RE: Group 2 Anti-psychotics
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KN is a 26 yo male with no comorbid disease state that was recently diagnosed with psychosis; a decision is being made to start an anti-psychotic.
- What is the major difference between atypical antipsychotics and the older typical ones?
- What medication would you treat this patient with and why?
- In this case what would you monitor for with respect to efficacy and side effects of the medication you prescribed.
- After 2 years of less than adequate response with various agents a decision was made to stop the antipsychotic and try lithium. What side effects must the APN monitor for in one taking lithium?
Anti-Psychotics
What is the major difference between atypical antipsychotic and the older typical ones?
The major difference between atypical and typical antipsychotics lies on their mode of action. While the typical antipsychotic targets the dopaminergic receptors, inhibiting the type 2 dopamine receptors, even though at a lower affinity, atypical ones blocks the dopaminergic receptors (D2) in addition to their high affinity for the serotonin receptors, 5-HT2A thus also affecting the serotonin levels (Rosenthal & Burchum, 2020).
What medication would you treat this patient with and why?
The medication that I would prescribe for this patient is the Clozapine atypical antipsychotic drug. The rationale for prescribing Clozapine is that it has a reduced tendency to evoke EPS and tardive dyskinesia besides having a wider spectrum of effectiveness such as considerably huge enhancements in negative, depressive and cognitive symptoms (Rosenthal & Burchum, 2020). Moreover, Clozapine has the highest efficacy compared to all other antipsychotics.
In this case what would you monitor for with respect to efficacy and side effects of the medication you prescribed?
With respect to efficacy of Clozapine, I would monitor the incidence of EPSs. Moreover, I would monitor the changes in positive, negative and cognitive symptoms over time.
Conversely, because Clozapine is associated with agranulocytosis as a great side effect, I would monitor the WBC count and the absolute neutrophil count (ANC). The ANC must be 2000/mm3 or greater and the WBC 3500/mm3 or greater at the beginning of Clozapine treatment. During then actual treatment, I would monitor both the WBC and ANC on a weekly basis for the beginning 6 months. Afterwards for the next 6 months, I would monitor the WBC and ANC after every 2 weeks. In case of drug withdrawal as a result of abnormal WBC and ANC values, I would monitor the blood counts for the subsequent 4 weeks. Moreover, because Clozapine is associated with weight gain as a metabolic side effect of central concern, I would monitor the body mass index at baseline, after 6 months and after 3 months thereafter. Furthermore, I would monitor the waist circumference at baseline and yearly thereafter (Rosenthal & Burchum, 2020). Besides, because Clozapine is associated with new-onset diabetes, I would monitor the fasting blood glucose at the beginning of the dose followed by 12 weeks later and yearly thereafter. Additionally, I would monitor the fasting lipid profile starting at the baseline and after every 6 months thereafter since Clozapine is associated with atherosclerosis and coronary heart disease.
After 2 years of less than adequate response with various agents a decision was made to stop the antipsychotic and try lithium. What side effects must be the APN monitor for in one taking lithium?
Lithium is associated with several side effects and thus the APN has to monitor several indicative signs and symptoms. Lithium affects the leukocytes count and can cause leukocytosis, thus, the APN should monitor the leucocytes count through measurement of complete blood count levels. Moreover, Lithium is associated with both hypothyroidism and hyperthyroidism, therefore, the APN should monitor the levels of thyroid hormones both the Thyroxine T4) and triiodothyroxine (T3). Furthermore, the APN should monitor the Renal function such as the glomerular filtration rate, the Blood Urea Nitrogen and Creatinine levels because Lithium is associated with the development of serious renal damage (Rosenthal & Burchum, 2020). Besides, the APN should monitor serum electrolytes such as Na+ ions since Lithium is associated with hyponatremia complications. Additionally, the blood glucose levels have to be monitored by the APN since Lithium is associated with nephrogenic diabetes insipidus. Fine tremors and polyuria might develop as a result of Lithium medication and thus should be considered indicative.
References
Rosenthal, L., & Burchum, J. (2020). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants-E-Book. Elsevier Health Sciences. https://books.google.com/books?hl=en&lr=&id=IPm9DwAAQBAJ&oi=fnd&pg=PP1&dq=lehne%27s+pharmacotherapeutics+for+advanced+practice+providers+second+edition&ots=rPYbfhGyMN&sig=3hPsHP3l2YdA6P4cKr0mcW5-HT0
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19 hours ago
Hollie De Block
RE: Group 2 Anti-psychotics
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Hi Jeanne,
Great post! I would agree Clozapine atypical drug would be a great choice for this patient. Also risperidone is a good choice, perhaps to be given if there was a failure in treatment being ineffective. Both of these medications act similarly, reducing positive effects. Clozapine does reduce more negative symptoms than risperidone. One the other hand risperidone is more cost effective. Most FGAs and SGAs are equally effective, except for clozapine, which is more effective than the rest. With regard to efficacy and safety, no single agent is clearly superior to the other. Initial selection criteria include efficacy, safety, and cost (Rosenthal & Burchum, 2021, p. 212).
In terms of lithium it should be monitored by blood work with labs being 0.4- 1 mEq/L. Blood work should be drawn in the morning 12 hours after evening dose and during maintenance therapy levels should be measured every 3 to 6 months (Rosenthal & Burchum, 2021, p. 230). Lithium toxicity side effects include diarrhea, vomiting, drowsiness, muscle weakness, tremors, unsteadiness, or other problems with muscle control or coordination.“Encephalopathic syndrome (brain problem) may occur in patients using this medicine together with a medicine to treat mental illness (eg, chlorpromazine [Thorazine®], clozapine [Clozaril®], fluphenazine [Prolixin®], haloperidol [Haldol®], perphenazine [Trilafon®], risperidone [Risperdal®], thioridazine [Mellaril®]). Check with your doctor right away if you have the following symptoms while using this medicine: fever, confusion, drowsiness, difficulty with speaking, uncontrolled body movements, and unusual tiredness or weakness” (Mayo Clinic, 2022).
When taking lithium one should monitor their salt intake as less salt makes lithium levels rise and increasing salt intake makes levels fall. Lithium is excreted by the kidneys and is affected by blood levels of sodium. Lithium excretion is reduced when levels of sodium are low, because the kidneys process lithium and sodium the same way. When the kidneys sense sodium levels are inadequate, it retains lithium in an attempt to compensate and then lithium tends to accumulate to toxic levels in the presence of low sodium (Rosenthal & Burchum, 2021, p. 230). Monitor caffeine intake as less caffeine can cause lithium levels to rise while more can cause it to lower. Alcohol should always be avoided. Other medications can also increase the risk of toxicity so patients must ensure to speak to their primary care provider. These medications include NSAIDs, diuretics, and anticholinergics. As there is no antidote for lithium, some treatment includes IV fluids, stomach pumping, monitoring vitals/ EKG/ blood and urine tests, hemodialysis, and meditations for possible seizure activity. Great points made, thanks for your post!
References:
Mayo Foundation for Medical Education and Research. (2022, February 1). Lithium (oral route) Side Effects. Mayo Clinic. Retrieved April 9, 2022, from https://www.mayoclinic.org/drugs-supplements/lithium-oral-route/side-effects/drg-20064603?p=1
Rosenthal, L., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.
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3 hours ago
Caterina Sousa
RE: Group 2 Anti-psychotics
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Hello Jeanne. Thanks for your informative post.
After reviewing the subject, I like to highlight some interesting points about the issue of treatment resistance in psychosis. This is particularly relevant given the reported recent increase in the incidence of mental health disorders in children and adolescents and that a large proportion of them are not receiving treatment (Reinert, n.d.).
Several factors were identified as predictors of treatment resistance:
- Lower premorbid functioning
- Lower level of education
- Negative symptoms from first psychotic episode
- Comorbid substance use
- Younger age at onset
- Lack of early response
- Non-adherence to treatment
- Longer duration of untreated psychosis (Bozzatello et al., 2019)
Investigations indicated that response to antipsychotic treatments begins in the first weeks of treatment, with the most considerable effect in reducing symptoms in the first two weeks. Remission was defined as a state of at least six months’ duration, in which no symptoms or only mild symptoms do not interfere with daily functioning. Some authors suggested that “patients who have not a minimal improvement after two weeks of treatment are unlikely to respond at a later phase and may benefit from a drug change.” The National Institute for Health and Care Excellence (NICE) criteria, as patients who had received two sequential antipsychotic trials, each of at least four weeks at a daily dose of 400–600 mg of chlorpromazine equivalents, but continued to have persistent psychotic symptoms. Findings showed that the most substantial effect on treatment resistance was exercised by the negative symptoms at the onset of illness. Other predictors of non-response and resistance were the younger age of onset and the diagnosis of schizophrenia. A lower degree of negative symptoms at baseline was responsible for a better response to treatment (Bozzatello et al., 2019).
In recent years, attempts to uncover neurobiological risk factors that predict treatment resistance. For example, authors have found that blunted cortisol awakening response and increased proinflammatory cytokines were considered strong predictive factors of non-response in the early phase of the illness. Neuroimaging findings suggest that poor treatment response is significantly related to the diminished volume of gray matter; in particular, subjects who did not respond to treatment showed hypogyria in bilateral insular regions, left frontal area, and right temporal area when compared with patients who responded. The potential relation to pituitary volume may be a predictor of response/non-response in psychosis at onset (Bozzatello et al., 2019).
Recent studies are suggestive of a tau-related neurodevelopmental disturbance in adolescent psychosis. Tau is a microtubule-associated protein with a crucial role in neuronal migration, differentiation, and maturation processes. Adolescents with early-onset psychosis (<18 years) display lower plasma tau concentrations and lower cortical orbitofrontal surface area compared to healthy subjects (Andreou et al., 2021).
Among all factors, two main predictors of resistance related to the disorder were the diagnosis of schizophrenia and younger age at onset. Substance use disorder is the most significant factor associated with treatment resistance and poor outcome among comorbidity conditions. Among others, lack of adherence to prescriptions, lack of early response (within two weeks) to antipsychotics, and prolonged duration of untreated psychosis are the most critical treatment-related factors that predict resistance (Bozzatello et al., 2019).
References
Andreou, D., Jorgensen, K. N., Nerland, S., Smelror, R. E., Wedervang-Resell, K., Johannessen, C. H., Myhre, A. M., Andreassen, O. A., Blennow, K., Zetterberg, H., &Agartz, I. (2021). Lower Plasma Total Tau In Adolescent Psychosis: Involvement of the Orbitofrontal Cortex. Journal of Psychiatric Research, 144, 255–261. https://doi.org/10.1016/j.jpsychires.2021.10.031
Bozzatello, P., Bellino, S., & Rocca, P. (2019). Predictive Factors of Treatment Resistance In First Episode of Psychosis: A Systematic Review. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00067
Reinert, M. (Ed.). (n.d.). The State of Mental Health in America. Mental Health America. Retrieved April 10, 2022, from https://mhanational.org/issues/state-mental-health-america
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