Antipsychotics

Managing Clozapine-Induced Constipation: Practical Advice

Routine management of constipation is a critical part of clozapine treatment. There are case reports of fatal ileus related to clozapine therapy.

-The first step is to minimize the use of systemic anticholinergics.
-Docusate should be used routinely.  Bulk agents can make constipation worse and should be avoided.
-After docusate, the next agent to add is PEG 3350.
-Lubiprostone, a more expensive agent, can also be tried. It can be used if the combination of docusate + PEG-3350 + a stimulant is not effective.

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Clozapine Augmentation for Treatment-Resistant Schizophrenia: What Does the Evidence Say?

Up to 30% of patients with treatment-resistant schizophrenia treated with clozapine have residual positive symptoms. Clozapine augmentation is a common approach, but the evidence supporting this practice is limited.
According to the latest evidence, risperidone, lamotrigine, topiramate, or ECT are potential augmenting options.

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Choosing Among Long-Acting Injectable Antipsychotics: Practical Aspects

David N. Osser, MD Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System   First-generation LAIs (haloperidol, fluphenazine) have higher rates of acute extrapyramidal symptoms, tardive dyskinesia and hyperprolactinemia symptoms compared to most second-generation antipsychotics. However, they have lower costs. Most second-generation antipsychotics cost more than $1000 a month,…

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Antipsychotic-Induced Dystonia: Diagnosis and Management

Michael D. Jibson, MD, PhD Professor of Psychiatry Director of Residency Education University of Michigan   Acute dystonic reactions are associated with antipsychotic use, especially with high-potency first-generation antipsychotics. About 90% of these reactions occur either in the first four days of treatment or after an increase in dose. Risk factors include large muscle mass,…

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Antipsychotics for Agitation: Differences Between Tablets, Orally Disintegrating Tablets and Sublingual Formulations

Michael D. Jibson, MD, PhD Professor of Psychiatry Director of Residency Education University of Michigan This presentation discusses how to prescribe oral antipsychotics for acute agitation (standard tablets, orally disintegrating tablets, and a sublingual formulation). Orally disintegrating antipsychotics (Abilify Discmelt, Zyprexa Zydis, Risperdal M-Tab) are not absorbed transmucosally, they have to be swallowed. Orally disintegrating…

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Bipolar Disorder Treatment Guidelines: A 2018 Update

By Flavio Guzman, MD Editor Psychopharmacology Institute This page offers direct links to the most recent guidelines for the treatment of bipolar disorder. You may notice that we have not included the guidelines published by the American Psychiatric Asssociation, this is because the document has not been updated since 2005. 2017 -Mixed Depression and Mixed…

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Long-Acting Injectable Antipsychotics: A Practical Guide for Prescribers

Author: Flavio Guzman, MD Competing interests: none This article summarizes the most clinically relevant features of long-acting injectable antipsychotics (LAIs, previously known as depot antipsychotics). We discuss general concepts as well as key prescribing facts of individual agents. The guide also includes two new formulations: aripiprazole lauroxil (Aristada) and 3-month paliperidone palmitate (Invega Trinza). Advantages and disadvantages of long-acting antipsychotics…

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Summary of Newly Approved Antipsychotics

By Flavio Guzman, MD Two new second-generation antipsychotics were approved in 2015: brexpiprazole (Rexulti) and cariprazine (Vraylar). Like aripiprazole (Abilify), they are both D2 partial agonists and are associated with risk of akathisia. Aripiprazole, brexpiprazole and cariprazine are FDA-approved for the treatment of schizophrenia. Aripiprazole and cariprazine are approved for the treatment of manic episodes in…

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Reviewing Antipsychotic Adverse Effects with Prof. Mark Taylor

Professor Mark Taylor is a consultant psychiatrist at the NHS in the UK. He is also Associate Professor at the University of Queensland in Brisbane Australia. He is the coauthor of a paper published in the Journal of Psychopharmacology: “First do no harm.” A systematic review of the prevalence and management of antipsychotic adverse effects”.…

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Aripiprazole Lauroxil Extended-Release Injectable (ARISTADA)

By Flavio Guzman, MD Prescribing information highlights To be administered by intramuscular injection in the deltoid (441 mg dose only) or gluteal (441 mg, 662 mg or 882 mg) muscle by a healthcare professional. For patients naïve to aripiprazole, establish tolerability with oral aripiprazole prior to initiating treatment with ARISTADA. ARISTADA can be initiated at…

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