Antipsychotics, atypical Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)
| Varies | Somnolence, dry mouth, orthostatic hypotension, extrapyramidal effects, akathisia, tardive dyskinesia, weight gain, hyperglycemia, neuroleptic malignant syndrome, hyperprolactinemia, sexual dysfunction | Lipid profile, fasting blood glucose level, waist circumference, body weight, and CBC in patients with prior clinically significant leukopenia; measure at baseline, monthly in the first three months of therapy, then every three months thereafter | Quetiapine, risperidone, and ziprasidone increase the risk of extrapyramidal effects Aripiprazole is the only atypical antipsychotic not associated with dyslipidemia, but it is associated with akathisia Caution should be used when decreasing dosages because rebound anxiety and psychosis are possible Increased risk of death in older patients with dementia*
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Antipsychotics, typical
Haloperidol lactate(Haldol) | 2 to 5 mg intramuscularly for acute episode; may repeat every hour as needed until symptoms are controlled; switch to oral form as soon as feasible Initial dosage is based on patient's age and severity of symptoms; dosage rarely should exceed 100 mg in 24 hours No recommendation for use after acute episode
| Insomnia, restlessness, anxiety, sedation, headache, seizures, weight gain, psychosis, hypotension, tardive dyskinesia, extrapyramidal effects, depression, QT prolongation, neuroleptic malignant syndrome, pneumonia, blood dyscrasia, hyperprolactinemia | CBC (in patients with prior clinically significant leukopenia) at baseline and monthly in the first three months of therapy Prolactin level as clinically indicated Monitor for extrapyramidal effects, tardive dyskinesia, and neurolepticmalignant syndrome
| Increased risk of death in older patients with dementia* Torsades de pointes possible, particularly with higher than recommended dosages
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| Benzodiazepines Lorazepam (Ativan) | 0.5 to 2 mg orally or intramuscularly, up to 4 mg per day Reduce dose by 50 percent in patients who are older and debilitated, patients taking valproate, and patients with hepatic or renal disease
| Sedation, nausea, blood dyscrasia, extrapyramidal effects, agitation, anterograde amnesia, cognitive impairment, respiratory depression, hyponatremia, syndrome of inappropriate antidiuretic hormone | Periodic CBC and liver function testing for patients on long-term therapy | Contraindicated in patients with myasthenia gravis or acute narrow-angle glaucoma Avoid in patients with history of substance abuse Continuous long-term use not recommended Paradoxical reactions are more likely in children and older persons; risk of seizure after discontinuation is greater in patients with preexisting seizure disorder and in those taking antidepressants
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| Carbamazepine (Tegretol) | 200 to 1,600 mg orally per day Begin with 200 mg twice per day, adjusting every day by 200 mg as tolerated Titrate to serum level of 4 to 12 mcg per mL
| Headache; fatigue; nystagmus; ataxia; rash, including Stevens-Johnson syndrome and toxic epidermal necrolysis*; leukopenia, hyponatremia | Serum carbamazepine levels every one to two weeks initially, then every three to six months or before and after dosage changes CBC and liver function testing monthly for the first two months, then every three to 12 months thereafter Screening for HLA-B1502 in patients with Asian ancestry; patients with positive screening results should avoid carbamazepine because of the risk of Stevens-Johnson syndrome and toxic epidermal necrolysis
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| Divalproex (Depakote), valproic acid (Depakene) | Target dosage: 1,000 to 3,000 mg orally per day 15 to 20 mg per kg load in patients with acute mania; may also start with 500 to 750 mg per day in divided doses and adjust every two to three days as tolerated Titrate to serum level of 50 to 125 mcg per mL
| Tremor, sedation, weight gain, nausea, diarrhea, hair loss, leukopenia, thrombocytopenia, elevated liver transaminase levels, hepatic failure,* pancreatitis,* polycystic ovary syndrome | Serum valproate levels every one to two weeks initially, then every three to six months or before and after dosage changes CBC and liver function testing monthly for the first two months, then every three to 12 months thereafter
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| Lamotrigine (Lamictal) | 200 mg orally per day Begin with 25 mg per day, and titrate over six weeks; titration and dosage adjustments differ for those taking valproic acid, carbamazepine, phenytoin (Dilantin), phenobarbital, primidone (Mysoline), rifampin, and oral contraceptives
| Dizziness; tremor; somnolence; headache; dry mouth; nausea; rash, including Stevens-Johnson syndrome and toxic epidermal necrolysis*; leukopenia; thrombocytopenia; pancytopenia; aseptic meningitis | CBC and liver function testing monthly for the first two months, then every three to 12 months thereafter | |
| Lithium | 900 to 1,800 mg orally per day Begin with up to 300 mg twice per day, and adjust dosage every two or three days as tolerated; titrate to serum level of 0.6 to 1.5 mEq per L
| Thirst, polyuria, cognitive effects, sedation, tremor, weight gain, diarrhea, nausea, hypothyroidism, diabetes insipidus | Serum lithium levels every one to two weeks initially, then every three to six months thereafter or before and after dosage changes Thyroid function testing† and renal indices every two or three months in the first six months of therapy, then every six to 12 months thereafter
| Toxicity is dose dependent; overdose can be fatal* Incidence of hypothyroidism is higher in women and increases with age High rates of withdrawal compared with valproate and lamotrigine in maintenance therapy
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