Anti-Psychotic Prescribing Aid

Anti-Psychotic Prescribing Aid

Antipsychotic medications should be used with caution in the primary care setting. The general term “antipsychotic” relates to the fact that medications in this class are used to treat schizophrenia, although schizophrenia and other mental health conditions with psychosis are rare in youth. Older medicines in this group are sometimes called “first generation antipsychotics” or FGAs and newer medicines in this group, which are used much more frequently and have some differences in their chemical effects from older agents, are sometimes called “second generation antipsychotics” or SGAs. In the pediatric population, SGAs are most often used to treat severe mood and/or aggressive behaviors. Most of this use is off label and comes with significant risk to patients, and proper use of these medicines involves weighing the risks and benefits of these medications and monitoring for common side effects.

Atypical Oral Antipsychotic Medications
Generic Name Brand Name Dosage Forms Starting Dose Max Daily Dose Notes
Aripiprazole Abilify

2 mg, 5mg, 10mg, 15 mg, 20 mg, 30 mg

Oral dissolving tablet: 10 mg, 15 mg

Liquid 1mg/ml

Oral: 2-5 mg Oral: 30 mg

Can help to lower the prolactin level if it has been raised by other medications

Works as partial agonist of Dopamine and Serotonin, whereas other antipsychotic medications are primarily Dopamine antagonists

Asenapine Saphris 2.5 mg, 5 mg, 10 mg (sublingual) 2.5 mg 20 mg

Sublingual, NOT swallowed; no PO for 10 minutes after;

Usually BID dosing

Clozapine Clozaril

25 mg, 50 mg, 100 mg, 200 mg

Oral dissolving tablet: 12.5 mg, 25 mg, 100 mg, 150 mg, 200 mg Liquid 50 mg/ml 25 mg, 50 mg, 100 mg, 200 mg

Oral dissolving tablet: 12.5 mg, 25 mg, 100 mg, 150 mg, 200 mg Liquid 50 mg/ml

25 mg 600-900 mg

May cause agranulocytosis, increase seizure risk;

Patient-specific registry (REMS) and requires highly regulated monitoring protocol; rarely prescribed by primary care physicians

Lurasidone Latuda 20 mg, 40 mg, 60 mg, 80 mg, 120 mg 20 mg 160 mg (80-160) Take with food (at least 350 cal)
Olanzapine Zyprexa

2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg

Oral dissolving tablet: 5 mg, 10 mg, 15 mg, 20 mg

5 mg 20-30 mg Metabolic effects can be prominent, associated with prolactin elevation
Paliperidone Invega 1.5 mg, 3 mg, 6 mg, 9 mg 1.5-3 mg 12 mg

Metabolite of risperidone with less hepatic metabolism

Associated with prolactin elevation

Tablets are XR OROS delivery system, an advanced controlled release system

Quetiapine Extended Release Seroquel XR XR 50 mg, 150 mg, 200 mg, 300 mg, 400 mg 50 mg 800 mg daily Allows for once daily quetiapine dosing
Quetiapine Seroquel 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400mg 25-50 mg 800 mg (Divided BID)

Can cause excessive sedation, orthostasis

Associated with less EPS

Risperidone Risperdal

0.25 mg, 0.5 mg, 1 mg, 2mg, 3 mg, 4 mg

Oral dissolving tab: 0.5 mg, 1 mg, 2 mg, 3 mg , 4 mg

Liquid 1 mg/1 ml

0.25-0.5 mg 4-6 mg (Divided BID) Associated with prolactin elevation, gynecomastia Dose-dependent EPS
Ziprasidone Geodon 20 mg, 40 mg, 60 mg, 80 mg 10-20 mg 160 mg (Divided BID)

Can cause QTc prolongation

Take with food (at least 500 cal)

 

See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.

Medicaid Unified Preferred Drugs List

 

Newest Antipsychotic Medications (Use of these agents in children and adolescents is off-label and not currently mainstream practice)
Generic Name Brand Name Dosage Forms Starting Dose Max Dose Notes
Brexipiprazole Rexulti 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg      
Cariprazine Vraylar 1.5 mg, 3 mg, 4.5 mg, 6 mg      
Iloperidone Fanapt 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg     Can cause QTc prolongation, orthostasis
Lumateperone Caplyta 42 mg      

 

Antipsychotics: Long-Acting Injectable Medications (Consultation with a psychiatrist is recommended prior to initiation and monitoring.)
Generic Name Brand Name Dosing Forms
Aripiprazole Abilify Maintena 300 mg, 400 mg
Aripiprazole Abilify Aristada 441 mg, 662 mg, 882 mg, 1064mg
Olanzapine Zyprexa Relprevv 210 mg, 300 mg, 405 mg
Paliperidone Invega Sustenna 39 mg, 78 mg, 117 mg, 156 mg, 234 mg
Paliperidone Invega Trinza 273 mg, 410 mg, 546 mg, 819 mg
Risperidone Risperdal Consta 12.5 mg, 25 mg, 37.5 mg, 50 mg

 

Atypical Antipsychotic FDA Approvals by Age Groups (Empty boxes not FDA approved)
  Manic/mixed, acute Manic/mixed, maint. Bipolar - depressed Schizoaffective d/o Schizophrenia Aggression in ASD
Aripiprazole ≥10 ≥10     ≥13 ≥6
Asenapine ≥10       ≥18  
Brexpiprazole         ≥18  
Cariprazine ≥18       ≥18  
Clozapine         ≥18  
Iloperidone         ≥18  
Lumateperone         ≥18  
Lurasidone     ≥10   ≥13  
Olanzapine ≥13     ≥13    
Paliperidone     ≥18 ≥18 ≥12  
Quetiapine ≥10 (manic, not mixed)       ≥13  
Risperidone ≥10       ≥13 ≥5
Ziprasidone ≥18       ≥18  

 

Monitoring Guidelines for Most Atypical Antipsychotics (not clozapine):
  Baseline 3 mo. after starting 6 monthly Annually
CBC/diff X     X
Fasting BMP (incl. glucose) X     X
Fasting Glucose     X  
LFTs X X   X
Fasting Lipid Panel X   X X
Height/weight/BMI X X X X
HR/BP X X   X
AIMS (for tardive dyskinesia) X X   X
Prolactin EKG
Recommendations vary: Consider checking at baseline and q6months if taking risperidone/paliperidone or symptomatic (breast enlargement, nipple discharge, changes in menstruation and sexual functioning);

Check if:

1) fam hx of prolonged QT or sudden cardiac death in 1st-degree relatives

2) personal hx of murmur, arrhythmia, tachycardia at rest, dizziness/syncope on exertion

3) co-treatment with another QTc-prolonging med

Also: consider insulin and hemoglobin A1C and obtain vitamin B12 level if on or considering metformin.