Atypical Antipsychotics

The ‘atypical antipsychotics’ may be better tolerated than other antipsychotics; extrapyramidal symptoms may be less frequent than with older antipsychotics. the atypical antipsychotics should be considered when choosing first-line treatment of newly diagnosed schizophrenia. an atypical antipsychotic is considered the treatment option of choice for managing an acute schizophrenic episode when discussion with the individual is not possible. an atypical antipsychotic should be considered for an individual who is suffering unacceptable side-effects from a conventional antipsychotic. an atypical antipsychotic should be considered for an individual in relapse whose symptoms were previously inadequately controlled. changing to an atypical antipsychotic is not necessary if a conventional antipsychotic controls symptoms adequately and the individual does not suffer unacceptable side-effects.

AMISULPRIDE:

Indications: schizophrenia and other psychoses.

Contraindications: the possibility of cerebrovascular events should be considered carefully before treating any patient with a history of stroke or transient ischaemic attack; risk factors for cerebrovascular disease (e.g. hypertension, diabetes, smoking, and atrial fibrillation) should also be considered. also phaeochromocytoma, prolactin-dependent tumours; pregnancy and breast-feeding.

Dose and Administration: Acute psychotic episode, 400–800 mg daily in 2 divided doses, adjusted according to response; max. 1.2 g daily; child under 15 years not recommended. Predominantly negative symptoms, 50–300 mg daily; child under 15 years not recommended.

ARIPIPRAZOLE:

Indications: Bipolar Disorder in Remission, Depression Treatment Adjunct, Manic Bipolar Disorder, Mixed Bipolar I Disorder, and Schizophrenia.

Contraindications: Lactating Mother, Chronic Heart Failure, Metabolic Syndrome X, Neuroleptic Malignant Syndrome, Senile Dementia, Suicidal Ideation, Tardive Dyskinesia.

Dose and Administration: Schizophrenia, by mouth, adult over 18 years 10– 15 mg once daily, usual maintenance 15 mg once daily; max. 30 mg once daily. Mania, by mouth, adult over 18 years, 15 mg once daily, increased if necessary; max. 30 mg once daily.

CLOZAPINE:

Indications: Suicidal Behavior in Schizoaffective Disorder, Suicidal Behavior in Schizophrenia, Treatment-Resistant Schizophrenia, Bipolar Disorder in Remission, Manic Bipolar Disorder.

Contraindications: Agranulocytosis, Alcohol-Induced Psychosis, CNS Depression, Coma, Lactating Mother, Neoplastic Myeloproliferative Disorders, Neuroleptic Malignant Syndrome, Paralytic Ileus, Severe Neutropenic Disorder, Substance Overdose, Uncontrolled Epilepsy, Benign Prostatic Hypertrophy, Bladder Outflow Obstruction, Coronary Artery Disease, Deep Venous Thrombosis, Dehydration, Dilated Cardiomyopathy, Eosinophilia, Fainting, Hypotension, Hypovolemia, Leukopenia, Lower Abdominal Procedure, Lower Seizure Threshold, Metabolic Syndrome X, Myocarditis, Narrow Angle Glaucoma, Orthostatic Hypotension, Pulmonary Thromboembolism, Respiratory Depression, Seizure Disorder, Senile Dementia.

Dose and Administration: Schizophrenia, adult over 16 years, 12.5 mg once or twice (elderly 12.5 mg once) on first day then 25–50 mg (elderly 25–37.5 mg) on second day then increased gradually (if well tolerated) in steps of 25–50 mg daily (elderly max. increment 25 mg daily) over 14–21 days up to 300 mg daily in divided doses (larger dose at night, up to 200 mg daily may be taken as a single dose at bedtime); if necessary may be further increased in steps of 50–100 mg once (preferably) or twice weekly; usual dose 200–450 mg daily (max. 900 mg daily). Psychosis in Parkinson’s disease, adult over 16 years, 12.5 mg at bedtime then increased according to response in steps of 12.5 mg up to twice weekly; usual dose range 25–37.5 mg at bedtime, usual max. 50 mg daily; exceptionally, dose may be increased further in steps of 12.5 mg weekly to max. 100 mg daily in 1–2 divided doses.

OLANZAPINE:

Indications: Bipolar Disorder, Bipolar Disorder in Remission, Manic Bipolar Disorder, Mixed Bipolar I Disorder, and Schizophrenia.

Contraindications: Agranulocytosis, Breast Carcinoma, Cerebrovascular Accident, Cerebrovascular Disorder, Conduction Disorder of the Heart, Diabetes Mellitus, Heart Failure, Leukopenia, Metabolic Syndrome X, Myocardial Infarction, Myocardial Ischemia, Neuroleptic Malignant Syndrome, Neutropenic Disorder, Obesity, Paralytic Ileus, Senile Dementia, Suicidal Ideation, Transient Cerebral Ischemia.

Dose and Administration: Schizophrenia, combination therapy for mania, preventing recurrence in bipolar disorder, by mouth, adult over 18 years, 10 mg daily adjusted to usual range of 5–20 mg daily; doses greater than 10 mg daily only after reassessment; max. 20 mg daily. Monotherapy for mania, by mouth, adult over 18 years, 15 mg daily adjusted to usual range of 5–20 mg daily; doses greater than 15 mg only after reassessment; max. 20 mg daily. Control of agitation and disturbed behaviour in schizophrenia or mania, by intramuscular injection, adult over 18 years, initially 5–10 mg (usual dose 10 mg) as a single dose followed by 5–10 mg after 2 hours if necessary; elderly initially 2.5–5 mg as a single dose followed by 2.5–5 mg after 2 hours if necessary; max. 3 injections daily for 3 days; max. daily combined oral and parenteral dose 20 mg.

QUETIAPINE:

Indications: Bipolar Disorder, Bipolar Disorder in Remission, Depression associated with Manic Depressive Disorder, Manic Bipolar Disorder, Schizophrenia.

Contraindications: Constipation, Dizziness, Drowsy, Dyspepsia, Insomnia, Nasal Congestion, Orthostatic Hypotension, Weight Gain, and Xerostomia.

Dose and Administration: Schizophrenia, 25 mg twice daily on day 1, 50 mg twice daily on day 2, 100 mg twice daily on day 3, 150 mg twice daily on day 4, then adjusted according to response, usual range 300–450 mg daily in 2 divided doses; max. 750 mg daily; elderly initially 25 mg daily as a single dose, increased in steps of 25–50 mg daily in 2 divided doses. Mania, 50 mg twice daily on day 1, 100 mg twice daily on day 2, 150 mg twice daily on day 3, 200 mg twice daily on day 4, then adjusted according to response in steps of up to 200 mg daily to max. 800 mg daily; usual range 400–800 mg daily in 2 divided doses; elderly initially 25 mg daily as a single dose, increased in steps of 25–50 mg daily in 2 divided doses; child under 18 years, not recommended.

RISPERIDONE:

Indications: Infantile Autism, Manic Bipolar Disorder, Mixed Bipolar I Disorder, and Schizophrenia.

Contraindications: Lactating Mother, Neuroleptic Malignant Syndrome, Agranulocytosis, Breast Carcinoma, Cerebrovascular Disorder, Chronic Heart Failure, Conduction Disorder of the Heart, Dehydration, Diabetes Mellitus, Diffuse Lewy Body Disease, Disease of Cardiovascular System, Hypotension, Hypovolemia, Leukopenia, Metabolic Syndrome X, Myocardial Infarction, Neutropenic Disorder, Parkinsonism, Predisposed to Torsades de Pointes Cardiac Arrhythmias, Senile Dementia, Severe Renal Disease, Tardive Dyskinesia.

Dose and Administration: Psychoses, 2 mg in 1–2 divided doses on first day then 4 mg in 1–2 divided doses on second day (slower titration appropriate in some patients); usual dose range 4–6 mg daily; doses above 10 mg daily only if benefit considered to outweigh risk (max. 16 mg daily); elderly initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1– 2 mg twice daily. Mania, initially 2 mg once daily, increased if necessary in steps of 1 mg daily; usual dose range 1–6 mg daily; elderly initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1–2 mg twice daily.​