1. Side effect of typical antipsychotics: NMS

-Lead pipe rigidity. 

-Fever

-Unstable vitals 

-CK can go high (when it gets >1,000,000, you may need to admit to dialyze) 

-Altered mental status. 

-Usually within the first week or two of taking the meds, but can happen idiosyncratically. Can eventually rechallenge with the same drug. 

2. Side effect of typical antipsychotics: Parkinsonism

-Classically Parkinson's develops unilaterally and med side effects present bilaterally. 

-Treat EPS with benztropine (ACh) rather than carbidopa/levodopa because it'll the latter will reverse the anti-dopamine effects and worsen psychosis 

-Bradykinesia, cogwheel rigidity, resting tremor

3. Side effect of typical antipsychotics: TD

-TD mostly presents orally, but can present in hands or feet or trunk. 

-People don't really notice they are doing it. 

-Irreversible. 

4. Side effect of typical antipsychotics: Dystonia

-oculogyric crisis

-laryngospasm

-torticollis (can treat w Botox since it's a large muscle you can inject). 

-Other treatments: antihistamines, benzos, benztropine. Can last hours or days. 

5. Side effect of typical antipsychotics: Akathesia

-Drug induced restlessness. People want to get up and walk/move around. 

-Feel anxious. 

-Most common w typical antipsychotics, but can happen with any psychotropic drug (even bupropion). -Can treat with benzos (first line), centrally acting b-blockers (second line)

-Persists with the duration of medicine, until  you change the meds or treat it. 

-Starts within weeks of taking the drug. 

6. Clozapine

-Clozapine works on serotonin receptors-- thus does not cause galactorrhea.
-It also works on dopamine, but hits D4 more than D2, which may explain why it is more effective than the other antipsychotics. 

-50-70% more effective than other antipsychotics. 

-People who partially or don't respond to other antipsychotics will respond to clozapine. 

-3% of white people get agranulocytosis -- may be lower in Asians (they use a lot of clozapine in china). 

-Black people have baseline WBC at 4-5, white people at 7-8. So black people can be hit harder. 

-Need weekly CBC at first 6 mos, then every 2 weeks, then monthly; you can't fill prescription without special form from doc and a lab white count. 

-5-10% of people who take it (>600mg/day dose) will develop seizures- best way to prevent is to use with valproate because it prevents seizures and boosts levels of clozapine. 

-Causes myocarditis. 

-Causes a lot of drooling, orthostatic hypotension.
-May treat tardive dyskinesia 

7. Antipsychotics that come in a immediate onset, short acting IM formulation:

-Haldol

-Ziprasidone (geodon) 

-Olanzapine (zyprexa): also very sedating, so a good choice to quickly take down a really crazy person. 

-Aripiprazole 

8. Antipsychotics that come in an long-acting IM formulation:

-Paliperidone (invega): monthly, derivative of haldol, medicare pays for it. 

-Risperidone 

-Haldol (should be q2 weeks, some people give it monthly)

-Fluphenazine (monthly)

-Olanzapine: nobody gives it though, bc the IM depot can cause life threatening hypotension. The instruction is to keep sb in your office for 3 hours to watch them after administration. 

9. Abilify:

-At low doses (~2mg) partial dopamine agonist, good for depression

-At high doses (~20-30mg) antagonist of dopamine, good for anti-psychotic. 

10. Seroquel:

-Low potency, doesn't bind D2 as tight, good for non-schizophrenics (i.e. organic or medication induced delirium)
-Only antipsychotic you'd use in diseases like MS or Lewy body dementia, where you don't want strong dopamine antagonism