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3. Use of Antipsychotic Medications in the Acute Phase

  • Initiate antipsychotic medication as soon as it is feasible. It may be appropriate to delay pharmacologic treatment for patients who require more extensive diagnostic evaluation or who refuse medications or if psychosis is caused by substance use or acute stress reactions.

  • Discuss risks and benefits of the medication with the patient before initiating treatment, if feasible, and identify target symptoms (e.g., anxiety, poor sleep, hallucinations, and delusions) and acute side effects (e.g., orthostatic hypotension, dizziness, dystonic reactions, insomnia, and sedation).

  • Assess baseline levels of signs, symptoms, and laboratory values relevant to monitoring effects of antipsychotic therapy.

    • Measure vital signs (pulse, blood pressure, temperature).

    • Measure weight, height, and body mass index (BMI), which can be calculated with the formula weight in kilograms/(height in meters)2 or the formula 703 x weight in pounds/(height in inches)2 or with a BMI table: http://win.niddk.nih.gov/statistics/index.htm#table

    • Assess for extrapyramidal signs and abnormal involuntary movements.

    • Screen for diabetes risk factors and measure fasting blood glucose.

    • Screen for symptoms of hyperprolactinemia.

    • Obtain lipid panel.

    • Obtain ECG and serum potassium measurement before treatment with thioridazine, mesoridazine, or pimozide; obtain ECG before treatment with ziprasidone in the presence of cardiac risk factors.

    • Conduct ocular examination, including slit-lamp examination, when beginning antipsychotics associated with increased risk of cataracts.

    • Screen for changes in vision.

    • Consider a pregnancy test for women with childbearing potential.

  • Minimize acute side effects (e.g., dystonia) that can influence willingness to accept and continue pharmacologic treatment.

  • Initiate rapid emergency treatments when an acutely psychotic patient is exhibiting aggressive behaviors toward self or others.

    • Try talking to the patient in an attempt to calm him or her.

    • Restraining the patient should be done only by a team trained in safe restraint procedures.

    • Use short-acting parenteral formulations of first- or second-generation antipsychotic agents with or without parenteral benzodiazepine.

    • Alternatively, use rapidly dissolving oral formulations of second-generation agents (e.g., olanzapine, risperidone) or oral concentrate formulations (e.g., risperidone, haloperidol).

  • See Tables 1 and 2 and Figure 1 for guidance in determining somatic treatment.

  • Select medication depending on the following factors:

    • Prior degree of symptom response

    • Past experience of side effects

    • Side effect profile of prospective medications (see Table 3)

    • Patient's preferences for a particular medication, including route of administration

    • Available formulations of medications (e.g., tablet, rapidly dissolving tablet, oral concentrate, short- and long-acting injection)

  • Consider second-generation antipsychotics as first-line medications because of the decreased risk for extrapyramidal side effects and tardive dyskinesia.

    • For patients who have had prior treatment success or who prefer first-generation agents, these medications are useful and for specific patients may be the first choice.

    • With the possible exception of clozapine for patients with treatment-resistant symptoms, antipsychotics generally have similar efficacy in treating positive symptoms.

    • Second-generation antipsychotics may have superior efficacy in treating global psychopathology and cognitive, negative, and mood symptoms.

  • Consider long-acting injectable antipsychotic medication for patients with recurrent relapses related to partial or full nonadherence. The oral form of the same medication (e.g., fluphenazine, haloperidol, and risperidone) is the logical choice for initial treatment.

  • Titrate as quickly as tolerated to the target therapeutic dose (sedation, orthostatic hypotension, and tachycardia are generally the side effects that limit the rate of increase), and monitor clinical status for at least 2 to 4 weeks.

    • The optimal dose of first-generation antipsychotics is, for most patients, at the "extrapyramidal symptom (EPS) threshold," or the dose at which minimal rigidity is detectable on physical examination.

    • For second-generation antipsychotics, target dose usually falls within the therapeutic dose range specified by the manufacturer and in the package labeling approved by the U.S. Food and Drug Administration.

  • If the patient is not improving, consider whether the lack of response can be explained by medication nonadherence, rapid medication metabolism, or poor medication absorption.

  • Consider measuring plasma concentration for those medications for which plasma concentration relates to clinical response (e.g., haloperidol, clozapine).

  • If the patient is adhering to treatment and has an adequate plasma concentration but is not responding to treatment, consider raising the dose for a finite period (if tolerated) or switching medications.

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TABLE 1. Commonly Used Antipsychotic Medications

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Table Reference Number
TABLE 1. Commonly Used Antipsychotic Medications
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TABLE 2. Choice of Medication in the Acute Phase of Schizophrenia

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Table Reference Number
TABLE 2. Choice of Medication in the Acute Phase of Schizophrenia
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FIGURE 1. Somatic Treatment of Schizophrenia

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FIGURE 1. Somatic Treatment of Schizophrenia
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TABLE 3. Selected Side Effects of Commonly Used Antipsychotic Medications

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Table Reference Number
TABLE 3. Selected Side Effects of Commonly Used Antipsychotic Medications
Table Reference Number
TABLE 1. Commonly Used Antipsychotic Medications
Table Reference Number
TABLE 2. Choice of Medication in the Acute Phase of Schizophrenia
Table Reference Number
TABLE 3. Selected Side Effects of Commonly Used Antipsychotic Medications

References

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