacy (ACP). This FPG provides a listing of medications

currently available for use through the DMHMRSASAfterCare Pharmacy. This FPG may not have all medicationsavailable on the market, as new medications come to marketrapidly, however we believe that what is on the formulary doesnot limit the quality of care provided to our clients. The FPGis intended to summarize guidelines and provide a referencethat includes charts and tables to enable the reader to havequick access to important information on medication use,

dosing and cost information. However, the use of the FPG isnot intended to replace sound clinical judgment.

Cost data have been included in the pocket guide. These fig-ures have been supplied for your information and not meant

to be utilized to formulate pharmacodations solely based on cost. These fto contribute to the informed decisisupports best practice values and pcomes, as an effective formulary shoucost effective drug therapy.

The FPG will be made available on SAS intranet and any updates will be aLook for additional information in th

We are interested in your feedback content of the FPG. Please notify us wimprovement, omissions or further into this Guide. Please send in your sugof Michele Thomas, Pharm.D., BCPPOffice of Health and Quality Care. Drby phone at (804) 786-9489, (804) [email protected].

James Evans MD. Medical Director;VA. DMHMRSAS

Michele Thomas Pharm.D., BCPPClinical PsychopharmacologistCentral State HospitalVA. DMHMRSAS

VA. DMHMRSAS Pharmacy Task F


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Pages

2 . . . . .ACP Therapeutic Class:Alcohol Deterrents-Insomnia

3 . . . . .ACP Therapeutic Class:Depression

4 . . . . .ACP Therapeutic Class: Psychosis & Potency Table

5 . . . . .Use of Cost Guide

6-7 . . . .ACP Formulary: Antianxiety Medications

8-9 . . . .ACP Formulary: Bipolar Disorders Medications

10 . . . .ACP Formulary: Side Effect Medications

11-15 . .ACP Formulary: Antidepressant Medications

16-20 . .ACP Formulary: Antipsychotic Medications

21 . . . .Common Antipsychotic Adverse Effects: Comparison

22 . . . .Anticholinergic Effects of Common Psychotropics

23-26 . .NASMHPD Psychiatric PolypharmacyRecommendations [abbreviated]

27-29 . .Antipsychotic Switch Methods

Pages

30-31 . .Conventional Antipsychot

31-39 . .Antipsychotic Dosing [Ad

Principles40-41 . .Treatment Resistance

41 . . . .Antipsychotic efficacy & w

42 . . . .Receptor Interactions & E

43 . . . .Clinical Signs of Excess BSecond Generation Antips

44 . . . .Mood Stabilizer / Anticon

45 . . . .Important Web links46-51 . .Generic / Trade Names of

Psychotropic Agents

52 . . . .Disclaimer

53-56 . .Notes / Important Phone

TABLE OF CONTENTS


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GENERIC NAME RELATIVE COST BRAND NAME

ALCOHOLDETERRENTS

disulfiram $$ ANTABUSE

ANXIETY

alprazolam $ XANAX

chlordiazepoxide $ LIBRIUM

diazepam $ VALIUM

hydroxyzine pamoate $ VISTARIL

buspirone $-$$ BUSPAR

lorazepam $-$$ ATIVAN

oxazepam $$$-$$$$ SERAX

GENERIC NAME RELATIVE COST

BIPOLAR DISORDERS

carbamazepine $

clozapine $lithium carbonate $

lithium carbonateext-rel tabs $

valproic acid $

lamotrigine $$

divalproex sodiumdelayed-rel $-$$

olanzapine $$$-$$$$

quetiapine $$$-$$$$

risperidone $$$-$$$$

topiramate $$$-$$$$

INSOMNIA

hydroxyzine pamoate $

temazepam $

2

ACP SUMMARY: FORMULARY BY DRUG "THERAPEUTIC" CL

Continued below


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GENERIC NAME RELATIVE COST BRAND NAME

DEPRESSION

amitriptyline $ ELAVIL

amitriptyline /perphenazine $ TRIAVIL

amoxapine $ ASENDIN bupropion $ WELLBUTRIN

clomipramine $ ANAFRANIL

desipramine $ NORPRAMIN

doxepin $ SINEQUAN

fluoxetine $ PROZAC

imipramine HCL $ TOFRANIL

maprotiline $ LUDIOMIL

nortriptyline $ PAMELOR

protryptylline $ VIVACTIL

tranylcypromine $ PARNATE

trazodone $ DESYREL

nefazodone $$ SERZONE

GENERIC NAME RELATIVE CO

fluvoxamine $$

escitalopram $$$

mirtazapine $$$$

bupropion ext-rel $$$$sertraline $$$$

paroxetine $$$$

venlafaxine ext-rel $$$$

Continued on next page


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ACP SUMMARY: FORMULARY BY DRUG "THERAPEUTIC" CLAGENERIC NAME RELATIVE COST BRAND NAME

PSYCHOSIS

chlorpromazine $ THORAZINE

clozapine $ CLOZARIL

fluphenazine decanoate $ PROLIXIN haloperidol $ HALDOL

haloperidol decanoate $ HALDOLDECANOATE

loxapine $ LOXITANE

perphenazine $ TRILAFON

thioridazine $ MELLARIL

thiothixene $ NAVANE

trifluoperazine $ STELAZINE

ziprasidone $$ GEODON

quetiapine $-$$$ SEROQUEL

risperidone $-$$$ RISPERDAL

olanzapine $$-$$$ ZYPREXA

aripiprazole $$$-$$$$ ABILIFY

risperidone long-acting injection $$$$ RISPERDAL

Potency Table:

Conventional AntipsychoHigh-Potency Mid-Potency Conventional Conventional

Haloperidol Perphenazine

Fluphenazine Loxapine

Trifluoperazine Molindone

Thiothixene

CONSTA


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The following tables on the upcoming pages representthe Virginia DMHMRSAS AfterCare Pharmacy (Va.DMHMRSAS ACP) drug prices, and cost comparisons.

Repacks are unit of use quantities repackaged at the ACP.

Available quantities are bottles of 30, 60, 90, and 120.

Cost Comparisons are per unit (tab, cap, etc.).

The Cost Guide is differentiated in two ways. First, bycolor (light green being the lowest cost, red being thehighest cost) and by the number of dollar signs withinthe color scheme. Each dollar sign represents the relative

cost of the product within the therapeutic class; the moredollars signs, the more cost, the less dollar signs, the lowerthe cost within each respective color/class. Note: costsreflect prices at time of printing & may differ slightly fromthe exact price due to rounding and/or contract negotiations.

Color Key Definition and

Green - Lowest cost (m

Yellow - Medium cost (m

Orange - Moderate cost (m

Red - Highest cost (m

Aftercare Pharmacy

Capsule

Cost per unit

Generic Available

Manufacturer

Milliter (volume)

Stock Bottle; used for cost com

Tablet


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6

ACP ACP ACP

NAME TRADE NAME VENDOR G

COSTREPACK30's

COSTREPACK60's

COSTREPACK90's


VA. DMHMRSAS (ACP) FORMULARY: ANTIANXIETY MEDS

ALPRAZOLAM ALPRAZOLAM 0.25MG TABLET ALPHARMA G 4.83 5.92 7.00

ALPRAZOLAM ALPRAZOLAM 0.5MG TABLET ALPHARMA G 5.03 6.32 7.60

ALPRAZOLAM ALPRAZOLAM 1MG TABLET ALPHARMA G 5.14 6.53 7.93

AMITRIPTYLINE AMITRIP/PERPHEN 10-2 MYLANHCL/PERPHENAZINE TABLET PHARMACEUTICALS G 5.43 7.10 8.78



BUSPIRONE HCL BUSPIRONE HCL5MG RANBAXYTABLET PHARMACEUTICALS INC G 5.00 6.26 7.51

BUSPIRONE HCL BUSPIRONE HCL 10MG TABLET IVAX PHARMACEUTICALS G 5.41 7.07 8.73

CHLORDIAZEPOXIDEHCL CHLORDIAZEPOXIDE 10MG CAP "WATSON PHARMA, INC." G 4.91 6.06 7.22




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ACP ACP ACP


COSTREPACK30's

COSTREPACK60's

COSTREPACK90's

CLONAZEPAM CLONAZEPAM 0.5MG TABLET CARACOPHARMACEUTICAL LABS G 4.22 4.68 5.15

CLONAZEPAM CLONAZEPAM 1MG TABLET CARACOPHARMACEUTICAL LABS G 4.56 5.37 6.18

CLONAZEPAM CLONAZEPAM 2MG TABLET CARACOPHARMACEUTICAL LABS G 5.01 6.27 7.53

DIAZEPAM DIAZEPAM 2MG TABLET IVAX PHARMACEUTICALS G 4.38 5.01 5.63

DIAZEPAM DIAZEPAM 5MG TABLET BARR LABS G 4.53 5.31 6.09

DIAZEPAM DIAZEPAM 10MG TABLET IVAX PHARMACEUTICALS G 4.63 5.51 6.39

HYDROXYZINEPAMOATE HYDROXYZINE PAM 25MG CAP IVAX PHARMACEUTICALS G 4.89 6.02 7.16

HYDROXYZINE

PAMOATE HYDROXYZINE PAM 50MG CAP EON LABS G 5.59 7.43 9.27LORAZEPAM LORAZEPAM 1MG TABLET MYLAN

PHARMACEUTICALS G 5.23 6.71 8.19

LORAZEPAM LORAZEPAM 0.5MG TABLET "WATSON PHARMA, INC." G 5.32 6.89 8.46

LORAZEPAM LORAZEPAM 2MG TABLET "WATSON PHARMA, INC." G 7.18 10.62 14.05

OXAZEPAM OXAZEPAM 10MG CAPSULE IVAX PHARMACEUTICALS G 8.18 12.61 17.04




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8Continued on next page

VA. DMHMRSAS (ACP) FORMULARY: BIPOLAR DISORDER M

CARBAMAZEPINE CARBAMAZEPINE 200MG MAJORTABLET PHARMACEUTICALS G 5.16 6.57 7.98

CLOZAPINE CLOZAPINE 25MG TABLET IVAX PHARMACEUTICALS G 12.41 21.06 29.72

CLOZAPINE CLOZAPINE 100MG TABLET IVAX PHARMACEUTICALS G 26.25 48.75 71.25DIVALPROEX SODIUM DEPAKOTE 250MG TABLET EC "ABBOTT

LABORATORIES, PPD" 30.83 57.92 85.00

DIVALPROEX SODIUM DEPAKOTE ER 500MG TAB SA "ABBOTTLABORATORIES, PPD" 51.39 99.02 146.66

DIVALPROEX SODIUM DEPAKOTE 500MG TABLET EC "ABBOTTLABORATORIES, PPD" 53.70 103.64 153.59

LAMOTRIGINE LAMICTAL 25MG TABLET GSK (GLAXOSMITHKLINE) 78.83 153.90 228.98




LITHIUM CARBONATE LITHIUM CARBONATE 300MGCAP ROXANE LABS INC G 5.04 6.33 7.62

LITHIUM CARBONATE LITHIUM CARBONATE 300MGTAB ROXANE LABS INC 8.46 13.18 17.89

OLANZAPINE ZYPREXA 7.5MG TABLET ELI LILLY & CO 199.28 394.82 590.35

OLANZAPINE ZYPREXA 10MG TABLET ELI LILLY & CO 248.14 492.54 736.93



ACP ACP ACP


COSTREPACK30's

COSTREPACK60's

COSTREPACK90's


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ACP ACP ACP

NAME TRADE NAME VENDOR GCOSTREPACK30's

COSTREPACK60's

COSTREPACK90's

QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 25MG TABLET PHARMACEUTICALS 44.64 85.52 126.41




RISPERIDONE RISPERDAL 1MG TABLET JOHNSON& JOHNSON HCS 89.22 174.70 260.17




TOPIRAMATE TOPAMAX 100MG TABLETJOHNSON& JOHNSON HCS

103.14 202.52 301.91TOPIRAMATE TOPAMAX 200MG TABLET JOHNSON& JOHNSON HCS 120.11 236.46 352.82

TOPIRAMATE TOPAMAX 25MG TABLET JOHNSON& JOHNSON HCS 44.55 85.35 126.15

VALPROIC ACID VALPROIC ACID 250MGCAPSULE UPSHER SMITH LABS G 8.78 13.80 18.83

*Lower doses required if co-administered with valproate


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ACP ACP ACP


COSTREPACK60's

COSTREPACK90's

VA. DMHMRSAS (ACP) FORMULARY: "SIDE EFFECT" MEDICA

AMANTADINE HCL AMANTADINE 100MG CAPSULE UPSHER SMITH LABS G 9.33 14.92 20.50

BENZTROPINEMESYLATE BENZTROPINE MES 1MG TABLET PAR PHARMACEUTICALS G 5.15 6.55 7.94

BENZTROPINEMESYLATE BENZTROPINE MES 2MG TABLET PAR PHARMACEUTICALS G 5.74 7.74 9.73

DIPHENHYDRAMINE MARLEXHCL DIPHENHYDRAMINE 25MG CAPS PHARMACEUTICALS G 4.03 4.31 4.60

DIPHENHYDRAMINE MARLEXHCL DIPHENHYDRAMINE 50MG CAPS PHARMACEUTICALS G 4.09 4.43 4.76

LORAZEPAM LORAZEPAM 1MG TABLET MYLANPHARMACEUTICALS G 5.23 6.71 8.19

LORAZEPAM LORAZEPAM 0.5MG TABLET "WATSON PHARMA, INC." G 5.32 6.89 8.46

LORAZEPAM LORAZEPAM 2MG TABLET "WATSON PHARMA, INC." G 7.18 10.62 14.05PROCYCLIDINE MONARCHHYDROCHLORIDE KEMADRIN 5MG TABLET PHARMACEUTICALS 20.95 38.14 55.34

PROPRANOLOL HCL PROPRANOLOL 20MG TABLET "PLIVA, INC." G 4.47 5.18 5.90



TRIHEXYPHENIDYL WEST-WARDHCL TRIHEXYPHENIDYL 2MG TABLET PHARMACEUTICAL CO G 5.52 7.29 9.06


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11 Continued on next page

ACP ACP ACP


COSTREPACK30's

COSTREPACK60's

COSTREPACK90's

VA. DMHMRSAS (ACP) FORMULARY: ANTIDEPRESSANTS

AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10MG TAB "QUALITESTPHARMACEUTICALS, INC" G 4.21 4.66 5.12

AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25MG TAB "QUALITEST

PHARMACEUTICALS, INC" G 4.27 4.80 5.32AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50MG TAB "QUALITEST

PHARMACEUTICALS, INC" G 4.38 5.00 5.63



AMITRIPTYLINE HCL/PERPHENAZINE AMITRIP/PERPHEN 10-2 TABLET MYLAN PHARMACEUTICALS G 5.43 7.10 8.78



AMOXAPINE AMOXAPINE 50MG TABLET "WATSON PHARMA, INC." G 14.57 25.38 36.20

AMOXAPINE AMOXAPINE 100MG TABLET "WATSON PHARMA, INC." G 22.28 40.80 59.33

BUPROPION HCL BUPROPION HCL 75MG TABLET MYLAN PHARMACEUTICALS G 8.70 13.65 18.60

BUPROPION HCL BUPROPION HCL100MG TABLET MYLAN PHARMACEUTICALS G 9.57 15.39 21.21

VA DMHMRSAS (ACP) F l A tid t


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VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from previous page

ACP ACP ACP


COSTREPACK30's

COSTREPACK60's

COSTREPACK90's

BUPROPION HCL WELLBUTRIN SR 150MG TAB SA GSK (GLAXOSMITHKLINE) 55.41 107.06 158.72

BUPROPION HCL WELLBUTRIN SR 100MG TAB SA GSK (GLAXOSMITHKLINE) 51.95 100.14 148.34

CLOMIPRAMINE HCL CLOMIPRAMINE 25MG CAPSULE TARO PHARMACEUTICALS G 5.67 7.58 9.50



DESIPRAMINE HCL DESIPRAMINE 25MG TABLET EON LABS G 8.42 13.10 17.77




DOXEPIN HCL DOXEPIN 10MG CAPSULE PAR PHARMACEUTICALS G 4.72 5.69 6.67





ESCITALOPRAM FORESTOXALATE LEXAPRO 10MG TABLET PHARMACEUTICALS 57.59 111.42 165.26

ESCITALOPRAM FORESTOXALATE LEXAPRO 20MG TABLET PHARMACEUTICALS 59.93 116.11 172.29

VA DMHMRSAS (ACP) Formulary: Antidepressants ti d f b


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VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from above

ACP ACP ACP


COSTREPACK60's

COSTREPACK90's

FLUOXETINE HCL FLUOXETINE 20MG CAPSULE "PLIVA, INC." G 4.60 5.46 6.31

FLUOXETINE HCL FLUOXETINE 10MG CAPSULE "PLIVA, INC." G 4.68 5.61 6.54

FLUVOXAMINEMALEATE FLUVOXAMINE MAL 100MG TAB EON LABS G 16.01 28.26 40.52

IMIPRAMINE HCL IMIPRAMINE HCL 10MG TABLET PAR PHARMACEUTICALS G 7.98 12.21 16.44



MAPROTILINE HCL MAPROTILINE 25MG TABLET MYLAN PHARMACEUTICALS G 10.89 18.03 25.17

MAPROTILINE HCL MAPROTILINE 50MG TABLET MYLAN PHARMACEUTICALS G 14.28 24.81 35.34

MIRTAZAPINE REMERON 30MG SOLTAB ORGANON 67.33 130.91 194.49

MIRTAZAPINE REMERON 45MG SOLTAB ORGANON 71.50 139.25 207.00

NEFAZODONE HCL NEFAZODONE HCL 200MGTABLET IVAX PHARMACEUTICALS G 10.65 17.54 24.44




VA DMHMRSAS (ACP) Formulary: Antidepressants continued from previous page


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Continued below

VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from previous page

ACP ACP ACP


COSTREPACK60's

COSTREPACK90's

NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10MG CAP TEVA PHARMACEUTICALSUSA G 4.82 5.88 6.95

NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25MG CAP "WATSON PHARMA, INC." G 5.08 6.40 7.73

NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50MG CAP TEVA PHARMACEUTICALS

USA G 5.52 7.29 9.06

NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75MG CAP TEVA PHARMACEUTICALSUSA G 6.00 8.25 10.51

PAROXETINE HCL PAROXETINE HCL 20MG TABLET MAJOR PHARMACEUTICALS G 49.56 95.36 141.17



PROTRIPTYLINE HCL VIVACTIL 5 MG TABLET ODYSSEYPHARMACEUTICALS 25.98 48.21 70.44

PROTRIPTYLINE HCL VIVACTIL 10MG TABLET ODYSSEYPHARMACEUTICALS 35.97 68.18 100.40

SERTRALINE HCL ZOLOFT 100MG TABLET PFIZER U.S. 72.71 141.68 210.64

TRANYLCYPROMINESULFATE PARNATE 10MG TABLET GSK (GLAXOSMITHKLINE) 21.99 40.22 58.46

TRAZODONE HCL TRAZODONE 50MG TABLET "PLIVA, INC." G 4.37 5.00 5.62

TRAZODONE HCL TRAZODONE 100MG TABLET "PLIVA, INC." G 4.98 6.21 7.44

VA DMHMRSAS (ACP) Formulary: Antidepressants continued from above


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VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from above

ACP ACP ACP


COSTREPACK60's

COSTREPACK90's

VENLAFAXINE HCL EFFEXOR XR 37.5MG CAP SA WYETH PHARMACEUTICALS 73.59 143.43 213.27

VENLAFAXINE HCL EFFEXOR XR 75MGCAPSULE SA WYETH PHARMACEUTICALS 81.99 160.23 238.47

VENLAFAXINE HCL EFFEXOR XR 150MGCAPSULE SA WYETH PHARMACEUTICALS 88.97 174.18 259.40


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VA. DMHMRSAS (ACP) FORMULARY: ANTIPSYCHOTICS

Continued below

ACP ACP ACP

GENERIC TRADE NAME VENDOR G

COSTREPACK30's

COSTREPACK60's

COSTREPACK90's

ARIPIPRAZOLE ABILIFY 10MG TABLET BRISTOL-MYERS SQUIBB 267.14 530.53 793.91

ARIPIPRAZOLE ABILIFY 15MG TABLET BRISTOL-MYERS SQUIBB 267.14 530.53 793.91

ARIPIPRAZOLE ABILIFY 20MG TABLET BRISTOL-MYERS SQUIBB 376.23 748.72 1,121.20ARIPIPRAZOLE ABILIFY 30MG TABLET BRISTOL-MYERS SQUIBB 376.23 748.72 1,121.20

CHLORPROMAZINE CHLORPROMAZINE 25MGHCL TABLET UPSHER SMITH LABS G 6.76 9.76 12.77







VA DMHMRSAS (ACP) Formulary: Antipsychotics continued from above


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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from above

ACP ACP ACP


COSTREPACK30's

COSTREPACK60's

COSTREPACK90's

FLUPHENAZINE FLUPHENAZINE DECDECANOATE 25MG/ML 5ML VL SICOR PHARMACEUTICAL G NA NA NA

FLUPHENAZINE HCL FLUPHENAZINE 1MG TABLET PAR PHARMACEUTICALS G 5.19 6.64 8.08

FLUPHENAZINE HCL FLUPHENAZINE 2.5MG TABLET PAR PHARMACEUTICALS G 5.29 6.83 8.37FLUPHENAZINE HCL FLUPHENAZINE 5MG TABLET PAR PHARMACEUTICALS G 5.74 7.73 9.71

FLUPHENAZINE HCL FLUPHENAZINE 10MG TABLET PAR PHARMACEUTICALS G 6.44 9.14 11.83

HALOPERIDOL HALOPERIDOL 0.5MG TABLET MYLAN PHARMACEUTICALS G 5.08 6.40 7.73

HALOPERIDOL HALOPERIDOL 1MG TABLET MYLAN PHARMACEUTICALS G 5.83 7.91 9.99



HALOPERIDOL HALOPERIDOL DECDECANOATE 50MG/ML 1ML VL SICOR PHARMACEUTICAL G NA NA NA

HALOPERIDOL HALOPERIDOL DECDECANOATE 100MG/ML 1ML VL SICOR PHARMACEUTICAL G NA NA NA

HALOPERIDOL HALOPERIDOL DECDECANOATE 100MG/ML 5ML VL BEDFORD LABS G NA NA NA

HALOPERIDOL HALOPERIDOL DECDECANOATE 50MG/ML 5ML VL BEDFORD LABS G NA NA NA

VA DMHMRSAS (ACP) Formulary: Antipsychotics continued from previous page


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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from previous page

Continued below

ACP ACP ACP


COSTREPACK30's

COSTREPACK60's

COSTREPACK90's

LOXAPINE SUCCINATE LOXITANE 5MG CAPSULE "WATSON PHARMA, INC." 34.45 65.15 95.85








PERPHENAZINE PERPHENAZINE 2MG TABLET RICHMOND G 7.85 11.96 16.06



PERPHENAZINE PERPHENAZINE 16MG TABLET IVAX PHARMACEUTICALS G 12.33 20.92 29.50

QUETIAPINE SEROQUEL 25MG ASTRA/ZENECAFUMARATE TABLET PHARMACEUTICALS 44.64 85.52 126.41

QUETIAPINE SEROQUEL 100MG ASTRA/ZENECAFUMARATE TABLET PHARMACEUTICALS 78.08 152.42 226.75

VA DMHMRSAS (ACP) Formulary: Antipsychotics continued from above


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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from above

ACP ACP ACP

GENERIC TRADE NAME VENDOR GCOSTREPACK30's

COSTREPACK60's

COSTREPACK90's



RISPERIDONE RISPERDAL 1MG TABLET JOHNSON & JOHNSON HCS 89.22 174.70 260.17




RISPERIDONE RISPERDAL CONSTAMICROSPHERES 25MG SYR 2ML JOHNSON & JOHNSON HCS NA NA NA

RISPERIDONE RISPERDAL CONSTA

MICROSPHERES 37.5MG SYR 2ML JOHNSON & JOHNSON HCS NA NA NA

RISPERIDONE RISPERDAL CONSTAMICROSPHERES 50MG SYR 2ML JOHNSON & JOHNSON HCS NA NA NA

THIORIDAZINE HCL THIORIDAZINE 10MG TABLET MYLAN PHARMACEUTICALS G 7.08 10.41 13.74




VA DMHMRSAS (ACP) Formulary: Antipsychotics continued from previous page


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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from previous page

ACP ACP ACP

GENERIC TRADE NAME VENDOR GCOSTREPACK30's

COSTREPACK60's

COSTREPACK90's

THIOTHIXENE THIOTHIXENE 1MG CAPSULE SANDOZ G 6.13 8.51 10.90

THIOTHIXENE THIOTHIXENE 2MG CAPSULE MYLAN PHARMACEUTICALS G 6.82 9.89 12.95



TRIFLUOPERAZINEHCL TRIFLUOPERAZINE 2MG TABLET MYLAN PHARMACEUTICALS G 8.13 12.51 16.89



ZIPRASIDONE HCL GEODON 20MG CAPSULE PFIZER U.S. 121.12 238.49 355.86





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COMMON ANTIPSYCHOTIC ADVERSE EFFECTS: COMPARISON / SUM

EPS Sedation TD Anticholinergic Cardiovascular Sexual Dysfunct. Prolactin W

Chlorpromazine(Thorazine) +++ ++++ ++++ +++ +++ +++ +++

Haloperidol (Haldol) ++++ + ++++ + + + ++++

Loxapine (Loxitane) +++ ++ +++ + ++ +++ +++

Aripiprazole (Abilify) + + ? - + ? -

Clozapine (Clozaril) +/- ++++ - ++++ +++ + -

Olanzapine (Zyprexa) + ++ + ++ + - +

Quetiapine (Seroquel) - ++ ? + ++ - -

Risperidone (Risperdal) ++ + + + + + +++

Ziprasidone (Geodon) + ++ + + + - ++

- Not noted + Possible + Mild / Low ++ Moderate +++ High

Bezchlibnyk-Butler & Jeffries, Clinical Handbook Psychotropic Drugs, 10th ed.; Fuller & Sajatovic, DI Handbook for PsyPuzantian & Stimmel, "Review of Psychotropic Drugs", Pharmacy Practice News, 2003; PI's: AZ, BMS, Janssen, Lilly, Pfizer

21

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ANTICHOLINERGIC EFFECTS OF COMMON PSYCHOTROP

ANTIPSYCHOTICS

DRUG COMMONADVERSE EFFECTS

Haloperidol

Molindone

Fluphenazine +

Perphenazine +

Thiothixene +

Trifluoperazine +

Loxapine +

Mesoridazine ++

Chlorpromazine +++

Thioridazine +++

Clozapine +++

ANTICHOLINERGICS

DRUG COMMONADVERSE EFFECTS*

Diphenhydramine ++

Benztropine +++

Trihexyphenidyl ++++

ANTIDEPRESSA

DRUG

Trazodone

Fluoxetine

Amoxapine

Maprotiline

Desipramine

Nortriptyline

Imipramine

Doxepin

Amitriptyline

*Anticholinergic adverse effects are related toanticholinergic action (as related to atropine); higher the

value, higher the risk. Psychotropics bolded in red are

most anticholinergic in class. Be sure to monitor for

additive anticholinergic effects between agents.

** Common GI Adverse Effects: constipation, blurredvision, N&V, dry mouth

*** Common CNS Adverse Effects: stimulation,disorientation, confusion, hallucinations,

restlessness, cognitive impairment

****Common CV Ad

Bezchlibnyk-Butler & Jef

Drugs, 10th ed.; Fuller &

Ed; Puzantian & Stimme

Pharmacy Practice News

*NASMHPD PSYCHIATRIC POLYPHARMACY RECOMMENDATI


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NASMHPD PSYCHIATRIC POLYPHARMACY RECOMMENDATIA. Before adding a second medication to a regimen,the following are considered appropriate practices:

For most psychiatric disorders, at least 2-3 trials ofmonotherapy with chemically distinct classes of agentsshould be tried prior to treatment with multiple agents.

Actual practice will vary by disorder. When polypharmacy isto be used, accepted evidence-based guidelines, if available,should be followed.

After failing therapy on single agents, the patients psychi-atric diagnosis should be reevaluated before initiating therapy

with multiple medications.

Only one medication should be changed at a time. In orderto assess the adverse effects of & therapeutic response to a med-

ication, only one actual medication trial can be monitored &evaluated at any time.

The first thing a clinician should consider when a patientdoes not respond to a medication is whether the patient istaking the medication correctly, (if at all). Therefore, con-sider the patients current adherence to treatment beforeadding medications. To increase adherence, preferenceshould be given to the simplest effective treatment regimen.

Many psychiatric medications can bfew need more than twice a day do

A single medication should be giveffective dose to produce a therincludes at least 5 half-lives at a singblood concentration, plus additionclinical response & adverse effects.

O For antidepressants & anti-anweeks are often needed to evadverse effects.

O For antipsychotics and m

months may be required foresponse / adverse effects.

An important aspect of polypharmations. A majority of psychotropic kinetic drug interactions are due toSystem (CYP450). Clinically signiare involved in problematic drug spharmacotherapy. These interaction


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24

ing. Drug-drug interactions are preventable. A clinicianshould have a comprehensive understanding of the liverenzyme system, CYP450.

The prescriber & patient should define an acceptableresponse to the new medication & what type of response

would result in discontinuance of the new medication.

The patient should be educated on how long the medica-tion will take to reach its maximum effect & the effect thenew medication is expected to produce.

The patients functioning should be considered moreimportant than treatment of the patients symptoms. Forexample, the use of sedating medications may reduce some of the patients symptoms, but may unfavorably reduce the

patients functioning.

Consider treatment alternatives, such as the use ofpsychosocial interventions, before prescribing additionalmedication.

The patients total drug load shconsider the patients ability to adhemedication regimen.

The patients ability to pay for or oshould be considered when adding

All other remedies the patient is

be addressed, including OTC mremedies, herbal remedies & illicit

The frequency and duration of phyfor appropriate assessment of respodischarged or further medication ch



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25

B. During treatment with multiple medications,these considerations should guide therapy:

The principle of start low, go slow should be followed wheninitiating new medications, particularly in elderly, pediatricpatients or medically compromised patients.

Drug interactions should be anticipated & monitored whenan additional medication is added. If an interaction drug isadded, blood levels of interacting medications should bechecked where appropriate. For example, adding fluoxetine toclozapine has been associated with at least one reported deathin the literature secondary to potential drug interaction.

The prescriber should communicate with all health careproviders involved with the patient.

Interventions to improve adherence with & access to med-ication therapy need to be identified & implemented.

For patients in an inpatient facility who have had their med-ication dose or regimen recently changed, time should beallowed for appropriate assessment of response before thepatient is discharged or further medication changes are made.

Bioethnic differences should be considered when assessing apatients response to medications.

C. After the patient has been usingconsider the following points when mon

Discontinuing medications that doresponse.

Cross-tapers initiated to switch theication to another should be compl

Patients who are using multiple mpotentially suffering from medicshould be considered for a wash-reassessment.

If possible, the medication regimendropping psychiatric medications patient close to baseline. This does n

ing all of the medications.


f f


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D. The following inappropriate use of polypharmacyshould be avoided:

Generally, same-class polypharmacy should not be used totreat the same symptoms in a patient.

More than one medication from any of the following med-ication classes should not be used in a single patient:

O Typical antipsychotics(haloperidol, fluphenazine, etc.),

O Selective serotonin reuptake inhibitors(paroxetine, fluoxetine, etc.),

O Tricyclic antidepressants(amitriptyline, imipramine, etc.),

O Monoamine oxidase inhibitors(phenelzine, tranylcypromine, etc.),

O Stimulants(methylphenidate, amphetamine),

O Benzodiazepines(diazepam, alprazolam, etc.).

More than two antipsychotic medical, should not be used simultaneou

The dose of medication should notlevels have reached steady state

achieve therapeutic effect has passe Patients should not be discharged fwithout allowing adequate time forication to be assessed. Patients on podischarge from a facility are at a higheication problems.

An increased level of monitoring &sidered when the patient is dischar

medication regimen.

* NASMHPD Technical Report on Psychiatric Polyp

Technical report originates from the National As

Program Directors.

26 Continued below

ANTIPSYCHOTIC SWITCH METHODS *NOTES *In most instances the rebound of


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27

ANTIPSYCHOTIC SWITCH METHODS NOTES

*No single crossover technique has been recognized as theaccepted protocol. Abrupt crossovers to early atypical antipsy-chotics have been unsuccessful; current accepted practicesinclude cross-titration (gradually reducing the dose of the firstantipsychotic while gradually increasing the dose of the new

antipsychotic) and slowly overlapping and tapering antipsy-chotics (maintaining the dose of the old antipsychotic untilthe new antipsychotic is at full therapeutic dose).

*The switch should be undertaken over a period of 4 to 5weeks if the switch does not involve clozapine and 7 to 8weeks if the switch involves clozapine.

*Withdrawal Symptoms. The signs and symptoms associated

with antipsychotic medication withdrawal are varied. Areemergence or worsening of psychosis, rebound or unmaskeddyskinesia, and cholinergic rebound can occur.

Reminder:

*Psychotic symptoms may be exacerbated by withdrawalsymptoms and by the patient's anxiety over switchingmedication.

In most instances, the rebound of al can be prevented by cautiously the existing antipsychotic agenantiparkinsonian drug or sedative h

*If the patient is taking an anticholnation with a conventional agent ued, the anticholinergic agent sho

over 1 to 2 weeks following discconventional antipsychotic (longertion was a depot formulation).rebound is greatest with low potewhich have stronger anticholinergic agents. It is recommended that all discontinued, if possible.

*Olanzapine and clozapine have co

gic, antiadrenergic, and antiserodrawal symptoms may be expectedrugs are discontinued.

*Medication dosage errors are commby the dosage regimens used durin

Bezchlibnyk-Butler & Jeffries, Clinical Handbook PsychotroGuidelines, J Clin Psych. 1999; 60 (suppl.11); Weiden. J Clin al., J Clin Psych 1998; 59 (suppl.19).

ANTIPSYCHOTIC [AP] SWITCH METHODS


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Abrupt discontinuation of first APand starting a new AP (e.g., stop

previous agent immediately & rapidlyincrease new agent)

Straightforward

Best for inpatient setting or wherepatients are supervised and fastcrossovers are needed

Medication errors less likely

Appropriate for patients on depotmeds secondary to long half-life

Increased chations associate

Not recommereceiving cloz

High risk of r

28

ANTIPSYCHOTIC [AP] SWITCH METHODS

1. ABRUPT DISCONTINUATION ADVANTAGES DISADVANTAG


Antipsychotic [AP] Switch Methods, continued


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29

2. CROSS TITRATION OR ADVANTAGES DISADVANTAGCROSS TAPERS

Overlap and tapering strategies(Note: slower titrations [e.g., 6 weeks ormore], result in improved effect).

A. Gradual Cross Taper (Begin todecrease dose of AP #1; at the sametime, initiate AP #2; increase dose tomaintenance over 2 to 6 weeks)

B. Full Dose CrossTitration (MaintainAP #1 dose; initiate AP #2 & increaseto maintenance; overlap & maintainstable doses for two weeks; decrease to

cessation AP #1)C. 50% Reduction Taper (Immediate50% dose decrease AP #1; simultaneousinitiation AP #2 to 50% maintenancedose; follow with gradual dose adjustmente.g., decrease AP #1 to cessation;increase AP #2 to maintenance)

Appropriate when relief from adverseeffects such as EPS is needed

Perhaps the safest method when

consequences of crossover relapse(s)are greatest concern

May be appropriate to use thecrossover time as a test period toascertain oral compliance for patientson depot antipsychotics

May be appropriate when switchingpatients who have been recentlystabilized (


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Haloperidol Perphenazine Chlorpromaz

Fluphenazine Loxapine Thioridazine

Trifluoperazine Molindone Mesoridazine

Thiothixene

30

CONVENTIONAL ANTIPSYCHOTICS: POTENCY TABLE

High Mid Low

REVIEW:

All First Generation Antipsychotics (FGA; conventionalantipsychotics) have equal efficacy; the selection of drug isbased on adverse effect profile and patient comorbidity.Conventional agents increase density of post-synaptic D2receptors (supersensitivity).A9 Tract / Nigrostriatal path

(midbrain to neostriatum),responsible for Extrapyramidal adverse effects

A 10 / Mesolimbic (midbrain to limbic structures) possiblyassociated with relief of positive symptoms / psychosis

A 10/ Mesocortical (midbrain to frontal and temporalcerebral cortex) possibly associated with relief of negativesymptoms

Adverse effects with convention

High-potency conventional agents:Dystonia

Akathisia

Parkinsonism

Low potency agentsSedationHypotension

Weight gain (molindone may producAnticholinergic symptoms (dry mou

constipation, blurred vision)

Continued below

S C O C OS G G

Continued from previous page


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Adverse effects unrelated to potency--(can occur with all D2 antagonists)Hyperprolactinemia (amenorrhea, galactorrhea, sexual

dysfunction)Tardive dyskinesiaNeuroleptic malignant syndrome

Other: Impaired heat regulation (hyper or hypothermia);pigmentary retinopathy (thioridazine >800mg/d); ECG

changes (pimozide, chlorpromazine, thioridazine)

Extrapyramidal Side Effects (EPS)

Dystonia

Involuntary muscle contraction--may involve tongue, neck,

back, eyesExtremely uncomfortable, jeopardizes future compliance

Usually occurs within first four days of neuroleptic treatment

Risk factors: young males and high-potency neuroleptics

All patients under age 30 started on high potency neurolep-tics should receive prophylaxis: benztropine 2 mg bid x 10days-then taper

ANTIPSYCHOTIC DOSING: GE

Treating first-break patients:

Avoid side effects (drug selection a Prophylax for dystonia if using con Develop alliance Educate patient and family about i

Best to use low to moderate fixed d15mg/d, risperidone 2-4 mg/d, quetiapine 300-600mg/d, zipraaripiprazole 10-15 mg/d)

An adequate trial should last 4-6 w Data suggests a rapid & early resp

of treatment

Gradual improvement seen over 4

Response of first-break patients:

Respond better than chronic patie 74% full remission; 12% partial re Respond to lower doses Early treatment associated with be


Blood levels Maintenance Treatment


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Blood levels Should not substitute for clinical titration Inconsistent evidence for haloperidol therapeutic window

(5-15 ng/mL) Approx 7% of patients (Caucasian, Asian), are slow metab-

olizers (low P450 2D6)-may develop toxic levels Blood levels useful in cases of nonresponse, noncompliance,

or drug interactionsTherapeutic Ranges

Haloperidol 5-15 ng/mL Chlorpromazine 30-100 ng/mL Fluphenazine 0.2-2.0 ng/mL Perphenazine 0.8-2.4 ng/mL Clozapine >350 ng/ml

Estimated Relapse Rates

Relapse rates in schizophrenia

Medication (N) Placebo (N)Relapse in first year 41% (814) 68% (189)Second year post discharge 15% (500) 65% (448)

C. Jackson, Pharm.D., BCPP, with permission.

Maintenance Treatment

Haloperidol conversion:10 mg/d ORAL x10-20mg = InHaloperidol time to steady stat3 months

Fluphenazine decanoate:

Conventional dose Fluphenazine dq 2wks

Low dose Fluphenazine decanoate cq 2 wks

Low dose and conventional doses odecanoate: approximately equal in in first year

Low dose produces significantly les

Conventional dose may be superiorpreventing relapse

Requires approx 4 dosing intervals Always establish tolerability with ora

Fluphenazine conversion: 10mg/d ORAL = 12.5 mg IM/SC Fluphenazine time to steady state a

32

SGAs or Atypical Antipsychotics


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33

Second Generation Antipsychotics (SGA)

SGAs share D2 & 5HT antagonismCause minimal EPSCause minimal elevation of prolactionGenerally, more effective for negative symptoms

Clozapine is the only agent clearly more effective forpsychotic symptoms

Risperidone may produce EPS and elevate prolactin athigh doses (partially atypical)

Clozapine (Clozaril) Atypical properties Minimal EPS More effective than conventional agents for Does not elevate prolactin

Pharmacology: Weak D2 antagonist Relatively greater D1 and D4 antagonism

Strongly anticholinergic Alpha adrenergic antagonist Histaminergic (H1) antagonist Serotonin (5HT2) antagonist Blocks ketamine behavioral effects (NMDA

Clinical Pharmacology Usual daily dose 300-600 mg/d (900 mg/d m Half life: 16 hrs Metabolized by cytochromes 1A2 and 3A4

Efficacy Effective in 30% of treatment-resistant patie

50% at 6 months) Prevents relapse Stabilizes mood; excellent anti-manic agent Improves negative symptoms Improves polydipsia & hyponatremia Reduces hostility, aggression, suicide Reduces cigarette smoking and substance ab

SGAs or Atypical Antipsychotics, continued


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SGAs or Atypical Antipsychotics, continued

Adverse Effects Sedation 39% (tolerance); Dizziness 19% Hypersalivation 31% (may impair swallowing) Constipation 14%; Nausea 11% Headache 11% Tachycardia 25%; Hypotension 9% (tolerance) Fever 5% (usually within first 3 wks, lasting few days)

Seizures 1-6% (related to absolute dose and rate of increase) Weight gain 30% Hypertriglyceridemia common Agranulocytosis (Granulocytes 3500 Repeat CBC if:

WBC=3000-3500 WBC drops by 3000 from previ 3 consecutive weekly drops

If WBC=3000-3500 & granuloctwice-weekly WBCs

Hold drug if WBC


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35

ADULT: SUGGESTED SECOND GENERATION ANTIPSYCHOTIC TITRATI(Dosing & titration schedule based on Monograph information for psychosis and not to be interpreted as specific to one pguidelines only. Medically comprised / elderly require lower doses; the chronic, treatment resistant population may require higher do

SGA First Dose Titration Range Schedule / Brief N

Clozapine 12.5mg Day 2: 25mg hs 200 900 Eventual maintenance dosemg/day (1/3 in am, 2/3 in p.m.)

Day 3: 25mg bid Day 3, dose is increased evDay 6: 25mg am

& 50mg hs

Day 9: 50mg bid

Day 12: 75mg bid Monitor weight, lipids, CV

Day 15: 100mg bid

Day 18: 125mg bid May cause agranulocytosis;

performed before initiating (initially weekly then biweefor 4 weeks after DC therap

Day 21: 150mg bid Should be used cautiously idiabetes; regular periodic mand fasting glucose is sugge

Day 24: 100mg am Blood levels for CLZ sugge& 200mg hs mg/day

Potential life threatening adMonitor weight, lipids, CV


SGA First Dose Titration Range Schedule / Brief N


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36

g

Olanzapine 5-10 mg 5 mg/week 10 20 Should be used cautiously mg/day diabetes; regular periodic m

and fasting glucose is sugge

Risperidone 1 mg 1 mg / 3-5 days 2 6 HS or AM; Monitor weighmg/day mg/day associated with inc

Quetiapine 25 mg bid 50 mg/day 150 800 BID; Monitor weight, lipidmg/day

Ziprasidone 20 mg bid Day 2: 20 mg bid 80 - 160 BID: Give with food; Quicw/food [OR 40 mg qod] mg/day monitor CV status

Day 3: 40 mg bid

Day 4: 40 mg bid

Day 5: 60 mg bid

Day 6: 60 mg bidDay 7: 80 mg bid

Day 8: 80 mg bid

Aripiprazole 15 mg qd 15 mg qd 10 - 15 QD; Quicker titrations nomg /day monitor weight; long half-

reccmd. dose not be increaseof 2 weeks therapy. Dosageday have not been shown t

Risperidone (Risperdal) Olanzapine (Zyprexa)


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Clinical Pharmacology 5HT2 and D2 antagonist and D4, noradrenergic and

histaminergic receptors Half life: 24 hours (can be given once daily) Metabolized by P450 2D6 Mean optimal dose:

4-6 mg/d in chronic patients 2-4 mg/d in treatment naive patients 0.5-2 mg/d in elderly/ compromised

Dose must be titrated up (start at 1-2 mg/d in non-elderly)

Efficacy Fewer EPS (EPS adverse effects increase with doses above 6 mg/d) More effective for negative symptoms (partly result of less EPS) More effective for psychotic symptoms (in some treatment-resistant

patients)

Adverse effects Dizziness/ hypotension (particularly after first dose) Headache Nausea/vomiting Anxiety Rhinitis; Coughing Hyperprolactinemia Weight gain QT delay (usually clinically insignificant)

Clinical Pharmacology High 5HT2/D2 ratio Histaminergic & alpha adrenergic antagonis Metabolized by CYP 1A2 & 3A4 Half life approx. 20 hrs Can start with 10 mg/d at hs in non-compr Optimal dose 10-20 mg/d (2.5-5 mg/d in el

Efficacy Antipsychotic efficacy comparable to halope May be more effective for negative symptom May have substantial antidepressant effect Anti-manic efficacy

Adverse effects Low incidence of EPS Somnolence; dizziness (without hypotension

Dry mouth Constipation Elevation of SGPT (no evidence of hepatoto Hypertriglyceridemia Weight gain common

37


Quetiapine (Seroquel) Ziprasidone (Geodon)


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Pharmacology High D2/5HT2 ratio (may be effective with


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Pharmacology High affinity for dopamine D2, D3, 5HT1A & 5HT2A receptors;

moderate for alpha 1-adrenergic and histaminic receptors. Alpha1-adrenergic receptors: decreased propensity for

orthostatic hypotension? H1 histamine receptors: decreased liability for weight

gain and somnolence?

No appreciable affinity for cholinergic muscarinic receptors: decreased potential for cognitive impairment?

Partial agonist at dopamine D2 & 5HT1A receptors, antagonist at5HT2A receptor

Most activity primarily due to the parent drug aripiprazole, and to a lesserextent, to an active, but major metabolite (dehydro-aripiprazole)

Half life: Approx. 75-hours for parent drug (aripiprazole) Approx. 94 hours for active metabolite (dehydro-aripiprazole)

Steady state attained within 14 days

Eliminated mainly through hepatic metabolism involving two P450isozymes:

CYP2D6 & CYP3A4 Agents that induce CYP3A4 (carbamazepine) could cause

an increase in clearance and lower blood levels Agents that inhibit CYP3A4 (ketoconazole) or CYP2D6

(floxetine, paroxetine) can inhibit elimination and causeincreased blood levels

Four pivotal, but separate trials indicating efplacebo, haloperidol, risperidone.

Dosing Recommended starting and target dose of 1 Peak plasma concentrations within 3 to 5 ho Administer once a day without regard to me Doses higher than 10 or 15 mg per day not

more effective

Adverse effects Orthostatic Hypotension Headache Anxiety Insomnia Nausea / vomiting Use with caution in patients with:

Cardiovascular disease (history m

ischemic heart disease, heart failuabnormalities),

Hypotension (or conditions thatdehydration, hypovolemia, antih

History of seizures or with condithreshold


TREATMENT RESISTANCE 4. Adjunctive agentsAdd i id l i i id


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1. Reassess diagnosis, consider: Substance abuse (alcohol, PCP, stimulants) Neurological disorders (partial complex seizures) Psychotic depression Drug toxicity/ delirium (steroid psychosis, anticholinergic delirium) Personality disorder PTSD

Identify psychosocial stressors

2. Adjust antipsychotic dose Assess compliance Time-limited trial of higher dose, particularly if:

No or mild EPS On drugs which induce hepatic enzymes (carbamazepine) Clozapine as high as tolerated (up to 900 mg/d)

Reduce dose, particularly if moderate or severe EPS or based on resultsof blood levels if applicable

3. Switch antipsychotics If failure on adequate dose of conventional agent, switch to atypicals Atypicals differ in patterns of efficacy; therefore, each one is worth

consideration Clozapine remains most effective agent

Add risperidone, or olanzapine, or ziprasido Add lithium (particularly if affective sympto

of 0.9-1.2 for 3-5 wk trial) ECT (catatonia, affective symptoms), most eff Antidepressants (SSRIs for negative sympto

response of psychosis) Buspirone (15-30 mg/d for agitation, anxiet

5. Psychosocial Interventions Family interventions: education, realistic exp Dual diagnosis treatment Assertive community treatment (ACT)

outreach compliance monitoring

Social skills training Supported employment Cognitive behavioral therapy

6. Question: is relapse due to: Medication noncompliance? Side effects (EPS, sexual side effects, weight) Lack of insight? Complexity of dosing:

Consider single dosing where ava Depot injections Minimize titrations

40 Continued below

7. Stressors Weight gain


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7. Stressors Expressed emotion in family memberscritical, affective arousal,

enmeshed Stressful life events

8. Substance abuse Alcohol Marijuana

Stimulants PCP & ketamine

Comparisons of SGAs (Atypical Antipsychotics)

Efficacy for Positive Symptoms

Clozapine is effective in treatment-resistant patients Risperidone more effective than haloperidol in some patients Olanzapine, quetiapine & ziprasidone comparable to haloperidol Olanzapine may not be effective in strictly treatment-resistant patients

Risperidone & olanzapine comparable to clozapine Clozapine is the Gold Standard

Efficacy for Negative symptoms

Conventional agents mayimprove some portion of negative symptomatol-ogy; watch out for EPS resulting in secondary negative symptoms

Clozapine more effective than chlorpromazine Risperidone & olanzapine more effective than Haloperidol Quetiapine & ziprasidone comparable to haloperidol

e g t gaClozapine> olanzapine> quetiapine> risperidoaripiprazole> or 10 kg/yr 20%

Not dose related; tends to plateau at six mon

Predictors: Increased appetite Good clinical response Low baseline weight Youth Male gender

Start nutritional education& counseling early

Approx. weight loss withbehavioral interventions:

Olanzapine 4kg Risperidone 2.5kg Haloperidol 2kg

Wirshing et al., 1999

Monitor serum glucose

C. Jackson, Pharm. D., BCPP, with permission

41

Me

Risk Fact

Abdominal OMen

WomenTriglycerideHDL Choles

MenWomen

Blood Press

Fasting Glu

Relative Receptor Interactions & Generalized Effects of SGAs (may be


44/60

Clozapine Risperidone Olanzapine Quetiapine Ziprasid

D2(Extrapyramidal

Side Effects) + (++) (+++) ++ + ++

5HT2(Antidepressant) (+) (++) ++++ +++ + ++++

ALPHA 1&2(Orthostatic Hypotension;

Sedation) +++ (++) (+++) +++ +++ (+) (+

H1(Sedation; Antihistaminic) +++ ++ (++) (+++) +++ (+) (+

M1(Antimuscurinic;Anticholinergic) +++ - +++ +/- -

Adapted from Matyunas, 2003; Davis 2003; PI's AZ, BMS, Janssen, Lilly, Pfizer

42

Clinical Signs / Symptoms: SGA Excessive Blood Levels


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+++ High ++ Moderate + Mid / Low +/- Possible - Not Noted

CNS Clozapine Risperidone Olanzapine Quetiapine Zipra

Lethargy ++ ++ +++ ++ +Somnolence NR NR NR NR NConfusion / Agitation + +/- ++ +/- NComa ++ +/- + +/- N

*Central Anticholinergic Syndrome +/- +/- + - ++ - N

Seizures + - - +/- NMyoclonus +/- +/- + - N

Cardiovascular

Tachycardia ++ + ++ + +

Hypotension/orthostasis + + + + +

ECG changes/dysrhythmias + ++ + +/- N

Respiratory Depression +/- - +/- +/-Other

EPS +/- +/- +/- - N

Pupil Contraction +/- +/- ++ +/- N

Pupil Dilation +/- +/- - - N

Vomiting NR NR NR NR N

*Central Anticholinergic Syndrome: altered mental status, disorientation, incoherent speech, delirium, hallucinations, agitation, violent behavior, somnolence, coma, centra

Matyunas 2003; Watanabe 2001; Bezchlibnyk-Butler & Jeffries, Clinical Handbook of Psychotropic Drugs, 10th ed.; PI's AstraZeneca, BMS, Janssen, Lilly, Pfizer43

Mood Stabilizer / Anticonvulsant Overview


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44

Clinical Use Drug Name

Lithium Divalproex Carbamazepine **Lamotrigine Clonazepam Olanzapine

Treatment of acute mania *+ *+ + - + *+

Treatment of rapid cycling - + + ? + +

Treatment of mixed mania - + + - - +

Treatment of recurrent mania + ? ? - - -

Prevention of recurrentdepression + ? ? + - -

Augmentation of other moodstabilizers / anticonvulsants + + + + + +

Rapid onset - + - - + +Treatment with comorbidsubstance / alcohol abuse - + + ? - ?

FDA approved + + - + - +

Green "+" signifies FDA indication Yes = + No = - More data needed = ?

* FDA Approved for Monotherapy & Use In Combination with Lithium or Valproate to Treat Acute Manic Episodes of Bipolar I Disorder.

** Serious rash associated with lamotrigine; please review current dosing guidelines. Best to avoid coadministration with enzyme inhibitors (e.g., valproic acid) due to incre

Web Links:


47/60

Web Links:

American Psychiatric Associationhttp://www.psych.org/

NASMHPD:National Assoc. of State Mental Health ProgramDirectors Technical Report on PsychiatricPolypharmacyhttp://www.nasmhpd.org/Polypharmacy.pdf

National Library of Medicinehttp://www.nlm.nih.gov/

OMAP:

Ohio Medication Algorithm Project.http://www.psychiatry.uc.edu/cqir/omap.asp

Pharmacy Benefits ManagementStrategic Healthcare Group Department of Veterans

Affairs http://www.vapbm.org/PBM/treatment.htm

The Psychiatric Society of Virginiahttp://www.psva.org/

Psychopharmacology Algorithms Directoryhttp://www.ipap.org/algorithms.php

TMAP/TIMA:Texas Medication Algorithm Projecthttp://www.mhmr.state.tx.us/centraloffice/medicator/TIMA.html

Virginia Association of Community Psychiatristshttp://www.vacp.net

Virginia Department of Medical Assistant Servichttp://www.dmas.state.va.us/pharm-home.htm

45

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48/60

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49/60

47

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pramine

Norp

ramin

Antidepressan

t

*

oxyn

methamphet-

amin

e

Psychostimula

nt/ADD

*

amethasoneDecadron

Diagnostictes

tfor

depression.

edrine

dextro-

Psychostimulant/ADD,

amp

hetamine

PotentiatesAntid

epressants

tro-

Psychostimulant/ADD,

phetamine

Dexedrine

PotentiatesAntid

epressants

epam

Valiu

m

Antianxiety

*

enhydramineBenadryl

Hypnotic,

Side-effectcontrol

*

lfiram

Anta

buse

Rxofalcoholism

*

lproex

Depakote

Moodstabilize

r

*

al

quazepam

Hypnotic

epin

Sine

quan,

Adapin

Antidepressant,Antipanic

*

xor

venlafaxine

Antidepressant,Anti-OCD

Antipanic

*

vil

amitriptyline

Antidepressan

t,

Antipanic

*

inil

mep

robamate

Antianxiety

alith

lithiumcarbonateMoodstabilize

r

*

azolam

Pros

om

Hypnotic

amate

Felb

atol

Anticonvulsant,

Moodstabilize

r

batol

felba

mate

Moodstabilize

r

xetine

Proz

ac

Antidepressan

t,

Anti-OCD,Anti-panic

*

henazine

Prolixin

Antipsychotic

*

azepam

Dalm

ane

Hypnotic

oxamine

Luvo

x

Antidepressan

t,

Anti-OCD,Antipanic

*

Halc

Hald

halop

hydr

pam

imipr

Inde

isoca

Kem

Kepp

Klon

Lam

lamo

levet

levot

Libri

liothy

lithiu

lithiu

Litho

Litho

loraz

loxap


50/60

cion

triazolam

Hypnotic

dol

haloperidol

Antipsychotic

*

peridol

Hald

ol

Antipsychotic

*

oxyzine

oate

Vista

ril

Hypnotic,Antianxiety

*

ramine

Tofra

nil


*

ral

prop

ranolol

Side-effectcontrol,

Angercontrol

*

arboxazid

Marplan

Antidepressan

t

madrin

proc

yclidine

Side-effectcontrol

pra

levetiracetam

Anticonvulsant,

Moodstabilize

r

opin

clonazepam

Antianxiety,

Moodstabilize

r

*

ictal

lamo

trigine

Anticonvulsant,

Moodstabilize

r

*

otrigine

Lam

ictal

Anticonvulsant,

Moodstabilize

r

*

tiracetam

Keppra

Anticonvulsant,

Moodstabilize

r

thyroxine

Synthroid

Potentiates

antidepressan

ts,

Moodstabilize

r

um

chlordiazepoxideAntianxiety

*

yronine

Cyto

mel

Potentiates

antidepressan

ts,

Moodstabilize

r

mcarbonateEska

lith,

Moodstabilize

r,

Litho

tab

Potentiates

antidepressan

ts

*

umcitrate

Ciba

lith-S

Moodstabilize

r,

Potentiates

antidepressan

ts

*

onate

lithiu

m

Moodstabilize

r,

carb

onate

Potentiates

antidepressan

ts

*

otabs

lithiu

m

Moodstabilize

r,

carb

onate

Potentiates

antidepressan

ts

*

zepam

Ativa

n

Antianxiety

pine

Loxitane

Antipsychotic

*

48

p

Marp

mepr

meso

metha

meth

meth

Ext.R

Milto

Mirap

mirta

Moba

moda

molin

naltre

Nard

nefaz

Nem

Neur

Norp

nortr

olanz

Orap

oxaz

oxca

Pam

Parn

parox

Paxil

pemo

Peria


51/60

49

p

plan

isocarboxazid


robamate

Milto

wn,EquinilAntianxiety

oridazine

Sere

ntil

Antipsychotic

*

amphetamineDesoxyn

Psychostimula

nt/ADD

ylphenidate

Ritalin

Psychostimula

nt/ADD

ylphenidate

Release

Concerta

Psychostimula

nt/ADD

own

meprobamate

Antianxiety

pex

pram

ipexol

Potentiates

antidepressants

azepine

Rem

eron

Antidepressan

t,

Antipanic

an

molindone

Antipsychotic

*

afanil

Prov

igil

Narcolepsy,Po

tentiates

antidepressants

ndone

Moban

Antipsychotic

*

exone

ReVia

Rxofalcoholism,

Potentiates

antidepressants

dil

phen

elzine

Antidepressan

t,

Antipanic

*

zodone

Serz

one

Antidepressan

t

*

mbutal

Pentobarbital

Hypnotic

rontin

gaba

pentin

Moodstabilize

r

*

pramin

desipramine

Antidepressan

t

*

riptyline

Aven

tyl,PamelorAntidepressant,Antipanic

zapine

Zypr

exa

Antipsychotic

*

p

pimo

zide

Antipsychotic

zepam

Sera

x

Antianxiety

*

arbazepine

Trileptal

Anticonvulsant,

Moodstabilize

r

elor

nortriptyline


*

nate

trany

lcypromineAntidepressant,Antipanic

*

xetine

Paxil

Antidepressant

,

Anti-OCD,Antipanic

*

l

paro

xetine

Antidepressan

t,

Anti-OCD,Antipanic

*

oline

Cyle

rt

Psychostimula

nt/ADD,

Potentiates

antidepressants

actin

cyproheptadineSide-effectcontrol

Placi

pram

praze

procy

Prolix

propr

Proso

protri

Provi

Proza

Quaz

queti

Rem

ReVi

Rispe

Rispe

rispe

rispe

acting

Ritali

seco

Seco

seleg

Serax

Sero

sertra

Serzo

Somn

Sona

Stela

Stratt

Surm


52/60

50

p

dyl

ethchlorvynol

Hypnotic

mipexole

Mirapex

Potentiates

antidepressants

epam

Centrax

Antianxiety

yclidine

Kem

adrin

Side-effectcontrol

*

xin

fluph

enazine

Antipsychotic

*

ranolol

Inderal

Side-effectcontrol

*

om

estazolam

Hypnotic

iptyline

Vivactil


*

igil

modafinil

Psychostimula

nt/ADD,

potentiates

ac

fluox

etine

Antidepressant,Anti-OCD,

Antipanic

*

zepam

Dora

l

Hypnotic

apine

Sero

quel

Antipsychotic

*

eron

mirta

zepine


*

a

naltrexone

Rxofalcoholis

m,

Potentiates

antidepressants

erdal

rispe

ridone

Antipsychotic

*

erdalConstarispe

ridonelongAntipsychotic

*

actin

ginjection

ridone

Risp

erdal

Antipsychotic

*

ridonelongRispe

rdalConstaAntipsychotic

*

ginjection

in

meth

ylphenidatePsychostimula

nt/ADD,

Potentiates

barbital

Seco

nal

Hypnotic

onal

seco

barbital

Hypnotic

giline

Elde

pryl

Antidepressan

t

x

oxaz

epam

Antianxiety

*

quel

quetiapine

Antipsychotic

*

aline

Zoloft

Antidepressan

t,

Anti-OCD,Antipanic

*

one

nefazodone

Antidepressan

t

*

note

chloralhydrateHypnotic

ata

zaleplon

Hypnotic

azine

trifluoperazine

Antipsychotic

*

tera

atom

oxetine

Anti-ADD

montil

trimipramine

Antidepressan

t,

Antipanic

g

tema

tenor

thiorid

Thora

tiaga

Tofra

Topa

topira

Tranx

trany

trazo

triazo

trihex

Trilafo

Trilep

trimip

Urech

Valium

Valpr

valpro

venla

Vista

Wellb

Xana

zalep

zipras

Zolof

zolpid

Zypre


53/60

51

p

zepam

Restoril

Hypnotic

*

rmin

atenolol

Side-effectcontrol

dazine

Mellaril

Antipsychotic

*

azine

chlorpromazineAntipsychotic

*

bine

Gabitril

Anticonvulsant,

Moodstabilize

r

nil

imipramine

Antidepressan

t,

Antipanic

*

max

topiramate

Anticonvulsant,

Moodstabilize

r

*

amate

Topa

max

Anticonvulsant,

Moodstabilize

r

*

xene

clora

zepate

Antianxiety

*

lcypromineParn

ate

Antidepressan

t,

Antipanic

*

done

Desyrel

Antidepressant,Hypnotic

*

olam

Halcion

Hypnotic

xyphenidylArtane

Side-effectcontrol

*

on

perphenazine

Antipsychotic

*

ptal

oxca

rbazepineAnticonvulsant,

Moodstabilize

r

pramine

Surm

ontil


holine

bethanechol

Side-effectcontrol

m

diazepam

Antianxiety

*

roate

Depakote/

Depakene

Moodstabilize

r

oicacid

Depakene

Moodstabilize

r

*

Antid

epressant,Anti-OCD,

afaxine

Effex

or

Antipanic

hydroxyzine

*

ril

pamoate

Hypnotic,Antianxiety

*

butrin

bupropion

Antidepressan

t

*

ax

alpra

zolam

Antianxiety

*

plon

Sonata

Hypnotic

sidone

Geodon

Antipsychotic,

Moodstabilize

r

*

t

sertraline

Antidepressan

t,

Anti-OCD,Antipanic

*

dem

Amb

ien

Hypnotic

exa

olanzapine

Antipsychotic

*


54/60

52

We have made every effort to ensure the accuracy of the data listed and that they are

within current practice recommendations at the time of publication. However, due to

changing regulations and drug information, the readers are strongly urged to checkthe package insert for drug data as well as updated versions of the State AfterCare

Formulary for current prices.

The authors and Virginia DMHMRSAS disclaim any responsibilities for consequences

secondary to the utilization of this Guide.

Notes


55/60

53

Notes


56/60

54

Notes


57/60

55

Notes


58/60

56


59/60

57


60/60

58

Produced in part under unrestricted educational grants fromAstraZeneca, Janssen and Pfizer Pharmaceuticals.

pocket psiquiatry guide[1]

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