Antipsychotics are considered the mainstay of treatment for psychotic disorders such as schizophrenia and schizoaffective disorders. While the first generation antipsychotics (typical antipsychotics) are effective for treating psychosis, the second generation antipsychotics (atypical antipsychotics) have largely supplanted their older cousins as the “go to” medications for this indication. The main reason for the switch to newer agents is not because of increased efficacy, but because of reduced adverse effect burden. The reduced propensity of the second generation antipsychotics to cause neurological adverse effects such as extrapyramidal symptoms and tardive dyskinesia has been established. However, these agents have a different adverse
This toolbox provides a summary in tabular form of the various metabolic changes that may be caused by atypical antipsychotics. Included here are: average changes in weight both short and long term (Table 1), average change in lipids short term (Table 2), average change in lipids long term (Table 3), average changes in fasting glucose short and long term (Table 4), and a ranking of the propensity of the atypical antipsychotics to cause metabolic changes (Table 5).
Hiccups are a product of involuntary, intermittent spasmodic contraction of the diaphragm and inspiratory intercostal muscles that results in sudden inspiration and abrupt closure of the glottis. The exact pathophysiology of hiccups remains unknown. However, certain neurotransmitters, medications, and other factors have been implicated. We report a case of a 38 year old patient who developed hiccups three days after adding aripiprazole 5 mg once a day to his medication regimen. Medical and environmental causes were ruled out and aripiprazole was discontinued. One day later, the hiccups resolved. Several case reports have described patients who developed hiccups when treated with aripiprazole and related this to changes in neurotransmitter concentrations. However, due to limited literature, it was difficult to determine rate of occurrence of this adverse event with aripiprazole. A temporal but not a causal relationship was observed between initiating aripiprazole and development of hiccups in this patient. A causal relationship cannot be established since the patient was not re-challenged with aripiprazole. Nonetheless, clinicians should be cognizant that use of aripiprazole may be associated with hiccups.
Background: Atypical antipsychotic agents serve an important role in the treatment of many psychiatric disorders but have the potential to cause adverse effects, notably metabolic disturbances. These agents are known to cause increases in obesity, glucose intolerance, dyslipidemia and hypertension. In 2004, the American Diabetes Association (ADA) and the American Psychiatric Association (APA), in collaboration with other organizations, acknowledged the association between the use of atypical antipsychotics and the development of metabolic abnormalities and provided monitoring recommendations for the use of these agents. Despite these recommendations, rates of monitoring remain low.
Objective: The purpose of this study is to assess whether a pharmacist recommendation form is effective in improving baseline metabolic monitoring for patients admitted to an acute inpatient psychiatry unit who are ordered a scheduled atypical antipsychotic.
Methods: A pharmacist recommendation form with metabolic monitoring parameters was placed on the charts of patients ordered a scheduled atypical antipsychotic during a two month period. A retrospective chart review was conducted to compare the percentage of baseline monitoring ordered pre-intervention versus the intervention period. Patients ages 18 years or older who were ordered a scheduled atypical antipsychotic were included.
Results: During the intervention period, there was a significant increase in documentation for presence or absence of diabetes (p = 0.018) and cardiovascular disease (p < 0.001). A significant difference in the number of orders for hemoglobin A1c (p = 0.007) and lipid panels (p < 0.001) were noted. No other significant differences were found.
Conclusion: A pharmacist recommendation form was effective in improving the baseline monitoring of personal history of diabetes and cardiovascular disease and monitoring of hemoglobin A1c and lipid panels, but rates of other baseline monitoring parameters did not improve.
Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are two rare, but serious adverse reactions associated with psychotropic medications. While the disorders may share certain features, there are differences in how they are managed and treated. This article reviews the risk factors, clinical presentation, and treatment of SS and NMS.
Background: Patients with schizophrenia are at increased risk for developing osteoporosis, which has historically been attributed to poor diet and lack of exercise. However, more recent data suggest a link between antipsychotic use and osteoporosis due to increased prolactin levels. Hyperprolactinemia can lead to suppression of hypothalamus-pituitary axis regulation of sex hormone production and over time, hypogonadism, which can affect bone health. There have been a few studies evaluating the link between antipsychotic use and osteoporosis; however, the link is not well established and there is very little guidance regarding monitoring of prolactin levels.
Objectives:Determine the prevalence of osteoporosis in patients receiv ing antipsychotic medications. Evaluate the duration of antipsychotic therapy, prolactin levels (prevalence of monitoring and mean levels), and incidence of fractures for the study patients diagnosed with osteoporosis.
Methods:The study was a retrospective cohort study evaluating patients 18 years of age and older who were prescribed an antipsychotic at the Dallas VA Medical Center from 1/1/2008-12/31/2009. The patients included had to be taking the same antipsychotic for at least one year. Subjects were excluded if they had significant co-morbidities or were taking other medications that increase osteoporosis risk. Patient demographics, antipsychotic information, and pertinent lab values such as vitamin D, prolactin, testosterone and FSH/LH levels were recorded. The use of other medications that may increase prolactin, smoking status, bone mineral density, and history of fracture were also noted.
Results:This study showed that 26% of patients taking antipsychotics for at least one year develope d osteoporosis. The dose or type of antipsychotic (prolactin-sparing versus prolactin-raising) did not appear to be contributing factors. Based on this study's data, the duration of antipsychotic therapy and the concurrent use of other prolactin raising medications may be more concerning.
Clozapine is an antipsychotic associated with superior efficacy compared to other atypical antipsychotics in the treatment of schizophrenia. However, clozapine use is limited due to its association with a rare but potentially fatal adverse effect, agranulocytosis. Patients receiving clozapine therapy require frequent monitoring of white blood cell (WBC) and absolute neutrophil counts (ANC). This article reviews the monitoring parameters for patients receiving clozapine therapy, and the management and prevention of clozapine-associated agranulocytosis.
Several cases of pulmonary embolism (PE) have been associated with antipsychotic treatment. We report a case of an otherwise healthy 27-year old male who developed a PE after receiving paliperidone long acting injection. The patient received risperidone long acting injection for over 3 months before initiating paliperidone, but was switched incorrectly. After 3 weeks on paliperidone long acting injection the patient developed a PE requiring hospitalization and a course of anticoagulation. A review of atypical antipsychotic-induced venous thromboembolism is discussed.
The job of the pharmacist rarely involves evaluating diagnostic impressions or making definitive diagnoses. However, the pharmacist may often be called upon to give his or her assessment of a clinical picture when drug-related or drug-induced factors may be at play. In addition, pharmacists may be called upon to give therapy recommendations, frequently evaluating appropriate dosing, drug interactions and even therapeutic endpoints of medications. As patient and drug-regimen complexity increase, the ability of the pharmacist to give valuable input to the diagnostic impression or assessment of drug-related factors regarding a patient's clinical presentation becomes paramount. This may be particularlyINTRODUCTION
Preventing, minimizing and managing risks associated with second generation antipsychotic (SGA) use in patients with schizophrenia and other psychotic disorders is a priority for clinicians working with this population. Among these risks is metabolic syndrome. As this population exhibits increased rates of obesity, diabetes and atherogenic dyslipidemia compared to the general population, metabolic syndrome deserves serious consideration in patient care planning for managing risks. This article comprehensively reviews different strategies and recommendations for prevention and/or management of metabolic abnormalities associated with the use of SGAs. Baseline screening and follow-up metabolic monitoring as well as education and counseling on risk for SGA-induced weight gain and other metabolic abnormalities, physical activity and healthy diet for weight maintenance/loss should be promoted shortly after initiation of SGAs. In select patients, the clinician can consider simplifying the antipsychotic treatment regimen by switching to an agent with a lower propensity of metabolic side effects or possibly adding metformin for weight loss and glucose metabolism regulation in those experiencing a first episode of schizophrenia. Future research should focus on combinations of interventions and treatment modalities and exploration of novel interventions.
Previous literature has highlighted an increase in morbidity and mortality associated with antipsychotic use in persons with severe mental illnesses (SMI), which include schizophrenia and bipolar disorder.1 Drug-induced hyperprolactinemia is a function of dopamine blockade in the anterior pituitary.2 Elevated prolactin levels are often accompanied by symptoms of decreased libido and erectile dysfunction (ED) in men, and galactorrhea and amenorrhea in women.2 However, the extent to which antipsychotic (AP) use is associated with sexual dysfunction has not been extensively reported.3 Hyperprolactinemia may also increase the risk for osteopenia.24 HyperprolactinemiaINTRODUCTION
CPNP members maintain a suggested reading list to provide information on peer recommended resources and convenient access to the highest quality neuropsychopharmacology publications. A reminder that if you shop with CPNP, by following the links below to Amazon, a small commission will be paid to CPNP which helps to financially support our mission to improve the minds and lives of individuals with psychiatric and/or neurologic disorders. You can help grow this list of resources by suggesting a book. Book: Essentials of Clinical Psychopharmacology, Third Edition This third edition of Essentials of PsychopharmacologyFROM THE PUBLISHER
Psychiatric pharmacists have been utilizing their specialized knowledge and skills to improve the minds and lives of individuals suffering from neuropsychiatric disorders since the first psychiatric pharmacy residencies were established in the mid 1970's. The first group of board certified psychiatric pharmacists were recognized by (BPS) in 1996 and there are now 758 board certified psychiatric pharmacists. One of the main goals in establishing board certification in psychiatric pharmacy was to show that an individual has demonstrated the knowledge and skills to care for our patients/clients. These facts are well known by CPNP members and most non- psychiatric pharmacists. Unfortunately,
Rex Lott, PharmD, BCPP Nominating Committee Chair Thanks to the contributions of time and talent, members have helped CPNP to make great strides in its short 17 years of existence. CPNP is truly a membership-driven organization. This is especially true in selecting future leaders of the organization. Another of the many ways you can contribute is to nominate your peers and colleagues with the dedication and time to take CPNP even further. On or before Tuesday, September 10, you have the opportunity to nominate leaders for 3GROW CPNP: PROVIDE YOUR NOMINATIONS TO THE CPNP BOARD