00:01
The mechanism of action now for atypical
antipsychotics.
00:05
So now we're moving into discussing the newer
forms of neuroleptics.
00:08
They're called atypicals.
00:10
So these have some affinity for dopamine
receptors, but far more affinity for other
neurotransmitters, things like serotonin
receptors, histamine receptors and alpha
receptors. And so therefore they have a very
different side effect profile.
00:26
And remember, these are very useful in the
treatment of negative symptoms of psychosis.
00:31
Some examples of atypical antipsychotics
include here Clozapine, Risperidone, Quetiapine,
Olanzapine and Ziprasidone.
00:41
There are, of course many more and newer ones
are on the market all the time and you're
looking out for side effects from your patient
who can incur any of the following.
00:50
So when it comes to Clozapine, this is a very
notable, atypical antipsychotic.
00:57
So it's actually one of the oldest atypical
antipsychotics, the oldest atypical, and it's
not used quite as frequently, despite it being
around for so long.
01:09
And that's because it has a number of
potentially deadly side effects that require
very intense monitoring.
01:15
Having said that, you must know that Clozapine
is a great medication to use in the patient who
is described as being treatment-resistant in
terms of their psychosis.
01:26
So although it's usually a later resort and
sometimes a last resort, it really is effective
in treating treatment-resistant psychosis.
01:35
Now, it's notable that there's a 1% incidence
of Agranulocytosis with this and a 2 to 5%
incidence of seizures with Clozapine.
01:45
So as I mentioned before, there are notable side
effects.
01:48
The one that tends to come up most commonly on
board exams is that side effect of
Agranulocytosis. So another atypical
antipsychotic is Olanzapine and
a little pearl to note about this is that it
actually can cause significant weight gain as
well as hyperlipidemia, glucose intolerance and
therefore it can lead to diabetes in patients.
02:13
So let's go through some of them in more
detail.
02:16
So here are some of the atypical
antipsychotics.
02:19
And you can read here that we've got their
features and potential side effects.
02:23
I mentioned with Olanzapine the potential for
weight gain.
02:26
And one of the things that's notable about
Quetiapine is that not only is it indicated for
psychosis, but this can actually be used as
well as a good antidepressant and mood
stabilizer in patients who have had a lot of
depression.
02:42
A notable thing about Risperidone is that it
actually comes in an injectable form, a long
acting injectable form for that patient who may
not be so compliant with medication.
02:52
Olanzapine and Ziprasidone, on the other hand,
have short acting injectable options.
02:58
So these are good for emergent situations on an
inpatient unit or in an emergency room.
03:04
However, these medications can disrupt the QTc
interval, especially Ziprasidone.
03:10
So remember to check an EKG as a baseline before
starting your patient on this.
03:16
I talked a little bit about Clozapine before
and the importance of knowing about its side
effect, Agranulocytosis.
03:22
There are a lot of other side effects that can
cause too, though.
03:25
It's extremely weight gaining medication.
03:30
So weight gain is important and it can lead to
something like diabetes and the metabolic
syndrome, which needs to be monitored for.
03:37
It can also cause myocarditis and sialorrhea,
where patients may describe waking up in a pool
of their own saliva.
03:45
So these are other things, and a neat little
trick for treating the sialorrhea is to actually
give a patient Atropine drops at night on their
tongue.
03:55
Now a constellation of symptoms that are
associated with the atypical antipsychotics are,
of course, the metabolic syndrome.
04:03
And the symptoms here include elevated fasting
glucose, hypertension, abdominal obesity,
elevated triglycerides and a decrease in HDL
cholesterol.
04:15
Things that really need to be monitored for
closely when you've got a patient on an atypical
antipsychotic. Here's a quiz for you.
04:23
Which two atypical antipsychotics are most
commonly associated with the metabolic syndrome?
So I talked about these earlier, there are two
atypicals that are really known for causing
profound weight gain.
04:35
Right, it's Clozapine and Olanzapine.
04:39
Now, how would you treat the metabolic
syndrome?
Well, you actually want to really encourage
your patient to get on a weight reduction
program, maybe exercising 30 minutes a day if
tolerated.
04:51
Also making healthy dietary changes, probably
getting a nutritional consult for your patient.
04:56
And then you may also consider reducing the
dose of their medication or switching them to
another agent that might be a little bit more
weight neutral.
05:04
So in terms of further going through our
atypical antipsychotics,
I want to bring back in the important point of
noting that some medications are available as
injectable forms.
05:21
This is a really important point because as I
mentioned, some patients will maybe not tolerate
medicine or not comply with it, and others may
just opt to not take a pill every day.
05:32
So both atypical and typicals alike come in
injectable forms.
05:37
So in terms of long-acting forms, Fluphenazine,
which is of course a typical medication, as is
Haloperidol, are available in long-acting
injections and so is Risperidone.
05:48
Some newer agents include Paliperidone.
05:51
This is an atypical agent that's newer and
comes in a monthly injection, as does
Aripiprazole. Now, not only do Paliperidone and
Aripiprazole come in long-acting injectables,
they're also available in short-acting
injectables for those emergent situations.
06:09
So we talked about a couple of them.
06:12
But overall, do you know of any other
antipsychotics that can be used emergently in
short-acting injectable form?
Well, Fluphenazine, Haloperidol,
Chlorpromazine, Aripiprazole, Ziprasidone and
Olanzapine are a few examples.
06:28
To go back to Clozapine, a very important
medication to know about for your boards,
because it can cause agranulocytosis, which is
a very important to remember,
it requires strict blood monitoring.
06:41
And so when monitoring blood counts for
patients who are on Clozapine, when should you
actually discontinue Clozapine?
So when are the blood counts so bad that you
have to stop the medication?
Well, it's when the white blood cell count
drops to below 2000 or 3000 or the absolute
neutrophil count falls below 1500.
07:04
Patients should be monitored if this happens.
07:07
Now, the typical monitoring schedule for
Clozapine includes weekly white blood cell
counts and absolute neutrophil counts every
week for the first six months of treatment.
07:19
If somebody has done fine on the medication for
six months, you can then taper back to checking
their white blood cell count and ANC twice a
month for six months.
07:31
If they do fine with that, then for the rest of
their treatment they need to be checked monthly.
07:37
So what are the recommendations?
And so I just went over this and here's a slide
to point out the baseline check.
07:45
And then the frequency of checking WBC and ANC.
07:49
And again, you're looking for it to remain for
the white blood cell count above 3500.
07:54
And you're looking for the ANC to remain above
1500 to know that your patient is safe to
continue with the medication, at least in terms
of evading agranulocytosis.
08:05
Other therapies that can be helpful to your
patient include non-pharmacological approaches.
08:10
So think about behavioral treatment, things
like social skills, self-sufficiency training,
and how to act appropriately in public.
08:18
This can all be fostered through both
individual psychotherapy and group therapy.
08:23
So I want to ask you, though, what cognitive
problems can be seen in schizophrenia?
Well, sometimes there's a deficit in processing
complex information, maintaining a steady focus,
working memory or distinguishing between
relevant and irrelevant stimuli as well as
abstract thinking.
08:41
So these are good things to keep in mind when
dealing with a patient with schizophrenia.
08:46
And there can be limitations in terms of
training someone.
08:50
Sometimes it's difficult to generalize what
they learn in a group or a classroom to the real
world setting.
08:57
So how can you, as a therapist, best help your
patient with schizophrenia?
Well, be direct and straightforward and take an
active and assertive posture to treatment.
09:07
So we've summarized now the pharmacotherapy of
antipsychotics.
09:11
I've given you some of the highlights, keeping
in mind when these medications are indicated and
useful. And definitely keep in mind the side
effect profile as you're studying for your
boards.