Clinical Handbook of Psychotropic Drugs · 2021. 7. 12. · Clinical Handbook of Psychotropic Drugs...

Ric M. ProcyshynKalyna Z. Bezchlibnyk-ButlerJ. Joel Jeffries(Editors)

Clinical Handbook of

Psychotropic Drugs

24

This document is for personal use only. Reproduction or distribution is not permitted. From Ric M. Procyshyn, Kalyna Z. Bezchlibnyk-Butler, &J. Joel Jeffries: Clinical Handbook of Psychotropic Drugs, 24th edition (ISBN 9781616765934) © 2021 Hogrefe Publishing.

HOW TO USE THIS BOOKThe Clinical Handbook of Psychotropic Drugs uses color coding and icons for intuitivenavigation:– Blue sections contain general information on drugs / treatments and their

availability.– Green sections cover drug action and dosing.– Red sections outline warnings and precautions.– Orange sections detail patient-related information, such as considerations for

special populations, nursing and patient advice.This page provides a summary of the colors and icons used.At the end of each chapter, additional useful sources of information are listed as��

��Further Reading

General Information / Availability��

��Classification, Definition�

��Product Availability

Indications��

��General Comments

Pharmacology / Mechanisms of Action��

��Pharmacology�

��Pharmacological & Psychiatric Effects�

��Dosing�

��Pharmacokinetics�

��Onset and Duration of Action�

��Switching, Augmentation Strategies

Warnings and Precautions��

��Adverse Effects�

��Contraindications�

��Discontinuation Syndrome�

��Precautions�

��Toxicity�

��Food Interactions�

��Drug Interactions

Patient-Related Issues��

��Lab Tests / Monitoring�

��Pediatric Considerations�

��Geriatric Considerations�

��Use in Pregnancy�

��Medicolegal Issues�

��Nursing Implications, Treatment�

��Patient Instructions

Clinical Handbook of Psychotropic Drugs24th edition

Ric M. Procyshyn, BScPharm, MSc, PharmD, PhD(A, B) (Principal Editor)Kalyna Z. Bezchlibnyk-Butler, BScPhm, FCSHP (Co-Editor)

J. Joel Jeffries, MB, FRCPC, DFCPA(C) (Co-Editor)The Editors wish to acknowledge contributions from the following chapter co-editors:

Alasdair M. Barr, PhD(D) (Drugs of Abuse)Agnieszka K. Biala, MPharm, PhD(E) (Sex-Drive Depressants)

Andrius Baskys, MD, PhD(F) (Drugs for Treatment of Dementia, Pharmacogenetic Information for Common Psychotropic Drugs)Vincent Dagenais-Beaulé, MSc, PharmD(G) (Antipsychotics)Lynda Eccott, BSc, MScPharm(H) (Natural Health Products)Dean Elbe, BScPharm, PharmD, BCPP(I) (Drugs for ADHD)

Katelyn Halpape, BSP, ACPR, PharmD, BCPP(J) (Mood Stabilizers)Gary Hasey, MD, FRCPC, MSc(K) (Repetitive Transcranial Magnetic Stimulation)

David D. Kim, MSc(D) (Antipsychotic-Induced Extrapyramidal Side Effects and Their Management, Drugs of Abuse)Melanie McLeod, BSP, ACPR, PharmD, BCPP(L) (Mood Stabilizers)

Reza Rafizadeh, BScPharm, RPh, ACPR, BCPP(M) (Antipsychotics, Treatment of Substance Use Disorders)Christian G. Schütz, MD, PhD, MPH, FRCPC(N) (Treatment of Substance Use Disorders)Jacky T. P. Siu, BScPharm, ACPR, PharmD, BCPP(M) (Anxiolytics, Hypnotics/Sedatives)

Fidel Vila-Rodriguez, MD, PhD, FRCPC, FAPA(A) (Electroconvulsive Therapy)Vivian Yih, BScPharm, PharmD(O) (Antidepressants)

Bree Zehm, PharmD(P) (Antidepressants)Tony Zhou, PharmD, ACPR(C, Q) (Antidepressants, Antipsychotics, Drug Interactions)

(A) Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; (B) British Columbia Mental Health & Addictions Research Institute, Vancouver, BC, Canada; (C) Centre for Addiction and Mental Health and Department ofPsychiatry, University of Toronto, Toronto, ON, Canada; (D) Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; (E) Department of Pediatrics, Canadian Pharmacogenomics

Network for Drug Safety, University of British Columbia, Vancouver, BC, Canada; (F) Riverside Psychiatric Medical Group Memory Disorders Program, Riverside, CA, USA; (G) Department of Clinical Pharmacy, Jewish General Hospital, Lady DavisInstitute for Medical Research & Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada; (H) Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; (I) Healthy Minds Centre, BC Children’s

Hospital, Vancouver, BC, Canada; (J) College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada; (K) Departments of Psychiatry and Behavioural Neurosciences, Biomedical, Electrical and Computer Engineering,McMaster University, Hamilton, ON, Canada; (L) Department of Psychiatry, Saskatchewan Health Authority, Regina, SK, Canada; (M) Lower Mainland Pharmacy Services and Faculty of Pharmaceutical Sciences, University of British Columbia,Vancouver, BC, Canada; (N) Institute of Mental Health, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada, and Burnaby Center for Mental Health & Addiction, Burnaby, BC, Canada; (O) Fraser Health Authority

Mental Health and Substance Use Tertiary Older Adult Program, Vancouver, BC, Canada; (P) Department of Pharmacy, Island Health, Victoria, BC, Canada; (Q) Lower Mainland Pharmacy Services and Surrey Memorial Hospital, Surrey, BC, Canada



Library of Congress Cataloging in Publication information for the print versionof this book is available via the Library of Congress Marc Database under theLC Control Number 2021938246

Canadian Cataloging-in-Publication Data

Main entry under title:Clinical handbook of psychotropic drugs21st rev. ed.Includes bibliographical references and indexISBN 978-0-88937-474-41. Psychotropic drugs – Handbooks, manuals, etc.I. Bezchlibnyk-Butler, Kalyna Z., 1947–.II. Jeffries, J. Joel, 1939–.RM315.C55 2015 615’.788 C93-094102-0

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The authors and publisher have made every effort to ensure that drug selections and dosagessuggested in this text are in accord with current recommendations and practice at the time ofpublication. However, due to changing government regulations, continuing research, and changinginformation concerning drug therapy and reactions, the reader is urged to check the package insertfor each drug for any change in indications and dosage, or for added precautions. The authors andpublisher disclaim any responsibility for any consequences which may follow from the use ofinformation presented in this book.

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INTRODUCTIONThe Clinical Handbook of Psychotropic Drugs is a user-friendly and practical resource guide for health care practitioners working in anysetting where psychotropic drugs are utilized. Its content is derived from various forms of published literature (including randomizedcontrolled trials, scientific data such as pharmacokinetic trials, cohort trials, case series, and case reports) as well as from leadingclinical experts. The handbook is continually updated as the scientific literature evolves, so we can provide current evidence-based andclinically relevant information to optimize patient care. New sections, periodically added, reflect changes in therapy and in currentpractice.For this 24th edition, we have again revised and updated the book throughout and added a number of new treatments and for-mulations that include: (1) viloxazine, the first new drug to be approved by the FDA for the treatment of ADHD in children andadolescents in over a decade, a non-stimulant medication with quick onset of action, it is due to become available as this editionof the Clinical Handbook of Psychotropic Drugs is being finalized, (2) brexanolone, a GABAA receptor positive modulator that is thefirst drug specifically developed to treat postpartum depression, (3) lumateperone, a second-generation antipsychotic that has aunique receptor binding profile and differs from other antipsychotics in that it modulates glutamate, serotonin, and dopamine, (4) anew extended-release subcutaneous formulation of risperidone, (5) lemborexant, a dual orexin receptor antagonist indicated for thetreatment of insomnia, and (6) a new initiation regimen for aripiprazole long-acting injection approved by the European MedicinesAgency and Health Canada that is based on modeling and simulation data. Augmentation strategies for both antidepressants andantipsychotics have been comprehensively revised, and the neuroscience-based nomenclature system that focuses on pharmacologyand mode of action has been added to product availability tables within individual chapters. And the developments don’t stop there.As in previous editions, charts and tables of comparisons are employed to enable the reader to have quick access to information.Both American and Canadian trade names are used in the text. Though plasma levels are given in SI units, conversion rates to ImperialUS units are available in the text.Given that changes may occur in a medication’s indications, and differences are seen among countries, specific “indications” listed inthis text as “approved” should be viewed in conjunction with product monographs approved in your jurisdiction of interest.Dose comparisons and plasma levels are based on scientific data. However, it is important to note that some patients will respond todoses outside the reported ranges. Age, sex, and the medical condition of the patient must always be taken into consideration whenprescribing any psychotropic agent.Patient Information Sheets for most drug categories are provided as printable pdf files to facilitate education/counselling of patientsreceiving these medications. For details, please see p. 458.For those who like the convenience of electronic resources, the Clinical Handbook of Psychotropic Drugs is also available as an onlineversion that provides even quicker access to all the information in the handbook, with some added extras: (1) An auto-completionpowered search function, (2) browse features for generic names, trade names, indications, and interacting agents, (3) column-selectorenhancement of comparison charts (dosages, side effects, pharmacokinetics, interactions, etc.) that allows you to choose whichinformation is displayed, and (4) hundreds of additional references. Further details on this can be found at https://chpd.hogrefe.com/On behalf of the editors, I would like to express my abundant gratitude to each of the contributors. The Clinical Handbook of Psy-chotropic Drugs would not be possible if it were not for their collective expertise, investment of time, and commitment to patientcare. Over the years, many readers have asked challenging questions and provided useful feedback regarding the content and formatof the handbook. This input is critical to keeping this handbook current, accurate, and relevant. Please feel free to e-mail me at theaddress below with your comments and questions.

Ric M. ProcyshynE-mail: [email protected]


TABLE OF CONTENTSAntidepressants 2

Selective Serotonin Reuptake Inhibitors (SSRIs) 3Norepinephrine Dopamine Reuptake Inhibitor (NDRI) 18Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) 24Serotonin-2 Antagonists/Reuptake Inhibitors (SARIs) 32Serotonin-1A Partial Agonist/Serotonin Reuptake

Inhibitor (SPARI) 38Serotonin Modulator and Stimulator (SMS) 43Noradrenergic/Specific Serotonergic Antidepressant

(NaSSA) 47Nonselective Cyclic Antidepressants 52Monoamine Oxidase Inhibitors 62Reversible Inhibitor of MAO-A (RIMA) 62Irreversible Monoamine Oxidase (A&B) Inhibitors (MAOIs) 66Irreversible MAO-B Inhibitor 72GABAA Receptor Positive Modulator 75NMDA Receptor Antagonist 78Effects of Antidepressants on Neurotransmitters/

Receptors 82Pharmacological Effects of Antidepressants on

Neurotransmitters/Receptors 83Frequency of Adverse Reactions to Antidepressants at

Therapeutic Doses 84Antidepressant Doses and Pharmacokinetics 87Switching Antidepressants 90Antidepressant Augmentation Strategies 92Electroconvulsive Therapy (ECT) 97

Bright Light Therapy (BLT) 105

Repetitive Transcranial Magnetic Stimulation (rTMS) 109

Antipsychotics 115

First-Generation Antipsychotics/FGAs 120Second-Generation Antipsychotics/SGAs 138Third-Generation Antipsychotics/TGAs 1685-HT2A Inverse Agonist Antipsychotic 182Effects of Antipsychotics on Neurotransmitters/Receptors 184Pharmacological Effects of Antipsychotics on

Neurotransmitters/Receptor Subtypes 185Relative Tolerability Profiles of Antipsychotics 186Frequency (%) of Adverse Reactions to Antipsychotics

at Therapeutic Doses 188Antipsychotic Doses and Pharmacokinetics (Oral and

Short-Acting Injections) 190Comparison of Long-Acting IM Antipsychotics 200

Switching Antipsychotics 206Antipsychotic Augmentation Strategies 207Antipsychotic-Induced Extrapyramidal Side Effectsand Their Management 212

Extrapyramidal Adverse Effects of Antipsychotics 212Treatment Options for Extrapyramidal Side Effects 217Effects on Extrapyramidal Symptoms 223Comparison of Agents for Treating Acute

Extrapyramidal Side Effects and Tardive Dyskinesia 224Doses and Pharmacokinetics of Agents for Treating

Extrapyramidal Side Effects and Tardive Dyskinesia 226Anxiolytic (Antianxiety) Agents 230

Benzodiazepines 231Comparison of the Benzodiazepines 239Buspirone 243Hypnotics/Sedatives 247

Comparison of Hypnotics/Sedatives 254Mood Stabilizers 261

Lithium 261Anticonvulsants 272Comparison of Anticonvulsants 291Frequency of Adverse Reactions to Mood Stabilizers

at Therapeutic Doses 299Drugs for ADHD 301

Psychostimulants 301Selective Norepinephrine Reuptake Inhibitors 312Comparison of Drugs for ADHD 316α2 agonists 322Augmentation Strategies in ADHD 326Drugs for Treatment of Dementia 329

Cholinesterase Inhibitors 329Memantine 336Comparison of Drugs for Treatment of Dementia 339Sex-Drive Depressants 344

Comparison of Sex-Drive Depressants 347Drugs of Abuse 352

Alcohol 354Stimulants 358Hallucinogens 363Opioids 372Inhalants/Aerosols 376

Gamma-hydroxybutyrate (GHB)/Sodium Oxybate 378Flunitrazepam (Rohypnol) 380Nicotine/Tobacco 381Treatment of Substance Use Disorders 384

Acamprosate 386Disulfiram 388Naltrexone 391Buprenorphine 394Methadone 398Pharmacotherapy for Nicotine/Tobacco Use Disorder 403Comparison of Treatments for Nicotine/Tobacco Use

Disorder 405Unapproved Treatments of Psychiatric Disorders 409

Adrenergic Agents 410Anti-inflammatory Agents 414Cannabinoids 418Dopaminergic Agents 418GABA Agents/Anticonvulsants 420Hormones 423NMDA Agents 4275-HT3 Antagonists 431Miscellaneous 431Natural Health Products 434

Ginkgo Biloba 434Kava Kava 436Melatonin 437Omega-3 Polyunsaturated Fatty Acids 439S-Adenosyl-L-Methionine (SAMe) 441St. John’s Wort 442Valerian 444Vitamins 445Pharmacogenetic Information for CommonPsychotropic Drugs 448

Genotype Effects on Pharmacokinetic Propertiesof Psychotropic Drugs 448

Pharmacogenomics-Based Dose AdjustmentRecommendations and Guidelines 449

Glossary 453

Drug Use in Pregnancy and Effects on Breast Milk 457

Patient Information Sheets 458

Index of Drugs 459


This document is for personal use only. Reproduction or distribution is not permitted. From Ric M. Procyshyn, Kalyna Z. Bezchlibnyk-Butler, &J. Joel Jeffries: Clinical Handbook of Psychotropic Drugs, 24th edition (ISBN 9781616765934) © 2021 Hogrefe Publishing. 2

ANTIDEPRESSANTSClassification • Antidepressants can be classified as follows:

Pharmacological Class Examples Page

Cyclic Antidepressants (*)

Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline See p. 3

Norepinephrine Dopamine Reuptake Inhibitor (NDRI) Bupropion See p. 18

Selective Serotonin-Norepinephrine Reuptake Inhibitor (SNRIs) Desvenlafaxine, duloxetine, levomilnacipran, venlafaxine See p. 24

Serotonin-2 Antagonists/Serotonin Reuptake Inhibitors (SARIs) Nefazodone, trazodone See p. 32

Serotonin-1A Partial Agonist/Serotonin Reuptake Inhibitor (SPARI) Vilazodone See p. 38

Serotonin Modulator and Stimulator (SMS) Vortioxetine See p. 43

Noradrenergic/Specific Serotonergic Agent (NaSSA) Mirtazapine See p. 47

Nonselective Cyclic Agents (Mixed Reuptake Inhibitor/Receptor Blockers) Amitriptyline, desipramine, imipramine, maprotiline, nortriptyline See p. 52

Monoamine Oxidase Inhibitors

Reversible MAO-A Inhibitor (RIMA) Moclobemide See p. 62

Irreversible MAO (A&B) Inhibitors (MAOIs) Phenelzine, tranylcypromine See p. 66

Irreversible MAO-B Inhibitor Selegiline See p. 72

GABAA Receptor Positive Modulator Brexanolone See p. 75

NMDA Receptor Antagonist Esketamine See p. 78

(*) Cyclic antidepressants are currently classified according to their effect on brain neurotransmitters. These neurotransmitter effects determine the antidepressants’ spectrum of activity and adverse effects (see table p. 82),

General Comments • Antidepressants are associated with a small (2–3%) risk of hostility or suicidal ideation and associated behaviors in children, adolescents, and youngadults (aged up to 24 years). Risk for suicide should be closely assessed and monitored during the initial weeks of antidepressant therapy

• In patients presenting with depression and a high risk of suicide, treatment selection should consider safety in overdose (i.e., consider using newerantidepressant agents rather than nonselective cyclic and MAOI antidepressants). Prescription quantities should be consistent with safe patient care

• Some antidepressants are associated with restlessness or psychomotor agitation prior to seeing any change in core symptoms of depression.On average, all antidepressants are equally efficacious at reducing symptoms of depression though some randomized double-blind, controlledtrials and systematic reviews suggest otherwise. Overall effects of antidepressants are modest when the effects of publication bias are considered.Compared to placebo, the effect size of antidepressant treatment is reported as 0.31

• Based on the most comprehensive network meta-analysis and systematic review thus far involving 21 antidepressants, only agomelatine,escitalopram, and vortioxetine demonstrated superior efficacy combined with better acceptability/tolerability when used as initial treatmentfor Major depressive disorder (MDD).[1] However, the authors make it clear that there are important limitations to these results – they may onlyhelp inform as to initial treatment choice, they do not reflect longer term tolerability or benefit with respect to functionality, and they do notaccount for individual factors which are typically used to help guide treatment selection in clinical practice

• Prophylaxis of depression is most effective if the therapeutic dose is maintained; continued therapy with all classes of antidepressants has beenshown to significantly reduce risk of relapse

• Different antidepressant classes may be combined in patients with a partial response or in refractory cases; however, combinations should beassessed for potential interactions such as serotonin syndrome; additional monitoring should be implemented when necessary


Antidepressant Doses and Pharmacokinetics (cont.)Drug Therapeutic

Dose Range(mg)

ComparableDose (mg)

SuggestedPlasma Level(nmol/L)

Bio-availability(%)

ProteinBinding(%)

Peak Plasma Level(h) (Tmax)

EliminationHalf-life (h) (T1/2)

Metabolizing Enzymes*

(CYP450; other)Enzyme Inhibition**

(CYP450; other)

SNRI

Venlafaxine (Effexor) 75–375 40 13 27 2 (immediaterelease)

3–7 (parent)(b) (d)

9–13 (metabolite)2D6(p), 3A4(c) (w), 2C9,2C19

2D6(w), 3A4(w)

Venlafaxine XR (Effexor XR) XR = 5.5 9–12 (absorptionhalf-life)

Desvenlafaxine (Pristiq) 50–100 40 – 80 30 7.5 11(d) UGT(p), 3A4 2D6

Duloxetine (Cymbalta) 60–120 ? 70 > 95 6 8–19(b) (d) 1A2, 2D6 2D6(m)

Levomilnacipran (Fetzima) 20–120 ? n/a 92 22 6–8 12 2C8, 2C19, 3A4

SARI

Nefazodone (Serzone) 100–600 130 99 15–23 2 2–5(h) (parent)3–18 (metabolites)

2D6(c), 3A4(p) 1A2(w), 2D6(w),3A4(p); P-gp (acutedosing); inducer ofP-gp

Trazodone (Desyrel) 150–600 100 70–90 93 2 4–9 2D6(c), 3A4(p) 2D6(w); inducer ofP-gp

SPARI

Vilazodone (Viibryd) 10–40 20 n/a 72 with food(50 fasting)

96–99 4–5 ~25 1A2(w), 2D6(w), 3A4(p) 2C8(w), 2D6(w)

SMS

Vortioxetine (Brintellix) 5–20 ? n/a 75 98 7–11 57 2A6, 2B6, 2C8, 2C9,2C19, 2D6, 3A4/5

–

NaSSA

Mirtazapine (Remeron) 15–60 12.5 50 85 2 20–40(b) (d) 1A2(p), 2D6(c) (p), 3A4(p),2C9

–

NONSELECTIVE CYCLIC AGENTS –Tricyclic

Amitriptyline (Elavil) 75–300 30 250–825(a) (g) 43–48 92–96 2–8 10–46(b) 1A2(w), 2B6(w), 2D6(m),3A4(p), 2C9(w), 2C19(p)

1A2(w), 2D6, 3A4(w),2C9(w), 2C19(w); P-gp

1A2, 2D6(m), 3A4,2C9(w), 2C19(m), 2E1;P-gp; UGT

Clomipramine (Anafranil) 75–300 30 300–1000 98 98 2–6 17–37(b) 1A2, 2D6(p) 2D6(m); UGT

Desipramine (Norpramin) 75–300 50 400–1000(g) 73–92 73–92 2–6 12–76(b) 1A2, 2D6(p), 3A4, 2C9(w),2C19(p)

2D6(m), 2C19(w), 2E1;P-gp


Effects of Antipsychotics on Neurotransmitters/Receptors∗

FGAs

Chlorprom-azine

Flu-penthixol

Fluphen-azine

Haloperi-dol

Loxapine Methotri-meprazine

Periciazine Perphen-azine

Pimozide Thiori-dazine

Thiothix-ene

Trifluo-perazine

Zuclo-penthixol

D2 blockade ++++ +++++ +++++ +++++ ++++ +++ ++++ +++++ ++++ ++++ +++++ ++++ +++++

H1 blockade +++ +++ +++ + +++ +++++ ? ++++ + +++ +++ ++ +++

M1 blockade +++ +++ + + ++ ? ? + + ++++ + + ++

M3 blockade +++ ? + + ++ ? ? + ? +++ ? ? ?

α1 blockade ++++ +++ +++ +++ +++ ? ? +++ +++ ++++ ++ +++ ++++

α2 blockade ++ ++ + + + ? + ++ ++ + ++ + ++

5-HT1A blockade + ? ++ + + ? ? ++ ++ ++ ++ ++ ?

5-HT2A blockade ++++ ++++ ++++ +++ ++++ ++++ ? ++++ +++ ++++ +++ ++++ ++++

5-HT2C blockade +++ ? ++ + +++ ? ? ++ + +++ + ++ ?

5-HT7 blockade +++ ? ++++ ++ +++ ? ? +++ +++++ +++ +++ ++ ?

SGAs TGAs

Asenapine Clozapine Iloperidone Lumatepe-rone

Lurasidone Olanzapine Paliperi-done

Quetiapine Risperi-done

Ziprasi-done

Aripipra-zole

Brexpi-prazole

Cariprazine

D2 blockade ++++ ++ +++ +++ ++++ +++ ++++ ++ ++++ ++++ +++++(a) +++++(a) +++++(a)

H1 blockade ++++ ++++ ++ – + ++++ +++ +++ +++ +++ +++ +++ +++

M1 blockade + +++(a) + – + ++++ ff ++ ff ff ff + ffM3 blockade ? +++ + – ? +++ ff + + + + ? ffα1 blockade ++++ ++++ ++++ +++ +++ +++ ++++ +++ ++++ +++ +++ +++ ++

α2 blockade ++++ ++ ++ +++ +++ ++ +++ +++ ++ ++ +++ +++ ?

5-HT1A blockade ++++ ++(a) ++(a) – ++++(a) + ++ ++(a) ++ +++(a) ++++(a) +++++(a) ++++(a)

5-HT2A blockade +++++ +++ +++++ +++++ +++++ ++++ +++++ +++ +++++ ++++ ++++ +++++ +++

5-HT2C blockade +++++ +++ +++ ++ ++ ++++ +++ + +++ +++ +++ ? ++

5-HT7 blockade +++++ +++ ++ – +++++ ++ +++ ++ ++++ ++++ ++++ ++++ ++

(a) Partial agonistKey: Ki (nM) > 10,000 = –; 1000–10,000 = +; 100–1000 = ++; 10–100 = +++; 1–10 = ++++; 0.1–1 = +++++; ? = unknownSee p. 185 for Pharmacological Effects on Neurotransmitters.Adapted from: [6, 25, 26] . See also the National Institute of Mental Health’s Psychoactive Drug Screening Program. Available at http://pdsp.med.unc.edu

∗ The ratio of Ki values (inhibition constant) between various neurotransmitters/receptors determines the pharmacological profile for any one drug

http://pdsp.med.unc.edu


Frequency (%) of Adverse Reactions to Antipsychotics at Therapeutic Doses

FIRST-GENERATION AGENTS

Reaction Chlor-promazine

Flu-penthixol

Fluphen-azine

Haloperi-dol

Loxapine Methotri-meprazine

Periciazine Perphena-zine

Pimozide Thiorida-zine

Thiothix-ene

Trifluoper-azine

Zuclo-penthixol

CNS Effects

Drowsiness, sedation > 30 > 2 > 2 > 2(a) > 30 > 30 > 30 > 10 > 10 > 30 > 10 > 2 > 30

Insomnia, agitation < 2 < 2 > 2 > 10 < 2 < 2 < 2 > 10 > 2 < 2 > 10 > 2 > 10Extrapyramidal Effects

Parkinsonism > 10 > 30 > 30 > 30(b) > 30 > 10 > 2 > 10 > 30 > 2 > 30 > 30 > 30

Akathisia > 2 > 30 > 30 > 30 > 30 > 2 > 2 > 10 > 10 > 2 > 30 > 30 > 10

Dystonic reactions > 2 > 10 > 10 > 30(b) > 10 < 2 < 2 > 10 > 2 < 2 > 2 > 10 > 10(b)

Anticholinergic Effects > 30 > 10 > 2 > 2 > 10 > 30 > 30 > 10 > 2 > 30 > 2 > 2 > 10(c)

Cardiovascular Effects

Orthostatic hypotension > 30(a) > 2 > 2 > 2 > 10 > 30(a) (d) > 10 > 10 > 2 > 30 > 2 > 10 > 2

Tachycardia > 10 > 2 > 10 < 2 > 10 > 10 > 10 > 10 > 2 < 2 > 2 < 2 > 2

ECG abnormalities* > 30(e) > 2 < 2 < 2 < 2 > 10 < 2 > 2 > 2(f) > 30(e) < 2 < 2 < 2

QTc prolongation(> 450 ms)

> 2(e) < 2 > 2(e) > 2(e) – > 2 > 2 < 2 > 2(f) > 10(e) < 2 > 2 < 2

Endocrine Effects

Sexual dysfunction** > 30(g) > 30(g) > 30(g) > 30(g) > 2 > 2(g) > 10(g) > 10(g) > 30 > 30(g) > 2(g) > 30(g) > 30(g)

Galactorrhea > 30 – > 10 < 2 > 2 > 30 > 10 > 10 < 2 > 30 < 2 > 10 –

Weight gain > 30 > 10 > 30 > 10 < 2(h) > 10 > 10 > 10 > 2(h) > 30 > 10 > 10 > 10

Hyperglycemia > 30 > 10 > 10 > 10 > 2(i) > 2(i) > 2(i) > 10 > 2 > 2(i) > 2(i) > 2 > 2(i)

Hyperlipidemia > 30 ? ? > 2 > 10 ? ? > 2(i) ? > 30 ? ? ?Ocular Effects ***

Lenticular pigmentation > 2 < 2 < 2 < 2 < 2 > 2 > 2 < 2 < 2 > 2 < 2 < 2 < 2

Pigmentary retinopathy > 2 < 2 – – < 2 > 2 – < 2 – > 10 < 2 < 2 –Blood dyscrasias < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2

Hepatic disorder < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2

Seizures# < 2(a) < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2 < 2Skin Reactions

Photosensitivity > 10 < 2 < 2 < 2 < 2 > 10 > 2 < 2 – > 10(e) < 2 < 2 < 2

Rashes > 10 > 2 < 2 < 2 > 2 > 2 > 2 < 2 > 2 > 10 < 2 < 2 < 2

Pigmentation*** > 30(e) – – < 2 – < 2 – – – > 2 > 2 – < 2


Benzodiazepines (cont.)Generic Name Neuroscience-based Nomenclature•

(Pharmacological Target/Mode of Action)Trade Name(A) Dosage Forms and Strengths

Temazepam GABA/Benzodiazepine receptor agonist(GABAA receptor positive allosteric modulator)

Restoril Capsules: 7.5 mg(B), 15 mg, 22.5 mg(B), 30 mg

Triazolam GABA/Benzodiazepine receptor agonist(GABAA receptor positive allosteric modulator)

Halcion Tablets: 0.125 mg(B), 0.25 mg

∗ Refer to Health Canada’s Drug Product Database or the FDA’s Drugs@FDA for the most current availability information • Developed by a taskforce consisting of representatives from the American College of Neuropsychopharmacology (ACNP), the Asian Collegeof Neuropsychopharmacology (AsCNP), the European College of Neuropsychopharmacology (ECNP), the International College of Neuropsychopharmacology (CINP), and the International Union of Basic and Clinical Pharmacology (IUPHAR) (see https://nbn2r.com),

(A) Generic preparations may be available, (B) Not marketed in Canada, (C) Not marketed in the USA

Approved Indications‡

( approved)

Anxiety Disorders Panic Disorder Insomnia PerioperativeSedation

Seizure Disorders Skeletal MuscleSpasticity

Alcohol Withdrawal

Short-acting Alprazolam

Triazolam

Intermediate Bromazepam(C)

Estazolam(B)

Lorazepam

Oxazepam

Temazepam

Long-acting Chlordiazepoxide

Clonazepam

Clorazepate

Diazepam

Flurazepam

Nitrazepam(C)

(A) Acute use only, (B) Not marketed in Canada, (C) Not marketed in the USA

Other Indications• Akathisia secondary to antipsychotic agents• Abnormal movements associated with tardive dyskinesia (clonazepam)• Sedation in severe agitation• Mania: Often used short-term with antipsychotics or lithium to control agitation• Social phobia (alprazolam, clonazepam, diazepam, lorazepam)• Catatonia (parenteral and sublingual lorazepam, diazepam, clonazepam)• Myoclonus, restless legs syndrome, Tourette’s syndrome (clonazepam)• Acute dystonia (sublingual or intramuscular lorazepam)

‡ Indications listed here do not necessarily apply to all countries. Please refer to a country’s regulatory database (e.g., US Food and Drug Administration, Health Canada Drug Product Database) for the mostcurrent availability information and indications

https://nbn2r.com


Buspirone (cont.)

Pharmacokinetics • Absorption is virtually complete; first-pass effect reduces bioavailability to about 4%• Food may reduce rate of absorption (95%), decrease extent of first-pass effect, and therefore increase oral bioavailability; Cmax increased up to 116%

(n=8)• Highly bound to plasma proteins (86%)• Tmax: 0.7–1.5 h• Elimination half-life: 2–3 h. Parent drug metabolized by CYP3A4; metabolite (1-(2-pyrimidinyl) piperazine) is active and metabolized by 2D6• Clearance reduced in renal and hepatic impairment

Adverse Effects • Causes little sedation; does not impair psychomotor or cognitive functions• Headache (up to 6%), dizziness (up to 12%), lightheadedness (3%), nervousness (5%), excitement (2%), fatigue, paresthesia, numbness, and GI upset

seen in less than 10% of patients• Buspirone binds to central dopamine receptors, potentially increasing the risk of dystonia, pseudoparkinsonism, and akathisia (not substantiated by

trials); however, a syndrome of restlessness appearing shortly after initiation of treatment has been reported, this could be the result of buspirone’sdopaminergic and/or noradrenergic activity

• Has been reported to precipitate hypomania or mania (primarily in the elderly); high doses may worsen psychosis• Dose-dependent increase in prolactin and growth hormone levels reported

Discontinuation Syndrome • Withdrawal effects have not been reported

Precautions • Has no cross-tolerance with benzodiazepines and will not alleviate benzodiazepine withdrawal; when switching, taper benzodiazepine dose whileadding buspirone to the regimen

• Buspirone does not have anticonvulsant activity and has not been evaluated in patients with a history of seizures; not recommended for patientswith seizures

Toxicity • Excessive doses produce extension of pharmacological effects including dizziness, nausea, and vomiting; monitor respiration, blood pressure, andpulse, and give symptomatic and supportive therapy

Pediatric Considerations • For detailed information on the use of buspirone in this population, please see the Clinical Handbook of Psychotropic Drugs for Children andAdolescents[1]

• Buspirone used in ADHD, aggression, autism, and to augment SSRIs in obsessive-compulsive disorder (10–30 mg/day)• Dizziness, behavior activation, euphoria, increased aggression, and psychosis reported

Geriatric Considerations • Buspirone is not known to cause sedation, cognitive impairment, disinhibition or motor impairment in the elderly• Dosage should be decreased in patients with reduced hepatic or renal function

Use in Pregnancy♢ • No fetal adverse effects reported in animal studies; inadequate human data, safety in pregnancy has not yet been determined

Breast Milk • In animals, buspirone is excreted into milk; unknown excretion into human milk; unknown effects on nursing infants. Consider alternative anti-anxiety agent

♢ See p. 457 for further information on drug use in pregnancy and effects on breast milk


Anticonvulsants (cont.)– Tremor, involuntary movements, opisthotonos, abnormal reflexes, myoclonus, ataxia, rhabdomyolysis– Mydriasis, nystagmus– Flushing, respiratory depression, cyanosis

• No known antidote, treat symptomatically. Hemodialysis if refractory seizures, hemodynamic instability, life-threatening dysrhythmiasValproate • Maximum plasma concentration may not occur for up to 18 h following an overdose, and serum half-life may be prolonged

• Onset of CNS depression may be rapid (within 3 h); enteric-coated preparations may delay onset of symptoms• Signs/symptoms: Severe dizziness, hypotension, supraventricular tachycardia, bradycardia; severe drowsiness; trembling; irregular, slow or shallow

breathing, apnea, and coma; loss of tendon reflexes, generalized myoclonus, seizures; cerebral edema – evident 2–3 days after overdose and maylast up to 15 days; hematological changes, electrolyte, and metabolic abnormalities; optic nerve damage reported

• Overdose can result in heart block, coma, or death; naloxone may reverse the CNS depressant effects, and may also reverse anti-epileptic effects• Supportive treatment [L-carnitine supplementation 100 mg/kg/day (maximum 6 g) followed by 15 mg/kg every 4 h until clinical improvement

recommended for patients with CNS depression, evidence of hepatic dysfunction, and hyperammonemia]. Hemodialysis may result in significantremoval of drug during acute overdose as unbound valproic acid concentration is high

Gabapentin • Signs and symptoms: Double vision, slurred speech, drowsiness, lethargy, unresponsiveness, and diarrhea. Most case reports of overdose arepolyintoxications. Symptoms of acute overdose are generally mild and most recover. Fatalities reported in polyintoxications

• No known antidote. Removed by hemodialysisLamotrigine • Overdose can result in ataxia, nystagmus, delirium, seizures, intraventricular conduction delay, and coma. Fatalities reported

• No known antidote – treat symptomaticallyOxcarbazepine • No deaths reported following overdose of up to 24,000 mg; no known antidote – treat symptomatically

• Removal of the drug by gastric lavage and/or inactivation by administering activated charcoal should be consideredTopiramate • Emesis and gastric lavage recommended; topiramate can be removed by hemodialysis

• Treat symptomatically• Overdose can result in severe metabolic acidosis

Lab Tests/Monitoring

Carbamazepine Valproate Gabapentin Lamotrigine Oxcarbazepine Topiramate

Work-up (1) CBC including platelets and differential(2) Serum electrolytes, urea, creatinine(3) Liver function(4) ECG (in patients over age 45 or with a cardiachistory)(5) HLA-B*1502/HLA-A*3101 typing in patients withhigh-risk ancestry(6) Pregnancy test if appropriate

(1) CBC including platelets anddifferential(2) Liver function(3) Total and HDL cholesteroland triglycerides(4) Body weight/BMI(5) Menstrual history(6) Bone density(7) Pregnancy test if appropriate

BUN and serumcreatinine

Liver functionBUN and serumcreatinine

Serum electrolytesSerum creatinine (doseneeds to be adjustedwith CrCl less than30 mL/min)

Baseline serumbicarbonate,BUN, and serumcreatinine

Comparison of AnticonvulsantsCarbamazepine Gabapentin Lamotrigine Oxcarbazepine Topiramate Valproate

GeneralComments

Positive predictors of re-sponse include: Non-classicor secondary mania, earlyage at onset, negativefamily history of mood dis-order, and patients withneurological abnormalitiesLess response noted in pa-tients with severe mania,dysphoric mania, and rapidcycling disorder

Not effective as amood stabilizerNot recommendedfor monotherapy inany phase of bipolardisorder

More effective in bipolardepression; suggestedto have antidepressantpropertiesFirst-line agent fortreatment of bipolardepression, acute andmaintenance (limited effi-cacy in preventing mania):Does not induce switchesto hypomania or maniaProphylaxis of rapidcycling and bipolar II disor-der

Pharmacologicalactivity is exertedprimarily throughthe 10-mono hydroxymetabolite (MHD) ofoxcarbazepineLower potential for se-rious adverse effectsand drug interactionscompared to carba-mazepine. Third-lineoption in bipolar dis-order as monotherapyfor acute mania and asadjunctive therapy inmaintenancePositive effects on ver-bal and visual memory,visuospatial function,naming ability, andfrontal executive func-tion in patients withepilepsy

Not recommended asmonotherapy in any phaseof bipolar disorder but may beuseful as adjunctive therapy inmaintenance

Positive predictors of response include:Pure mania, mixed or dysphoric mania,and patients with secondary or rapid cy-cling disorderRecommended if multiple prior episodes,predominant irritable or dysphoric mood,comorbid substance abuse, or headtraumaGood response in adolescents (however,menstrual concerns for female patients)Less response noted in patients withcomorbid personality disorder, severe ma-nia, and those previously treated withantidepressants or stimulantsMay be more effective in treating andpreventing manic and mixed episodes

Pharmacology Anticonvulsant, anti-kin-dling, and GABA-ergicactivityBlocks voltage-dependentsodium channelsMay also act on other ionchannels for calcium andpotassium

Anticonvulsant,anti-kindling, andGABA-ergic activityBlocks voltage-dependent sodiumchannels and calciumchannelsInhibits excita-tory amino acids(glutamate)

Anticonvulsant and GABA-ergic activityBlocks voltage-dependentsodium channels and cal-cium channelsInhibits excitatory aminoacids (glutamate)

MHD metabolite hasanticonvulsant, anti-kindling, and GABA-ergic activity Blocksvoltage-dependentsodium channels andcalcium channels

Anticonvulsant, anti-kindling,and GABA-ergic activityInhibits excitatory amino acids(glutamate)Inhibits carbonic anhydraseand blocks voltage-dependentsodium channels and calciumchannels

Anticonvulsant, anti-kindling, and GABA-ergic activityIndirectly blunts excitatory activity of glu-taminergic systemBlocks calcium channelsIndirectly blocks voltage-dependentsodium channelsIncreases serotonergic function


Mood Stabilizers291

DRUGS FOR ADHDClassification • Drugs for ADHD can be classified as follows:

Drug Class Agent(A) Page

Psychostimulants Amphetamine and related drugs (e.g., lisdexamfetamine) See p. 301

Methylphenidate, dexmethylphenidate(B)

Selective norepinephrine reuptakeinhibitors

Atomoxetine See p. 312

Viloxazine

α2 agonists Clonidine See p. 322

Guanfacine

Antidepressants Bupropion See p. 18

Venlafaxine, desvenlafaxine See p. 24

Tricyclic agents See p. 52

Dopaminergic agents Modafinil See p. 419

Armodafinil(B)

(A) Generic preparations may be available, (B) Not marketed in Canada

Psychostimulants

Product Availability∗

Generic Name Neuroscience-based Nomenclature•

(Pharmacological Target/Mode of Action)Trade Name(A) Dosage Forms and Strengths

Methylphenidate (MPH) Dopamine, norepinephrine/Multimodal ACT Methylphenidate ER(C),Apo-Methylphenidate ER(C),PMS-Methylphenidate ER(C),Teva-Methylphenidate ER-C(C)

Extended-release tablets: 18 mg, 27 mg, 36 mg, 54 mg

Adhansia XR(B) Extended-release capsules: 25 mg, 35 mg, 45 mg, 55 mg, 70 mg, 85 mg

Aptensio XR(B) Extended-release capsules: 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

Biphentin(C) Controlled-release capsules: 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg

Concerta Extended-release tablets: 18 mg, 27 mg, 36 mg, 54 mg

Cotempla XR-ODT(B) Extended-release orally disintegrating tablets: 8.6 mg, 17.3 mg, 25.9 mg

Foquest(C) Controlled-release capsules: 25 mg, 35 mg, 45 mg, 55 mg, 70 mg, 85 mg, 100 mg


Drugs for ADHD301


Acamprosate

Product Availability∗

Generic Name Chemical Class Trade Name Dosage Forms and Strengths

Acamprosate calcium Calcium acetyl-homotaurine Campral Delayed-release enteric-coated tablets: 333 mg (equiv. to 300 mg acamprosate)∗ Refer to Health Canada’s Drug Product Database or the FDA’s Drugs@FDA for the most current availability information.

Indications‡

( approved)

Alcohol use disorder: Maintenance of abstinence; reduces alcohol cravings and prevents relapse

General Comments • Meta-analyses have shown that patients treated with acamprosate had significantly higher continuous abstinence rates than those on placebo• Detoxification before an acamprosate trial and a goal of abstinence rather than controlled drinking improves outcome with acamprosate• May not be effective in patients who are actively drinking at the start of treatment; it is not effective for acute withdrawal and does not treat

delirium tremens. Initiate treatment as soon as possible after alcohol withdrawal; treatment should be continued during relapses• Acamprosate treatment should be part of a comprehensive alcohol management program that includes psychosocial support• Mixed results seen when combined with naltrexone as to increased efficacy and success of abstinence (see Drug Interactions p. 387); acamprosate

appears more useful in maintaining abstinence as it reduces dysphoric effects that trigger some patients to resume drinking, while naltrexonecontrols alcohol consumption by reducing the pleasurable effects of alcohol

• Has been used in combination with disulfiram to increase abstinence• Efficacy for promoting abstinence from alcohol has not been demonstrated in patients who abuse multiple substances[1]

Pharmacology • N-Methyl-D-aspartate (NMDA) receptor modulator, decreases activity at NMDA receptors• Decreases dopamine hyperexcitability• Restores glutamate tone and modulates neuronal hyperexcitability following withdrawal from alcohol, decreases activity of glutamate• Weak inhibitor of presynaptic GABAB receptors in the nucleus accumbens, increases GABA-ergic system

Dosing • Adults over 60 kg: 666 mg tid; under 60 kg: 666 mg bid; to minimize GI effects, can initiate more gradually (i.e., 333 mg tid and increase dose by1 tablet per week until target dose is reached)

• Hepatic disorders: No dosage adjustment needed• Renal dysfunction: Give 333 mg tid if CrCl is 30–50 mL/min; avoid in patients with CrCl under 30 mL/min

Pharmacokinetics • Bioavailability = 11%; food reduces bioavailability by 20%, not clinically significant• Tmax = 3–9 h once steady state is reached• Steady state is reached in 5–7 days• Has low protein binding• Half-life = 20–33 h• Is not degraded by the liver and is primarily excreted as unchanged drug by the kidneys – not involved in CYP450 interactions

Adverse Effects • Common: Nausea, flatulence, and diarrhea (dose related and decrease over time), headache, asthenia, and pruritus• Depression, anxiety, insomnia, and suicidal ideation reported• Less common: Vomiting, dizziness, fluctuations in libido, maculopapular rash, anorexia, xerostomia, hyperhidrosis, and metallic taste

‡ Indications listed here do not necessarily apply to all countries. Please refer to a country’s regulatory database (e.g., US Food and Drug Administration, Health Canada Drug Product Database) for the mostcurrent availability information and indications

Clinical Handbook of Psychotropic Drugs24th edition

9 780889 375932

90000

ISBN 978-0-88937-593-2

The Clinical Handbook of Psychotropic Drugs has become a standard reference and work-ing tool for psychiatrists, psychologists, physicians, pharmacists, nurses, and other mental health professionals.

• Packed with unique, easy-to-read compari-son charts and tables (dosages, side effects, pharmacokinetics, interactions…) for a quick overview of treatment options

• Succinct, bulleted information on all classes of medication: on- and off-label indications, side effects, interactions, pharmacodynamics, precautions in the young, the elderly, and pregnancy, nursing implications, and much more – all you need to know for each class of drug

• Potential interactions and side effects summarized in comparison charts

• With instantly recognizable icons and in full color throughout, allowing you to find at a glance all the information you seek

Recent praise for the Clinical Handbook:

“Comprehensive … clearly organized … an ideal resource for rapid and straightforward retrieval of essential clinical information … a ‘must have’ for those who work in mental health care.” Marshall Cates, PharmD, in Annals of Pharmacotherapy

“A powerhouse of practical information ... Unrivalled in scope ... This outstanding and unique handbook is as rich in useful content as many full textbooks.” Barbara Jovaisas, PharmD, in Canadian Pharmacists Journal

“Should be available at all nursing stations.”C. Lindsay DeVane, PharmD, in American Journal of Health Systems Pharmacy

“The handbook is easy to use, comprehensive in scope, and up to date – a winner!” Catherine Chiles, MD, in Journal of Clinical Psychiatry

“As a psychiatrist who routinely prescribes medications, I find this handbook invaluable. It is the most comprehensive book on this topic that I have come across.”Corey Goldstein, MD, Rush University Medical Center

New in this edition:

• Neuroscience-based nomenclature – added to product availability tables

• Antidepressants chapter includes new section on GABAA receptor positive modulator (brexanolone IV injection; trade name Zulresso); also covers Qelbree (viloxazine extended-release capsules), the first new ADHD medication approved by the FDA in over a decade; as well as updates to SSRI use in pregnancy and antidepressant augmentation strategies

• Antipsychotics updates include revised dosing, especially adjustments in hepatic and renal impairment

• Mood stabilisers chapter sections on lithium and anticonvulsants extensively revised

• Chapter on pharmacogenetic information for common psychotropic drugs completely revised

• New formulations and trade names include: Adhansia XR (methylphenidate extended-release capsules), Caplyta (lumateperone), Dayvigo (lemborexant), Perseris (risperidone extended-release subcutaneous injection), Probuphine (buprenorphine subdermal implant), Propecia (finasteride tablets), Trelstar (triptorelin slow-release injection), Qelbree (viloxazine extended-release capsules) Zulresso (brexanolone IV injection)

Also

available:

CHPD

Online

Hogrefe Publishing Group

Göttingen · Berne · Vienna · Oxford · Paris Boston · Amsterdam · Prague · Florence Copenhagen · Stockholm · Helsinki · Oslo Madrid · Barcelona · Seville · Bilbao Zaragoza · São Paulo · Lisbon

www.hogrefe.com

Clearly written patient information sheets can be downloaded as printable PDF files from the Hogrefe website after registration

This book is a must for everyone who needs an up-to-date, easy-to-use, comprehensive summary of all the most relevant information about psychotropic drugs.

Clinical Handbook of Psychotropic Drugs · 2021. 7. 12. · Clinical Handbook of Psychotropic Drugs...

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