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  • Antispychotics are warranted in acute episodes of mania and hypomania

  • 2nd generation or atypical antispychotics are  licensed for the treatment of mania, which include : 

 

 

 

 

 

 

 

  • They may be used in isolation or combination with lithium or valproate where the patient suffers from frequent relapses or continuing functional impairment 

 

  • Combination therapy with lithium or valproate may also be considered in the initial stages of severe acute mania

 

  • Drowsiness: patients must be warned about feeling drowsy especially in the initial stages of treatment, as it may affect their driving or other skills 

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  • Withdrawal: If the  patient is continuing with other antimanic drugs, the dose should be gradually reduced over 4 weeks

​If the patient has a history of manic relapse or if they are NOT currently takin other antimanic drugs the dose should be gradually reduced over 3 months  

 

 

A closer look at antipsychotics

 

Olanzepine

  • Formally licencsed as prophylactic treatment 

  • More effective than placebo IN mania 

  • Atleast as effective as valproate and lithium 

  • Most effective when used in combination with a mood stabiliser 

  • May be beneficial in patients who are on long term treatment 

  • May be more effective than lithium 

  • Present in breast milk therefore should be avoided 

 

Quetiapine 

  • Data relasing to questiapine suggests robust efficacy in all aspects of bipolar

  • Sedative anxiolytic,  antimanic mood stabilising and antidepressant prop  

  • Patients must be advised to take on an empty stomach and swallow WHOLE in cases of modified release preparations 

 

Asenapine 

  • Licensed for moderate-severe manic episodes in bipolar patients 

  • As effective as olanzepine 

  • Administered sublingually 

  • Must be avoided in breastfeeding : no information is available 

  • During long term treatment, efficacy remains consistent 

  • Less sedating compared to olanzepine with a similar low propensity for akathesia and other movement disorders 

  • Less likely to cause weight gain and metabolic disturbances 

 

Risperidone 

Shown efficacy in mania, especially when used as combination therapy with mood stabilisers

 

Pregnancy

Extrapyrimidal and withdrawal  effects have occassionally been reported in neonates when antipsychotics are taken dring the third trimester 

 

The neonate must also be monitored for the following: 

  • agitation

  • hypotonia

  • tremor

  • drowsiness 

  • feeding issues

  • respiratory distress 

 

Breast feeding 

Long term treatment in patients taking antipsychotics should be avoided unless absolutely necessary 

 

Antipsychotics must be use with CAUTION in the following:

  • Patients with cardiovascular disease (ECG may be required, especially if physical examinations confirm cardiovascular risk factors )

  • Patients with a personal history of cardiovascular disease 

  • In patients admission 

  • Paskinson patients  ; parkinsons may be exacerbated by the use of these drugs 

  • Epiletic patients 

  • Depressive patients 

  • Myasthenia gravis 

  • Prostatic hypertrophy 

  • Patients suffering from sevre respiratpory disease 

  • Patients with a personal history of jaundice or blood dyscrasis

  • Schizophrenic patients  

  • Patients with a susceptibility with angle closure glaucoma â€‹

  • ​Patients must avoid sunlight as higher doses of antipsychotics may induce photosensitivity

 

 

Contraindications

  • CNS depression

  • Comatose states

  • Phaeochromocytoma 

 

Renal patients

Small doses should be intitaed in patients with severe renal impairment due to increased cerebral sensitivity 

 

Hepatic patients

In hepatic impairment, antipscyhotics can induce coma 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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  • Olanzepine 

  • Quetiapine 

  • Risperidone

  • Aripriprazole

  • Asenapine 

 

Monitoring 

Baseline measurements are taken at the start of antipsychotic therapy  

 

In a primary care setting, patients should be monitored for the following:

Body weight: 3 months after starting treatment, then every 12 months, or more often if the person is gaining weight rapidly.

Serum electrolytes and urea including creatinine and estimated glomerular filtration rate — on an annual basis

Full blood count : on an annual basis 

Blood lipids:  3 months after starting treatment, then on an annual basis

Plasma glucose:  4–6 months after starting treatment, then every 12 months.

In the case of clozapine and olanzapine repeat after the first month  

Ask about symptoms of hyperglycaemia (such as polydipsia, polyuria, and increased appetite).

Blood pressure: frequently during dose titration. Not required for amisulpride, aripiprazole, trifluoperazine, and sulpiride.

Electrocardiography : after dose changes. Ideally, also annually.

Mandatory for haloperidol, pimozide, and sertindole; not required for antipsychotics with no effect, or a low-to-moderate effect, on the QT interval and no other risk factors for arrhythmia.

Prolactin: 6 months after starting treatment, then every 12 months. Patients should be asked about symptoms of raised prolactin (these include low libido, sexual dysfunction, menstrual abnormalities, gynaecomastia, and galactorrhoea).Not required for aripiprazole, clozapine, quetiapine, or olanzapine (less than 20 mg daily).

Liver function tests: on an annual basis

Creatinine phosphokinase : measure again only if neuroleptic malignant syndrome is suspected.Tests which need to be done every 12 months may be carried out at the annual physical review.

 

Drug interactions common with all antipsychotics include the following :

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  • Grapefruit juice: must be avoided in patients taking pimozide as it increases pimozide concentrations. High concetrations of pimozide can possibly result in fatal arrythmias or Torsades de Points   

  • SSRIs: increases the levels of some antipsychotics 

  • Carbamazepine : halves the plasma concentrations of  clozapine, haloperidol, and risperidone. Levels of aripiprazole, fluphenazine, olanzapine, quetiapine, and sertindole are also reduced by carbamzaepine.

  • Diuretics: may cause hypokalaemia, which may increase the risk of arrhythmias; monitor potassium levels in people taking diuretics.

  • Sedative drugs e.g. TCAs, alcohol, analgesics, antihistamines: enhance the sedative effects of antipsychotics 

  • Antihypertensives: will enhance the hypotensive effect of antipsychotic 

  • Smoking cessation : reduces metabolism of  olanzepine and clozapine. In such cases, the patients should be monitored for increased adverse effects.  

Antipsychotics 

 

 

 

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