Should be reexamined for diagnosis, substance abuse, medication adherence issues, psychosocial stressors Clozapine is the only medication that has shown superiority over other antipsychotics in randomized clinical trials for the management of treatment-resistant schizophrenia Augmentation and combination strategies o Little evidence exists to guide treatment decisions for patients who do not respond to clozapine o Mood stabilizers have been used but are not recommended o Limited data support antidepressant therapy Antipsychotic polypharmacy o NO EVIDENCE exists to prove that antipsychotic combinations are superior to monotherapy Some guidelines list it as a fourth or fifth line treatment option when ALL other options have failed o The Joint Commission has established three situations in which more than one is justified: 1. Three or more failed trials of antipsychotic monotherapy 2. Cross titration of antipsychotic medications 14
AKrysiak || Schizophrenia || Spring 2020 3. Augmentation of clozapine AGAIN… CHOOSING AN AGENT Based on: o Patient-specific factors such as comorbidities, history (including family) of use with agent, etc. o Cost of medication o Side effect profile of medication FIRST GENERATION = MORE _________________________ SECOND GENERATION = MORE _____________________________ ADEQUATE DOSE RANGES *Dosage ranges included in this table were adopted from a combination of the WFSBP and PORT guidelines and medication package inserts **Please see appendix! FIRST GENERATION ANTIPSYCHOTICS DRUG DOSING SAFETY/SE/MONTORING LOW Potency Chlorpromazine (Thorazine) Thioridazine (Mellaril) 300 – 1000mg/day, divided 300 – 800 mg/day, divided LOW Potency: EPS, sedation, cardiovascular effects (orthostatic HTN, tachycardia) HIGH Potency: EPS, sedation BBW: risk of death for dementia r/t psychosis Thioridazine QT prolongation Adasuve bronchospasm (REMS) MID Potency Loxapine (Loxitane, Adasuve inh REMS) Perphenazine (Trilafon) 30 – 100mg/day, divided 8 – 64mg/day, divided HIGH Potency Haloperidol (Haldol) Oral (tablet, solution): 0.5 – 15 Chlorpromazine (Thorazine) Thioridazine (Mellaril) Fluphenazine (Prolixin, decanoate) Perphenazine (Trilafon) Thiothixene(Navane) Trifluperazine (Stelazine) Loxapine (Loxitane, Adasuve Inhaled Powder) Molindone (Moban) Haloperidol (Haldol, Haldol-D)
AKrysiak || Schizophrenia || Spring 2020 IV, IM, Oral Haldol Decanoate (LAI) Fluphenazine (Prolixin) Thiothixene (Navane) Trifluoperazine (Stelazine) 2mg BID-TID, up to 30mg/day Haldol Decanoate : IM monthly (10-20x PO dose) 6 – 12mg/day, divided Fluphenazine Decanoate : IM every 2 weeks 15 – 60mg/day, divided 15 – 50mg/day, divided SE: leukopenia, neutropenia, agranulocytosis, sexual dysfunction, seizures Haldol IV: risk of orthostasis, tachycardia Haldol, thioridazine, chlorpromazine: QT prolongation Loxapine Staccato (Adasuve) inhaled powder Approved by the FDA for acute agitation associated with schizophrenia and bipolar disorder Must be administered by a healthcare professional o Before administration, patients must be screened for history of asthma, COPD, or other lung
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- Spring '18
- Schizophrenia, Antipsychotic