**Be familiar with both Generic and brand names of medications - All exams will
have the Generic names of meds**
1. Study guides provided in the course shell (under course content)
2. Knowledge Checks in PowerPoint slides
3. Recap videos under each discussion week- if you missed these or need a refresher
4. Worksheets-optional
Review the 4 Dopamine pathways – Symptoms of breast tenderness, spontaneous lactation,
and menstrual irregularities occur when dopamine is decreased in the Tuberoinfundibular
pathway – Hyperprolactinemia
Mesolimbic: DA hyperactivity = Positive sx
Neurotransmitters increase DA in the mesolimbic area
Hallucinations, delusions, etc
Excess DA in this pathway will produce positive psychotic sx
Mesocortical: DA deficit = Negative sx.
Neurotransmitters decrease DA activity in the mesocortical area
i.e. cognition, affect, apathy, behavior, etc
believed negative sx are r/t a deficit of DA in this particular pathway
Nigrostriatal: blockade of DA in this pathway produces increased motor movements
Dopamine blockade in this pathway = decrease DA = increase ACh
Deficient DA in this pathway causes movement disorders
e.g. EPS (Pseudo parkinsonism, Akathisia, dystonia & TD
Tardive: D2 blockade in this pathway. Late occurring, mostly irreversible
Tuberoinfundibular: D2 blockade = Hyperprolactin. Common w/Risperdal
Dopamine inhibits prolactin
Blockade of DA = decrease DA = increase Prolactin
Sx of elevated prolactin levels: galactorrhea, amenorrhea, possible sexual dysfunction
**Important Note: Dopamine inhibits prolactin
Therefore: Blockade of dopamine = decrease DA = increase Prolactin
,WEEK 2 Management of Acute Psychosis
IM haloperidol should be administered with benztropine (Cogentin) or diphenhydramine to
reduce the risk oof severe EPS or dystonia
Severely agitated patients: use a benzodiazepine combination w/the antipsychotic
(e.g. Haldol + Lorazepam + Cogentin)
**Important Note
Antipsychotic polypharmacy can increase the risk for re-hospitalization, diabetes, EPS, sedation,
seizures, metabolic effects, mortality, and sudden cardiac death.
Know the meds that are First generation (e.g. Haldol, Chlorpromazine) vs. Second generation
(e.g. Risperidone, Olanzapine, Quetiapine)
FGA/Typical/1st generation SGA/Atypical/2nd generation
-block D2 receptors -serotonin-dopamine antagonist
Haloperidol (Haldol) Risperidone (Risperdal)
Can be given PO/IM/IV; Decanoate (LAI) Greatest prolactin elevation
Given in acute agitation or psychosis S/E: NMS
S/E: Neuroleptic Malignant Syndrome (NMS)
Chlorpromazine (Thorazine) Olanzapine (Zyprexa)
Can cause blue-gray skin discoloration and corneal/lens deposits Acute agitation IM acts w/in 15 min
Causes Orthostatic hypotension Monitor for dose-related hyperprolactinemia
Also used for N/V & intractable hiccups Relprevv (injection)= monitor 3 hrs d/t risk delirium & sedation
PO & IM formulation (effective for agitation in emergencies) S/E: NMS
Fluphenazine (Prolixin) Quetiapine (Seroquel)
PO/IM. Decanoate (LAI) available Strongest H1 antagonism
S/E: Neuroleptic Malignant Syndrome (NMS)
Perphenazine (Trilafon) Clozapine (Clozaril)
S/E: NMS, hypersalivation (sialorrhea)
Lowest risk of TD
Only antipsychotic shown to decrease SI risk
Agranulocytosis
Loxapine (Loxitane) Ziprasidone (Geodon)
Higher risk of seizures Weight neutral
Thioridazine (Mellaril) Aripiprazole (Abilify)
Associated w/retinitis pigmentosa Weight neutral
watch for orthostatic hypotension
adjunctive tx of depression, bipolar
Trifluoperazine (Stelazine) Pimavanserin (Nuplazid)
Approved for nonpsychotic anxiety Used in Parkinson’s related psychosis (newer med)
** Haldol and Prolixin: watch for allergic Lurasidone (Latuda)
reactions in patients sensitive to sesame Low risk for metabolic syndrome
Use w/caution in pts w/hepatic impairment
Manage positive sx of schizophrenia First line tx
Can worsen negative sx secondary to decrease DA in the Accounts for 80% of total antipsychotics prescribed
Mesocortical pathway Effective for both positive and negative symptoms
S/E: QTC prolongation -obtain baseline EKG MOA: blocks both D2 and 5HT2A
Orthostasis -blockade of a1 receptors Can cause EPS but at a lower risk
Elevated liver enzymes: EPS, Akathisia, dystonia, Parkinsonism Lower incidence oof TD
Hyperprolactinemia
Higher risk of causing TD
, Clozapine (Clozaril)
Agranulocytosis in 1% of patients
Only antipsychotic shown to decrease SI risk
Hypersalivation (sialorrhea) occurs in 30-80%
Monitor WBC and absolute neutrophil count (ANC)
D/C med if ANC is <1.5 (1500)
Monitor weekly for 6 months
REM system: patient database
Tx for Hypersalivation (sialorrhea)
Medication: Glycopyrrolate (Robinul) – fewer anticholinergic s/e
Benztropine, Artane
Chew sugarless gum
Common adverse effects: HTN, hypotension, tachycardia, dyslipidemia, weight gain,
constipation, sialorrhea, drowsiness/sedation
Note: Smoking induces CYP1A2 enzymes and lowers the levels of certain antipsychotic
medications
BLACKBOX warning for ALL antipsychotics:
Increase risk of death when used in the elderly and those w/dementia related psychosis
Increase risk of falls and non-vertebral fractures in patients 65+
No antipsychotic medication is approved in pts w/dementia
Mechanism of Action for FGA – is primarily D2 receptor blockade (e.g. Haloperidol,
Chlorpromazine, Fluphenazine). Mechanism of Action of SGA is primarily D2 receptor
blockade and 5HT2a antagonism (e.g. Risperidone, Clozapine, Olanzapine, etc.)
Antipsychotics: not just used for psychosis or Schizophrenia. Used for for mania and
depression in Bipolar Disorder. Off-label for many disorders including mood, anxiety, PTSD
have the Generic names of meds**
1. Study guides provided in the course shell (under course content)
2. Knowledge Checks in PowerPoint slides
3. Recap videos under each discussion week- if you missed these or need a refresher
4. Worksheets-optional
Review the 4 Dopamine pathways – Symptoms of breast tenderness, spontaneous lactation,
and menstrual irregularities occur when dopamine is decreased in the Tuberoinfundibular
pathway – Hyperprolactinemia
Mesolimbic: DA hyperactivity = Positive sx
Neurotransmitters increase DA in the mesolimbic area
Hallucinations, delusions, etc
Excess DA in this pathway will produce positive psychotic sx
Mesocortical: DA deficit = Negative sx.
Neurotransmitters decrease DA activity in the mesocortical area
i.e. cognition, affect, apathy, behavior, etc
believed negative sx are r/t a deficit of DA in this particular pathway
Nigrostriatal: blockade of DA in this pathway produces increased motor movements
Dopamine blockade in this pathway = decrease DA = increase ACh
Deficient DA in this pathway causes movement disorders
e.g. EPS (Pseudo parkinsonism, Akathisia, dystonia & TD
Tardive: D2 blockade in this pathway. Late occurring, mostly irreversible
Tuberoinfundibular: D2 blockade = Hyperprolactin. Common w/Risperdal
Dopamine inhibits prolactin
Blockade of DA = decrease DA = increase Prolactin
Sx of elevated prolactin levels: galactorrhea, amenorrhea, possible sexual dysfunction
**Important Note: Dopamine inhibits prolactin
Therefore: Blockade of dopamine = decrease DA = increase Prolactin
,WEEK 2 Management of Acute Psychosis
IM haloperidol should be administered with benztropine (Cogentin) or diphenhydramine to
reduce the risk oof severe EPS or dystonia
Severely agitated patients: use a benzodiazepine combination w/the antipsychotic
(e.g. Haldol + Lorazepam + Cogentin)
**Important Note
Antipsychotic polypharmacy can increase the risk for re-hospitalization, diabetes, EPS, sedation,
seizures, metabolic effects, mortality, and sudden cardiac death.
Know the meds that are First generation (e.g. Haldol, Chlorpromazine) vs. Second generation
(e.g. Risperidone, Olanzapine, Quetiapine)
FGA/Typical/1st generation SGA/Atypical/2nd generation
-block D2 receptors -serotonin-dopamine antagonist
Haloperidol (Haldol) Risperidone (Risperdal)
Can be given PO/IM/IV; Decanoate (LAI) Greatest prolactin elevation
Given in acute agitation or psychosis S/E: NMS
S/E: Neuroleptic Malignant Syndrome (NMS)
Chlorpromazine (Thorazine) Olanzapine (Zyprexa)
Can cause blue-gray skin discoloration and corneal/lens deposits Acute agitation IM acts w/in 15 min
Causes Orthostatic hypotension Monitor for dose-related hyperprolactinemia
Also used for N/V & intractable hiccups Relprevv (injection)= monitor 3 hrs d/t risk delirium & sedation
PO & IM formulation (effective for agitation in emergencies) S/E: NMS
Fluphenazine (Prolixin) Quetiapine (Seroquel)
PO/IM. Decanoate (LAI) available Strongest H1 antagonism
S/E: Neuroleptic Malignant Syndrome (NMS)
Perphenazine (Trilafon) Clozapine (Clozaril)
S/E: NMS, hypersalivation (sialorrhea)
Lowest risk of TD
Only antipsychotic shown to decrease SI risk
Agranulocytosis
Loxapine (Loxitane) Ziprasidone (Geodon)
Higher risk of seizures Weight neutral
Thioridazine (Mellaril) Aripiprazole (Abilify)
Associated w/retinitis pigmentosa Weight neutral
watch for orthostatic hypotension
adjunctive tx of depression, bipolar
Trifluoperazine (Stelazine) Pimavanserin (Nuplazid)
Approved for nonpsychotic anxiety Used in Parkinson’s related psychosis (newer med)
** Haldol and Prolixin: watch for allergic Lurasidone (Latuda)
reactions in patients sensitive to sesame Low risk for metabolic syndrome
Use w/caution in pts w/hepatic impairment
Manage positive sx of schizophrenia First line tx
Can worsen negative sx secondary to decrease DA in the Accounts for 80% of total antipsychotics prescribed
Mesocortical pathway Effective for both positive and negative symptoms
S/E: QTC prolongation -obtain baseline EKG MOA: blocks both D2 and 5HT2A
Orthostasis -blockade of a1 receptors Can cause EPS but at a lower risk
Elevated liver enzymes: EPS, Akathisia, dystonia, Parkinsonism Lower incidence oof TD
Hyperprolactinemia
Higher risk of causing TD
, Clozapine (Clozaril)
Agranulocytosis in 1% of patients
Only antipsychotic shown to decrease SI risk
Hypersalivation (sialorrhea) occurs in 30-80%
Monitor WBC and absolute neutrophil count (ANC)
D/C med if ANC is <1.5 (1500)
Monitor weekly for 6 months
REM system: patient database
Tx for Hypersalivation (sialorrhea)
Medication: Glycopyrrolate (Robinul) – fewer anticholinergic s/e
Benztropine, Artane
Chew sugarless gum
Common adverse effects: HTN, hypotension, tachycardia, dyslipidemia, weight gain,
constipation, sialorrhea, drowsiness/sedation
Note: Smoking induces CYP1A2 enzymes and lowers the levels of certain antipsychotic
medications
BLACKBOX warning for ALL antipsychotics:
Increase risk of death when used in the elderly and those w/dementia related psychosis
Increase risk of falls and non-vertebral fractures in patients 65+
No antipsychotic medication is approved in pts w/dementia
Mechanism of Action for FGA – is primarily D2 receptor blockade (e.g. Haloperidol,
Chlorpromazine, Fluphenazine). Mechanism of Action of SGA is primarily D2 receptor
blockade and 5HT2a antagonism (e.g. Risperidone, Clozapine, Olanzapine, etc.)
Antipsychotics: not just used for psychosis or Schizophrenia. Used for for mania and
depression in Bipolar Disorder. Off-label for many disorders including mood, anxiety, PTSD
