Generic Name Brand Name Mechanism of Action

1. ARIPRIPAZOLE (ABLIFY) The mechanism of action of aripiprazole, as with

Dosage and Frequency other drugs having efficacy in schizophrenia and bipolar
Adult disorder, is unknown. However, it has been proposed that
Pediatric the efficacy of aripiprazole is mediated through a
PO: 15–30 mg/day combination of partial agonist activity at D2 and 5-HT1A
PO: 2 mg/day receptors and antagonist activity at 5-HT2A receptors.
I: Up to 30 mg/day Actions at receptors other than D2, 5-HT1A, and 5-HT2A
Patients < 50 kg 2 mg/day, recommended 5 mg/day, may explain some of the other clinical effects of
Maximum 10mg/day aripiprazole, e.g., the orthostatic hypotension observed
Patients ≥ 50 kg 2 mg/day, Recommended 10 mg/day, with aripiprazole may be explained by its antagonist
Maximum 20 mg/day activity at adrenergic alpha1 receptors.
Indication
Acute treatment of manic or mixed episodes in
bipolar I disorder as monotherapy; or as an adjunct to
lithium or valproate. Adjunct to antidepressants for major
depressive disorder (MDD). Irritability associated with
autistic disorder.
Contraindication Black Box Warning: Elderly patients with
• Contraindicated in patients hypersensitive to dementia-related psychosis treated with atypical
drug. antipsychotics are at an increased risk for death.
• Use cautiously in patients with CV disease, Abilify isn’t approved for the treatment of patients
cerebrovascular disease, or conditions that with dementia-related psychosis.
could predispose the patient to hypotension, Adverse Effects
such as dehydration or hypovolemia. CNS: headache, anxiety, insomnia, lightheadedness,
• Use cautiously in patients with history of somnolence, akathisia, increased suicide risk, neuroleptic
seizures or with conditions that lower the malignant syndrome, seizures, suicidal thoughts,
seizure threshold. extrapyramidal disorder (children), tremor, asthenia,
• Use cautiously in patients who engage in depression, fatigue, dizziness,
strenuous exercise, are exposed to extreme heat, nervousness, hostility, manic behavior, confusion,
take anticholinergics, or are susceptible to abnormal gait, cogwheel rigidity,
dehydration. fever, tardive dyskinesia, restlessness.
• Use cautiously in patients at risk for aspiration CV: peripheral edema, chest pain, hypertension,
pneumonia, such as those with Alzheimer’s tachycardia, orthostatic hypotension, bradycardia.
disease. EENT: rhinitis, blurred vision, increased salivation,
• Use cautiously in pregnant and breastfeeding conjunctivitis, ear pain.
women. GI: nausea, vomiting, constipation, anorexia, dry mouth,
Black Box Warning: Abilify isn’t approved for use dyspepsia, diarrhea,
in children with depression. abdominal pain, esophageal dysmotility.
Nursing Considerations swallowing, loss of balance control, pill rolling of
 Assess mental status (orientation, mood, behavior) hands, masklike face, shuffling gait, rigidity,
before and periodically during therapy. Assess for tremors; and dystonic—muscle spasms, twisting
suicidal tendencies, especially during early therapy motions, twitching, inability to move eyes,
for depression. Restrict amount of drug available to weakness of arms or legs) periodically throughout
patient. Risk may be increased in children, therapy. Report these symptoms.
adolescents, and adults 24 yrs.  Monitor for tardive dyskinesia (uncontrolled
 Assess weight and BMI initially and throughout rhythmic movement of mouth, face, and
therapy. Compare weight of children and extremities; lip smacking or puckering; puffing of
adolescents with that expected during normal cheeks; uncontrolled chewing; rapid or worm-like
growth. movements of tongue). Notify health care
 Obtain fasting blood glucose and cholesterol levels professional immediately if these symptoms occur,
initially and periodically during therapy. as these side effects may be irreversible.
 Monitor BP (sitting, standing, lying), pulse, and
respiratory rate before and periodically during Patient Teaching
therapy.  Advise families and caregivers to closely observe
 Observe patient carefully when administering patient for
medication to ensure that medication is actually clinical worsening, suicidality, or unusual changes in
taken and not hoarded or cheeked. behavior.

 Monitor patient for onset of akathisia (restlessness  Tell patient to use caution while driving or
or desire to keep moving) and extrapyramidal side operating hazardous machinery because
effects (parkinsonian—difficulty speaking or
 psychoactive drugs may impair judgment, thinking, Generic Name Brand Name
or motor skills. 2. ASENAPINE (SAPHRIS)
 Tell patient that drug may be taken without regard Dosage and Frequency
to meals. Adult
 Advise patients that grapefruit juice may interact Acute Treatment: PO 5 mg BID <10 years:
with aripiprazole and to limit or avoid its use. Maintenance: PO 5 mg BID, 10-17 years: 2.5 SL q12hr
 Advise patient that gradual improvement in initially; recommended 5 or 10 mg BID may increase to 5
symptoms should occur over several weeks rather mg SL q12hr after 3 days and to 10 mg SL q12hr after 3
than immediately. additional days

 Tell patients to avoid alcohol use while taking drug. Pediatric: Safety & efficacy not established

 Advise patients to limit strenuous activity while

taking drug to avoid dehydration.
 Tell patient to keep ODT in blister package until
ready to use. Using dry hands, he should carefully
peel open the foil backing and place tablet on the
tongue. Tell him not to split tablet.
 Tell patient to store oral solution in refrigerator, and
that the solution can be used for up to 6 months after
opening
Mechanism of Action Contraindications
Saphris (asenapine) is a sublingual psychotropic  Elderly patients with dementia-related psychosis
agent. The exact mechanism of action is unknown. treated with atypical or conventional antipsychotics
However, it has been suggested that the efficacy of are at increased risk for death.
asenapine in schizophrenia is mediated through a  Antipsychotics aren’t approved for the treatment of
combination of antagonist activity at D2 and 5-HT2A dementia-related psychosis.
receptors.  Alert: Watch for signs and symptoms of neuroleptic
Saphris is specifically indicated for the acute malignant syndrome (extrapyramidal effects,
treatment of schizophrenia in adults and for the acute hyperthermia, autonomic disturbance), which are
treatment of manic or mixed episodes associated with rare but can be fatal.
bipolar I disorder with or without psychotic features in  Alert: Avoid use in patients with conditions that
adults. may increase risk of torsades de pointes and in those
Saphris is supplied as a tablet for sublingual taking other drugs that prolong QTc interval.
administration.  It isn’t known if drug appears in breast milk.
Indication Because of risk of adverse effects, an alternative
Acute treatment of manic or mixed episodes method of feeding the baby is recommended.
associated with bipolar I disorder, as monotherapy or  Safety and efficacy in children haven’t been
adjunctive therapy with lithium or valproate. Maintenance established.
treatment of bipolar I disorder as monotherapy. Adverse effects
CNS: akathisia, anxiety, depression, dizziness,
extrapyramidal symptoms, fatigue, headache, insomnia,
irritability, somnolence.
CV: hypertension, prolonged QTc interval.
EENT: dry mouth, oral hypoesthesia, salivary
hypersecretion, toothache.
GI: constipation, dyspepsia, increased appetite, stomach
discomfort, taste perversion, vomiting.
Metabolic: weight gain.
Musculoskeletal: arthralgia, extremity pain.
Nursing Considerations
 Monitor ECG before and regularly during treatment
for prolongation of QTc interval.
 Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may disappear
spontaneously or persist for life, despite stopping
drug.
 Drug may alter glucose control in diabetics.
Monitor glucose levels closely.
 Monitor CBC frequently during first few months of
therapy in those with history of leukopenia or
neutropenia. If WBC count decreases, monitor
patient for signs and symptoms of infection; if
infection occurs, discontinue drug in the absence of
another cause.
 Obtain blood pressure before starting drug and
monitor pressure regularly. Watch for orthostatic
hypotension.
 Monitor patient for dysphagia, which can lead to
aspiration and aspiration pneumonia.
 Dispense lowest appropriate quantity of drug, to
reduce risk of overdose.
 Monitor patient for abnormal body temperature
regulation, especially if he exercises, is exposed to
extreme heat, takes anticholinergics, or is
dehydrated.
Patient Teaching
 Instruct patient to peel back colored tab on tablet
pack, gently remove tablet, place under the tongue,
and allow to dissolve completely. Advise patient
not to eat or drink for 10 minutes after taking drug.
 Warn patient to avoid activities that require mental
alertness, such as operating hazardous machinery or
operating a motor vehicle, until drug’s effects are
known.
 Advise patient to contact prescriber if palpitations
or rapid heartbeat occurs.
  Advise patient not to stand up quickly but to get up
slowly from a sitting position to avoid dizziness.
 Inform patient that weight gain may occur.
 Warn patient against exposure to extreme heat
because drug may impair body’s ability to reduce
temperature.
 Advise patient to avoid alcohol.
Pediatric
<6 months: Safety and efficacy not established
≥6 months: 50-100 mg/day PO/IM; 200 mg/day or more
may be necessary for older hospitalized patients; for
outpatients, may administer 0.55 mg/kg q4-6hr PRN

Generic Name Brand Name

3. CHLORPROMAZINE (THORAZINE)
Dosage and Frequency
Adult
Mechanism of Action
30–800 mg/day in 1–4 divided doses M
Chlorpromazine blocks post-synaptic D2 dopamine
PO: 30-75 mg/day divided q6-12hr initially; maintenance:
receptors. It is considered that dopamine receptor blockade
usually 200 mg/day (up to 800 mg/day in some patients;
in the mesolimbic area accounts for the antipsychotic
some patients may require 1-2 g/day)
effect, whilst blockade in the nigrostriatal system produces
IV/IM: 25 mg initially, followed PRN with 25-50 mg after
the extrapyramidal effects associated with chlorpromazine
1-4 hours, then increased to maximum of 400 mg q4-6hr
use. The anti-emetic effect results from dopamine
until patient is controlled; usual dosage 300-800 mg/day
antagonism in the chemoreceptor trigger zone.
Chlorpromazine also possesses antimuscarinic properties.
It is an antagonist at histamine (H1), serotonin and alpha-1-
adrenergic receptors (Dollery 1991).
Indication
 For the treatment of schizophrenia.
 To control nausea and vomiting.
 For relief of restlessness and apprehension
before surgery.
 For acute intermittent porphyria.
 As an adjunct in the treatment of tetanus.
Contraindication
 Contraindicated in patients hypersensitive to drug;
in those with CNS depression, bone marrow
suppression, or subcortical damage, and in those in
coma.
 Use cautiously in elderly or debilitated patients and
in patients with hepatic or renal disease, severe CV

 To control the manifestations of the manic type of disease (may suddenly decrease blood pressure),

manic-depressive illness. respiratory disorders, hypocalcemia, glaucoma, or

 For relief of intractable hiccups. prostatic hyperplasia. Also use cautiously in those

 For the treatment of severe behavioral problems in exposed to extreme heat or cold (including

children (1 to 12 years of age) marked by antipyretic therapy) or organophosphate

combativeness and/or explosive hyperexcitable insecticides.

behavior (out of proportion to immediate  Use cautiously in acutely ill or dehydrated children

provocations), and in the short-term treatment of Adverse Effects

hyperactive children who show CNS: extrapyramidal reactions, sedation, tardive

excessive motor activity with accompanying dyskinesia, pseudo parkinsonism, neuroleptic malignant

conduct disorders consisting of some or all of the syndrome, seizures, dizziness, drowsiness.

following symptoms: impulsivity, difficulty CV: orthostatic hypotension, tachycardia, quinidine-like

sustaining attention, aggressivity, mood lability and ECG effects.

poor frustration tolerance. EENT: ocular changes, blurred vision, nasal congestion.
GI: dry mouth, constipation, nausea.
GU: urine retention, menstrual irregularities, inhibited
ejaculation, priapism.
Hematologic: leukopenia, agranulocytosis, aplastic anemia,
thrombocytopenia, eosinophilia, hemolytic anemia.
Hepatic: jaundice
Skin: mild photosensitivity reactions, pain at I.M. injection
site, allergic reactions, sterile abscess, skin pigmentation
changes.
Nursing Considerations
 Obtain baseline blood pressure measurements
before therapy, and monitor regularly. Watch for
orthostatic hypotension, especially with parenteral
administration.
 Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may not appear until
months or years later and may disappear
spontaneously or persist for life, despite stopping
drug.
 After abrupt withdrawal of long-term therapy,
gastritis, nausea, vomiting, dizziness, or tremor may
occur. Alert: Watch for evidence of neuroleptic
malignant syndrome (extrapyramidal effects,
hyperthermia, autonomic disturbance), which is
rare but usually fatal. It may not be related to length
of drug use or type of neuroleptic; more than 60%
of affected patients are men.
 If jaundice, symptoms of blood dyscrasia (fever,
sore throat, infection, cellulitis, weakness), or
persistent extrapyramidal reactions (longer than a
few hours) develop, or if such reactions occur in
children or pregnant women, withhold dose and
notify prescriber.
 Don’t withdraw drug abruptly unless required by
severe adverse reactions. Elderly patients with
dementia related psychosis treated with atypical or
conventional antipsychotics are at increased risk for
death. Antipsychotics aren’t approved the treatment
of dementia-related psychosis
Patient teaching
 Warn patient to avoid activities that require
alertness or good coordination until effects of drug
are known. Drowsiness and dizziness usually
subside after first few weeks.
 Tell patient to avoid alcohol while taking drug.
  Have patient report signs of urine retention or
constipation.
 Tell patient to use sunblock and to wear protective
clothing to avoid oversensitivity to the sun. This
drug is more likely to cause sun sensitivity than
other drugs in its class.
 Tell patient to relieve dry mouth with sugarless gum
or hard candy.
 Advise patient receiving drug by any method other
than by mouth to remain lying down for 1 hour
afterward and to rise slowly
Mechanism of Action
Clozapine is an anti-psychotic medication that
Generic Name Brand Name
works by blocking receptors in the brain for several
4. CLOZAPINE (CLOZARIL)
neurotransmitters (chemicals that nerves use to
Dosage and Frequency
communicate with each other) including dopamine type 4
Adults
receptors, serotonin type 2 receptors, norepinephrine
12.5 mg PO once daily or q12hr initially; increased daily in
receptors, acetylcholine receptors, and histamine receptors.
increments of 25-50 mg/day, if well tolerated, to achieve
Unlike traditional anti-psychotic agents, such as
target dosage of 300-450 mg/day by end of 2 weeks
chlorpromazine (Thorazine) and haloperidol (Haldol) as
Pediatric
well as the newer anti-psychotics, risperidone (Risperdal)
Safety and efficacy not established
and olanzapine (Zyprexa), clozapine only weakly blocks
dopamine type 2 receptors.
Indication
CLOZARIL is indicated for the treatment of
severely ill patients with schizophrenia who fail to respond
adequately to standard antipsychotic treatment. Because of
the risks of severe neutropenia and of seizure associated
with its use, CLOZARIL should be used only in patients
who have failed to respond adequately to standard
antipsychotic treatment.
The effectiveness of CLOZARIL in treatment-
resistant schizophrenia was demonstrated in a 6-week,
randomized, double-blind, active-controlled study
comparing CLOZARIL and chlorpromazine in patients
who had failed other antipsychotics.
Contraindication
 Contraindicated in patients with uncontrolled
epilepsy, history of clozapine induced
agranulocytosis, WBC count below 3,500/mm3,
severe CNS depression or coma, paralytic ileus, and
myelosuppressive disorders.
 Contraindicated in patients taking other drugs that
suppress bone marrow function.
 Use cautiously in patients with prostatic hyperplasia
or angle-closure glaucoma because
Adverse effects
CNS: drowsiness, sedation, dizziness, vertigo, headache,
seizures, syncope, tremor, disturbed sleep or nightmares,
restlessness, hypokinesia or akinesia, agitation, rigidity,
akathisia, confusion, fatigue, insomnia, hyperkinesia,
weakness, lethargy, ataxia, slurred speech, depression,
myoclonus, anxiety, fever.
CV: tachycardia, cardiomyopathy, myocarditis, pulmonary
embolism, cardiac arrest, hypotension, hypertension, chest
pain, ECG changes, orthostatic hypotension.
EENT: visual disturbances.
GI: constipation, excessive salivation, dry mouth, nausea,
vomiting, heartburn, diarrhea.
GU: urinary frequency or urgency, urine retention,
incontinence, abnormal ejaculation.
Hematologic: leukopenia, agranulocytosis, granulo-
cytopenia, eosinophilia.
Metabolic: hyperglycemia, weight gain,
hypercholesterolemia, hypertriglyceridemia.
Musculoskeletal: muscle pain or spasm, muscle weakness.
Respiratory: respiratory arrest.
Skin: rash, diaphoresis.
Nursing consideration
 ODTs contain phenylalanine.
 Drug carries significant risk of agranulocytosis. If
possible, give patient at least two trials of standard
antipsychotic before starting clozapine. Obtain
baseline WBC and differential counts before
clozapine therapy. Baseline WBC count must be at
least 3,500/mm3 and baseline antineutrophil
cytoplasmic antibody (ANCA) at least 2,000/mm3.
Monitor WBC and ANCA values weekly for at least
4 weeks after stopping drug, regardless of how often
you were monitoring when therapy stopped
 During the first 6 months of therapy, monitor
patient weekly and dispense no more than a 1-week
supply of drug. If acceptable WBC and ANCA
values [WBC 3,500/mm3 or higher and ANCA
2,000/mm3 or higher] are maintained during the
first 6 months of continuous therapy, reduce
monitoring to every other week. After 6 months of
every other-week monitoring without interruption
by leukopenia, reduce frequency of monitoring
WBC and ANCA to monthly.
Patient teaching
 Tell patient about need for weekly blood tests to
check for blood-cell deficiency. Advise him to
report flulike symptoms, fever, sore throat,
lethargy, malaise, or other signs of infection.
 Warn patient to avoid hazardous activities that
require alertness and good coordination while
taking drug.
 Tell patient to check with prescriber before
taking alcohol or OTC drugs. Advise patient
that smoking may decrease drug effectiveness.
 Tell patient to rise slowly to avoid dizziness.
 Tell patient to keep ODTs in the blister package
until he is ready to take them.
 Inform patient that ice chips or sugarless candy
or gum may help relieve dry mouth.
Generic Name Brand Name disorganized speech. It is also known to have antagonistic
5. FLUPHENAZINE (DECANOATE) properties at alpha-1 adrenergic receptors which contribute
Dosage and Frequency to its cardiac and orthostatic side effects (see below).
Adult Fluphenazine, like most other antipsychotic medications,
Initially: 12.5–25mg IM or SC every 4–6 wks.; max has relatively strong antagonistic effects at both
100mg/dose. muscarinic-1 receptors and histamine-1 receptors.
Pediatric
Safety and efficacy not established Indication
Fluphenazine Decanoate Injection is a long acting
parenteral antipsychotic drug intended for use in the
management of patients requiring prolonged parenteral
neuroleptic therapy (e.g., chronic schizophrenics).
Fluphenazine Decanoate Injection has not been shown
effective in the management of behavioral complications in
patients with mental retardation.
Contraindication
Mechanism of Action
 Contraindicated in patients hypersensitive to drug
Fluphenazine acts primarily through antagonism of
and in those with coma, CNS depression, bone
postsynaptic dopamine-2 receptors in mesolimbic,
marrow suppression or other blood dyscrasia,
nigrostriatal, and tuberoinfundibular neural pathways. The
subcortical damage, or liver damage.
blockage of postsynaptic dopamine-2 receptors in the
mesolimbic pathway targets positive symptoms in  Use cautiously in elderly or debilitated patients and

schizophrenia, such as hallucinations, delusions, and in those with pheochromocytoma, severe CV

 disease (may cause sudden drop in blood pressure),
peptic ulcer, respiratory disorder, hypocalcemia,
seizure disorder (may lower seizure threshold),
severe reactions to insulin or electroconvulsive
therapy, mitral insufficiency, glaucoma, or prostatic
hyperplasia.
 Use cautiously in those exposed to extreme heat or
cold (including antipyretic therapy) or phosphorus
insecticides.
 Use parenteral form cautiously in patients who have
asthma or are allergic to sulfites.
Adverse effects
CNS: extrapyramidal reactions, tardive dyskinesia, pseudo
parkinsonism, seizures, neuroleptic malignant syndrome,
sedation, EEG changes, drowsiness, dizziness.
CV: orthostatic hypotension, tachycardia, ECG changes.
EENT: blurred vision, ocular changes, nasal congestion.
GI: dry mouth, constipation, increased appetite.
GU: urine retention, dark urine, menstrual irregularities,
inhibited ejaculation.
Hematologic: leukopenia, agranulocytosis, aplastic anemia,
thrombocytopenia, eosinophilia, hemolytic anemia.
Hepatic: cholestatic jaundice.
Metabolic: weight gain. Skin: mild photosensitivity
reactions, allergic reactions.
Other: gynecomastia, galactorrhea.
Nursing Consideration
 Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may not appear until
months or years later and may disappear
spontaneously or persist for life, despite ending
drug. Watch for signs and symptoms of neuroleptic
malignant syndrome (extrapyramidal effects,
hyperthermia, autonomic disturbance), which is
rare but often fatal. It may not be related to length
of drug use or type of neuroleptic; more than 60%
of affected patients are men.
 Withhold dose and notify prescriber if patient,
especially child or pregnant woman, develops signs
or symptoms of blood dyscrasia (fever, sore throat,
infection, cellulitis, weakness) or extrapyramidal
reactions persisting longer than a few hours. Alert:
 Elderly patients with dementia related psychosis
treated with atypical or conventional antipsychotics
are at increased risk for death. Antipsychotics aren’t
approved for the treatment of dementia-related
psychosis.
 Don’t withdraw drug abruptly unless serious
adverse reactions occur.
 Abrupt withdrawal of long-term therapy may cause
gastritis, nausea, vomiting, dizziness, tremor,
feeling of warmth or cold, diaphoresis, tachycardia,
headache, or insomnia.
Patient teaching
 Warn patient to avoid activities that require
alertness and good coordination until effects of drug
are known. Drowsiness and dizziness usually
subside after first few weeks.
 Warn patient to avoid alcohol while taking drug.
 Tell patient to relieve dry mouth with sugarless gum
or hard candy.
 Have patient report signs of urine retention or
constipation
 Tell patient that drug may discolor urine
Generic Name Brand Name
6. HALOPERIDOL (DECANOATE)
Dosage and Frequency
Adult
Initial: IM dose 10-20 times daily PO dose administered
monthly; not to exceed 100 mg; if conversion requires
initial dose >100 mg, administer in 2 injections (eg, 100 mg
initially, then remainder in 3-7 days)
Maintenance: Monthly dose 10-15 times daily PO dose
Pediatric
<3 years: Safety and efficacy not established
3-12 years (15-40 kg): 0.25-0.5 mg/day PO divided q8-12hr
initially; may be increased by 0.5 mg/day every 5-7 days
PRN; maintenance: 0.05-0.15 mg/kg/day PO divided q8-
12hr
6-12 years: Lactate (prompt-acting): 1-3 mg IM q4-8hr
PRN; not to exceed 0.15 mg/kg/day
>12 years: Moderate disease, 0.5-2 mg PO q8-12hr
initially; severe disease, 3-5 mg PO q8-12hr; not to exceed
30 mg/day
Mechanism of Action
Haloperidol decanoate has no intrinsic activity.
The pharmacological effects are those of haloperidol which
is released by bioconversion. The precise mechanism of
antipsychotic action is unclear, but is considered to be
associated with the potent dopamine D2 receptor blocking
activity of haloperidol and the resulting adaptive changes
Contraindications
in the brain.
 Contraindicated in patients hypersensitive to drug
Haloperidol is also a potent antagonist of opiate receptors,
and in those with parkinsonism, coma, or CNS
and has weak antagonist activity at muscarinic, histamine
depression.
H1, alpha-adrenergic, and serotonin receptors (Dollery
 Use cautiously in elderly and debilitated patients; in
1991).
patients with history of seizures or EEG
Indications
abnormalities, severe CV disorders, allergies,
Haloperidol, marketed under the trade
glaucoma, or urine retention; and in those taking
name Haldol among others, is a typical antipsychotic
anticonvulsants, anticoagulants, antiparkinsonians,
medication. Haloperidol is used in the treatment of
or lithium
schizophrenia, tics in Tourette syndrome, mania in bipolar
disorder, nausea and vomiting, delirium, agitation, acute
Adverse effects
psychosis, and hallucinations in alcohol withdrawal.
CNS: severe extrapyramidal reactions, tardive dyskinesia,
neuroleptic malignant syndrome, seizures, sedation,
drowsiness, lethargy, headache, insomnia, confusion,
vertigo.
CV: tachycardia, hypotension, hypertension, ECG changes,
torsades de pointes, with I.V. use.
EENT: blurred vision.
GI: dry mouth, anorexia, constipation, diarrhea, nausea,
vomiting, dyspepsia.
GU: urine retention, menstrual irregularities, priapism.
Hematologic: leukopenia, leukocytosis.
Hepatic: jaundice. Skin: rash, other skin reactions,
diaphoresis.
Other: gynecomastia
Nursing Considerations
 Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may not appear until
months or years later and may disappear
spontaneously or persist for life, despite ending
drug. Watch for signs and symptoms of neuroleptic
malignant syndrome (extrapyramidal effects,
hyperthermia, autonomic disturbance), which is
rare but commonly fatal. Patients with dementia-
related psychosis treated with atypical
conventional antipsychotics are at increased risk for
death. Antipsychotics aren’t approved for the
treatment of dementia-related psychosis.
 Don’t withdraw drug abruptly unless required by
severe adverse reactions. Alert: Haldol may contain
tartrazine.
Patient teaching
 Although drug is the least sedating of the
antipsychotics, warn patient to avoid activities that
require alertness and good coordination until effects
of drug are known. Drowsiness and dizziness
usually subside after a few weeks.
 Warn patient to avoid alcohol during therapy.
 Tell patient to relieve dry mouth with sugarless gum
or hard candy.
or
Generic Name Brand Name Mechanism of Action
7. ILOPERIDONE (FANAPT) The mechanism of action of iloperidone, as with
Dosage and frequency other drugs having efficacy in schizophrenia, is
Adult unknown. However, it is proposed that the efficacy of
Day 1: 1 mg PO q12hr; increase qDay to effective dose of iloperidone is mediated through a combination of
6-12 mg PO q12hr dopamine type 2 (D2) and serotonin type 2 (5-HT2)
Day 2: 2 mg PO q12hr, THEN increase qDay by 2 mg/day antagonisms. Play the video below to learn more about the
to effective dose of 6-12 mg PO q12hr; not to exceed 24 5HT2A/D2 theory of "atypicality".
mg/day Indications
Pediatric FANAPT is an atypical antipsychotic agent
Safety and efficacy not established indicated for the acute treatment of schizophrenia in adults
(1). In choosing among treatments, prescribers should
consider the ability of FANAPT to prolong the QT interval
and the use of other drugs first. Prescribers should also
consider the need to titrate FANAPT slowly to avoid
orthostatic hypotension, which may lead to delayed
effectiveness compared to some other drugs that do not
require similar titration.
Contraindications
 Contraindicated in patients hypersensitive to drug
or its components.
 Avoid use with other drugs known to prolong QT
interval and in elderly patients with dementia-
related psychosis.
 Use cautiously in patients with history of stroke,
transient ischemic attack, arrhythmia, QT-interval
prolongation, diabetes, seizures, orthostatic
hypotension, neuroleptic malignant syndrome,
tardive dyskinesia, leukopenia, neutropenia,
agranulocytosis, suicidal ideation, or priapism.
 Safe use in pregnancy hasn’t been established. Use
only if benefit to mother outweighs risk to fetus. It
isn’t known if drug appears in breast milk. Patient
shouldn’t breast-feed during therapy
Adverse effects
CNS: aggression, delusion, dizziness, extrapyramidal
effects, fatigue, lethargy, restlessness, somnolence, tremor.
CV: hypotension, orthostatic hypotension, palpitations,
tachycardia.
EENT: blurred vision, conjunctivitis, dry mouth, nasal
congestion, nasopharyngitis.
GI: abdominal discomfort, diarrhea, nausea.
GU: ejaculation failure, erectile dysfunction, urinary
incontinence.
Metabolic: weight gain, weight loss.
Musculoskeletal: arthralgia, muscle spasm,
musculoskeletal stiffness, myalgia.
Respiratory: dyspnea, upper respiratory tract infection.
Nursing Considerations
 Fatal cardiovascular events may occur in elderly
patients with dementia. Drug isn’t approved for use
in patients with dementia-related psychosis. Obtain
baseline blood pressure measurements before
starting therapy, and monitor blood pressure
regularly. Watch for orthostatic hypotension,
especially during first dosage adjustments. Watch
for evidence of neuroleptic malignant syndrome
(hyperthermia, muscle rigidity, altered mental
status, and autonomic instability), which is rare but
can be fatal. Life-threatening hyperglycemia may
 occur in patients taking atypical antipsychotics.
Monitor patients with diabetes regularly. Monitor
fasting blood glucose level at drug initiation and
periodically during therapy in patients with risk
factors for diabetes.
 Monitor patient for tardive dyskinesia, which may
occur with prolonged use of drug. If tardive
dyskinesia occurs, discontinue drug unless patient’s
condition warrants continued use.
 Monitor patient for suicidal thinking and behavior.
 Dispense lowest appropriate quantity of drug to
reduce the risk of overdose.
 Monitor patient for weight gain.
 Periodically reassess patient to determine
continued need for therapy.
 Monitor CBC frequently during the first few
months of therapy and discontinue drug if WBC
count drops with no other underlying cause.
 Drug may lower seizure threshold in patients with a
history of seizures; monitor these patients closely.
Patient teaching
 Warn patient to avoid driving and other hazardous
activities that require mental alertness until the
drug’s effects are known.
 Tell patient drug can be taken with or without food.
 Warn patient to rise slowly, avoid hot showers, and
use other precautions to avoid fainting when
starting therapy.
 Advise patient to avoid becoming overheated or
dehydrated.
 • Tell women of childbearing age to notify
prescriber about planned, suspected, or known
pregnancy.
 Advise breast-feeding women not to breast-feed
during therapy.
 Instruct patient to report symptoms of dizziness,
palpitations, or fainting to prescriber.
  Advise patient to avoid alcohol use while taking
drug.
 Tell male patient to seek emergency medical care if
an erection lasts more than 4 hours.
 Warn patient and caregiver about the risk of
neuroleptic malignant syndrome and advise them to
seek emergency medical care if symptoms
occur.
Pediatric
Not recommended
Mechanism of Action
Loxapine is a dopamine antagonist, and also a
serotonin 5-HT2 blocker. The exact mode of action of
Loxapine has not been established, however changes in the
level of excitability of subcortical inhibitory areas have

 Tell patient to notify prescriber about other been observed in several animal species in association with

prescription or OTC drugs he’s taking or plans to such manifestations of tranquilization as calming effects

take. and suppression of aggressive behavior.

Indications

Generic Name Brand Name Loxapine is used to treat certain mental/mood

8. LOXAPINE (SUCCINATE) disorders (such as schizophrenia). This medicine helps you

Dosage and frequency to think more clearly, feel less nervous, and take part in

Adult everyday life. It can reduce aggression and the desire to hurt

Initial: 10-25 mg PO q12hr yourself/others.

Maintenance: 60-100 mg/day divided q6-12hr; not to

exceed 250 mg/day
 It may also help to decrease hallucinations (such as GI: dry mouth, constipation, nausea, vomiting, paralytic
hearing/seeing things that are not there). Loxapine is a ileus.
psychiatric medication (antipsychotic type) that works by GU: urine retention, menstrual irregularities.
helping to restore the balance of certain natural substances Hematologic: leukopenia, agranulocytosis,
(such as dopamine) in the brain. thrombocytopenia.
Contraindications Hepatic: jaundice.
 Contraindicated in patients hypersensitive to Metabolic: weight gain.
dibenzapines, in those in a coma, and in those with Nursing considerations
severe CNS depression or drug-induced depressed  Obtain baseline blood pressure measurements
states. before starting therapy and monitor pressure
 Use cautiously in patients with seizure disorder, CV regularly.
disorder, glaucoma, or history of urine retention.  Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may not appear until
Adverse effects months or years later and may disappear
CNS: extrapyramidal reactions, sedation, tardive spontaneously or persist for life, despite ending
dyskinesia, neuroleptic malignant syndrome, seizures, drug.
drowsiness, numbness, confusion, syncope, pseudo Patient teaching
parkinsonism, EEG changes, dizziness.  Warn patient to avoid activities that require
CV: orthostatic hypotension, tachycardia, ECG changes, alertness and good coordination until effects of drug
hypertension. are known. Drowsiness and dizziness usually
EENT: blurred vision, nasal congestion. subside after first few weeks.
  Advise patient to report bruising, fever, or sore
throat immediately.
 Tell patient to avoid alcohol while taking drug.
 Advise patient to get up slowly to avoid dizziness
upon standing quickly.
IM: Oral dosage 10 mg/day: 210 mg IM every 2 weeks or
405 mg IM every 4 weeks for 1st 8 weeks, then 150 mg
every 2 weeks or 300 mg every 4 weeks
Pediatric
<13 years: Safety and efficacy not established

 Tell patient to relieve dry mouth with sugarless gum 13-17 years: 2.5-5 mg/day PO initially; target dosage, 10

or hard candy. mg/day; adjust by increments/decrements of 2.5-5 mg;

 Recommend periodic eye examination dosage range, 2.5-20 mg/day

Mechanism of Action
The exact mechanism of action of olanzapine is not
known. It may work by blocking receptors for several
neurotransmitters (chemicals that nerves use to
communicate with each other) in the brain. It binds to

Generic Name Brand Name alpha-1, dopamine, histamine H-1, muscarinic, and

9. OLANZAPINE (ZYPREXA) serotonin type 2 (5-HT2) receptors.

Dosage and frequency

Adult
PO: 5-10 mg/day initially; if necessary, may be titrated
upward in increments of 5 mg/day at intervals >1 week
Maintenance: 10-20 mg/day; not to exceed 20 mg/day
Indication
Olanzapine is an antipsychotic medication that
affects chemicals in the brain. Olanzapine is used to treat
the symptoms of psychotic conditions such as
schizophrenia and bipolar disorder (manic depression) in
adults and children who are at least 13 years old.
Contraindication
 Contraindicated in patients hypersensitive to
drug. Sedation (including coma) or delirium
have been reported following injections of
danzapine extended release formula. This drug
must be administered in a registered health care
facility with ready access to emergency
response services. After each injection, patient
must be observed at the health care facility by a
health care provider for at least 3 hours.
Olanzapine extended-release is available only
through the restricted Zyprexa Relprevv Patient
Care Program.
 Use cautiously in patients with heart disease,
cerebrovascular disease, conditions that
predispose patient to hypotension, history of
seizures or conditions that might lower the
seizure threshold, and hepatic impairment.
 Use cautiously in elderly patients, those with a
history of paralytic ileus, and those at risk for
aspiration pneumonia, prostatic hyperplasia, or
angle-closure glaucoma.
Adverse effects
CNS: somnolence, insomnia, parkinsonism, dizziness,
neuroleptic malignant syndrome, suicide attempt, abnormal
gait, asthenia, personality disorder, akathisia, tremor,
articulation impairment, tardive dyskinesia, fever,
extrapyramidal events (I.M.).
CV: orthostatic hypotension, tachycardia, chest pain,
hypertension, ecchymosis, peripheral edema, hypotension
(I.M.).
EENT: amblyopia, rhinitis, pharyngitis, conjunctivitis.
GI: constipation, dry mouth, dyspepsia, increased appetite,
increased salivation, vomiting, thirst.
GU: hematuria, metrorrhagia, urinary incontinence, UTI,
amenorrhea, vaginitis.
Hematologic: leukopenia.
Metabolic: hyperglycemia, weight gain.
Musculoskeletal: joint pain, extremity pain, back pain, neck
rigidity, twitching, hypertonia.
Respiratory: increased cough, dyspnea. Skin: sweating,
injection site pain (I.M.).
Other: flulike syndrome, injury.
Nursing considerations
 ODTs contain phenylalanine.
 Monitor patient for abnormal body temperature
regulation, especially if he exercises, is exposed to
extreme heat, takes anticholinergics, or
dehydrated.
 Obtain baseline and periodic liver function test
results.
 Monitor patient for weight gain.
 Monitor patient for mental status changes, sedation,
coma, or delirium.
 Monitor patient for tardive dyskinesia, which may
occur after prolonged use. It may not appear until
months or years later and may disappear
spontaneously or persist for life, despite stopping
drug.
 Periodically reevaluate the long-term usefulness of
olanzapine. May increase risk of cardiovascular or
infection-related death in elderly patients with
dementia. Olanzapine isn’t approved to treat
patients with dementia-related psychosis.
 A patient who feels dizzy or drowsy after an I.M.
injection should remain recumbent until he can be
assessed for orthostatic hypotension and
bradycardia. He should rest until the feeling passes.
is Alert: Drug may increase the risk
Patient teaching
 Warn patient to avoid hazardous tasks until full
effects of drug are known.
 Warn patient against exposure to extreme heat; drug
may impair body’s ability to reduce temperature.
 Inform patient that he may gain weight.
 Advise patient to avoid alcohol.
 Tell patient to rise slowly to avoid dizziness upon
standing up quickly.
 Inform patient that ODTs contain phenylalanine.
  Tell patient to peel foil away from ODT, not to push Pediatric
tablet through. Have patient take tablet <12 years: Safety and efficacy not established
immediately, allowing tablet to dissolve on tongue ≥12 years (<51 kg): 3 mg/day PO initially; may be
and be swallowed with saliva; no additional fluid is increased if necessary, in increments of 3 mg/day at
needed. intervals ≥5 days; not to exceed 6 mg/day
 Tell patient to take drug with or without food. ≥12 years (≥51 kg): 3 mg/day PO initially; may be
 Urge woman of childbearing age to notify increased if necessary, in increments of 3 mg/day at
prescriber if she becomes pregnant or plans or intervals ≥5 days; not to exceed 12 mg/day
suspects pregnancy

Generic Name Brand Name

10. PALIPERIDONE (INVEGA)
Dosage and frequency
Adult
PO: 6 mg PO qAM; may be titrated upward or downward
in increments of 3 mg/day at intervals ≥5 days; not to
Mechanism of Action
exceed 12 mg/day
Paliperidone is the major active metabolite of
IM: 234 mg in deltoid on treatment day 1, then 156 mg 1
risperidone. The mechanism of action of paliperidone, as
week later (day 8)
with other drugs having efficacy in schizophrenia, is
Recommended maintenance dose is 117 mg IM once
unknown, but it has been proposed that the drug's
monthly, although some patients may require lower or
therapeutic activity in schizophrenia is mediated through a
higher dosages (monthly dose range 39-234 mg)
combination of central dopamine Type 2 (D2) and
serotonin Type 2 (5HT2A) receptor antagonism.
Indications
INVEGA® is an atypical antipsychotic agent
indicated for the acute and maintenance treatment of
schizophrenia, acute treatment of schizoaffective disorder
as monotherapy and acute treatment of schizoaffective
disorder as an adjunct to mood stabilizers and/or
antidepressants.
Contraindications
 Contraindicated in patients hypersensitive to
paliperidone or risperidone. Elderly patients with
dementia-related psychosis treated with atypical or
conventional antipsychotics are at increased risk
for death. Antipsychotics aren’t approved for the
treatment of dementia-related psychosis.
 Contraindicated in patients with congenital long
QT syndrome or history of cardiac arrhythmias.
 Contraindicated in patients with preexisting severe
GI narrowing (esophageal motility disorders, small
bowel inflammatory disease, short gut syndrome).
 Use cautiously in patients with a history of
seizures or diabetes; those at risk for aspiration
pneumonia; and those with bradycardia,
hypokalemia, hypomagnesemia, CV disease,
cerebrovascular disease, dehydration, or
hypovolemia.
 Use cautiously in patients taking antihypertensives
and drugs that lower the seizure threshold.
 Use cautiously in patients with history of suicide
attempts.
Adverse effects
CNS: akathisia, headache, parkinsonism, somnolence,
anxiety, asthenia, dizziness, dystonia, extrapyramidal
disorder, fatigue, hypertonia, pyrexia, tremor, dyskinesia,
hyperkinesia, insomnia, suicidal ideation.
CV: abnormal T waves, hypertension, orthostatic
hypotension, palpitations, sinus arrhythmia, tachycardia,
AV BLOCK, bundle branch block, PROLONGED QTC
INTERVAL.
EENT: blurred vision.
GI: abdominal pain, dry mouth, dyspepsia, nausea,
salivary hypersecretion, vomiting, diarrhea, constipation.
Metabolic: blood insulin increases, hyperprolactinemia.
Musculoskeletal: back pain, extremity pain.
Respiratory: cough.
Skin: injection-site reaction
Nursing considerations
 Establish tolerability with oral paliperidone or oral
risperidone before initiating treatment with
paliperidone injection
 Obtain baseline blood pressure before starting
therapy and monitor pressure regularly. Watch for
orthostatic hypotension.
 Monitor patient for tardive dyskinesia; it may
disappear spontaneously or persist for life, despite
ending drug. Seek smallest dosage and shortest
duration of treatment that produce a satisfactory
clinical response. Periodically reassess need for
continued treatment.
 Monitor patient for seizure activity, especially if
patient has conditions that lower the seizure
threshold.
 Monitor patient for dysphagia that can lead to
aspiration and aspiration pneumonia
 Monitor patient for abnormal body temperature
regulation, especially if he exercises, is exposed to
extreme heat, takes anticholinergics, or is
dehydrated.
 Monitor patient for somnolence and sedation.
Antipsychotics, including paliperidone, have the
potential to impair judgment, thinking, or motor
skills.
 Dispense lowest appropriate quantity of drug, to
reduce risk of overdose.
Patient teaching
 Tell patient that remains of the tablet may appear
in feces.
 Tell patient to swallow whole with liquids and not
to chew, crush, or break tablets.
 Instruct the patient not to perform activities that
require mental alertness until effects of drug are
known.
 Warn patient to use caution in performing
excessively strenuous activities because his body
temperature may be disrupted.
 Advise patient that drug may lower blood pressure
and to change positions slowly.
 Advise patient to seek medical attention if he
experiences an erection lasting more than 4 hours.
 Instruct patient to contact prescriber before taking
any other drugs to avoid potential interactions.
 Advise patient to avoid alcohol while taking this
medication.
 Advise patient to contact prescriber if she becomes
pregnant or wants to breast-feed.