Drsherispirt.com



SHERI SPIRT, M.D.PSYCHIATRY16 East 96th Street Unit 1ANEW YORK, N.Y. 10128(212) 595-6901SSDR18@WWW.GeodonSchizophrenia20 mg PO q12hr with food initially; may be increased every other day PRN; not to exceed 80 mg q12hrPeriodically assess need for maintenance; clinical trials have documented no added benefit with doses above 20 mg q12hrAcute Agitation With SchizophreniaIM: 10 mg q2hr or 20 mg q4hr; not to exceed 40 mg/day; use IM for up to 3 days, and switch to PO if continuing past this timeBipolar I DisorderAcute treatment of manic or mixed episodes; maintenance therapy as adjunct to lithium or valproateAcute treatment: 40 mg PO q12hr with food?initially; on day 2, may be increased if necessary to 60-80 mg PO q12hr; adjust dose according to tolerance and efficacy within range of 40-80 mg q12hrMaintenance: Continue at same dose at which patient was initially stabilized; periodically reassess need for maintenance therapyDosing ModificationsRenal impairment: Dose adjustment not necessary with PO administration; caution required with IM administrationHepatic impairment: Use caution; drug undergoes extensive hepatic metabolism, which can increase systemic exposurePharmacologyMechanism of ActionActs as antagonist at dopamine D2 and serotonin type 1 and 2 (5HT1D, 5HT2A) receptors; acts as agonist at serotonin 5HT1A receptor; moderately inhibits reuptake of norepinephrine and serotonin; has alpha-blocking and antihistaminic activityAbsorptionBioavailability: 60% (PO); 100% (IM)Peak plasma time: 6-8 hr (PO); ≤60 min (IM)DistributionProtein bound: 99%Vd: 1.5 L/kgMetabolismMetabolized in liver by CYP3A4 (major) and CYP1A2 (minor)EliminationHalf-life: 7 hr (PO); 2-5 hr (IM)Total body clearance: 7.5 mL/min/kgExcretion: Feces (66%), urine (20%)Adverse Effects>10%Somnolence (11-15%)Headache (11%)Nausea (4-12%)Extrapyramidal symptoms (2-31%)Dizziness (3-16%)1-10%Respiratory disorders (1-8%)Constipation (2-9%)Dyspepsia (1-8%)Rash (4-5%)Tachycardia (2%)Hypoesthesia (2%)Priapism (1%)Orthostatic hypotension (5%)Xerostomia (1-5%)Anorexia (2%)Myalgia (2%)Rhinitis (1-4%)Cough (3%)<1%SyncopeSeizuresFrequency Not DefinedProlongation of QT intervalNeuroleptic malignant syndrome (NMS)HyperprolactinemiaDrug reaction with eosinophilia and systemic syntomsPostmarketing reportsStevens-Johnson syndromeContraindicationsDocumented hypersensitivityAny drugs or conditions that prolong QT intervalRecent acute myocardial infarctionUncompensated heart failureCautionsSeizure disorders; may cause hypotension, EPS, and somnolenceAtypical antipsychotics have been associated with metabolic changes (eg, hyperglycemia, dyslipidemia, and body weight gain) that may increase cardiovascular/cerebrovascular risk Hyperglycemia may occur and in some cases may be extreme, resulting in ketoacidosis, hyperosmolar coma, or death; monitor blood glucose of high-risk patientsNeuroleptic malignant syndrome reported with antipsychotic drugs Tardive dyskinesia, acute dystonic reactions, pseudoparkinsonism, or akathisia may develop acutely or chronicallyDiscontinue if rash develops without an identified causeDrug reaction with eosinophilia and systemic symptoms (DRESS) reported; DRESS consists of combination of three or more of the following: cutaneous reaction (such as rash or exfoliative dermatitis), eosinophilia, fever, lymphadenopathy and one or more systemic complications such as hepatitis, nephritis, pneumonitis, myocarditis, and pericarditis; DRESS is sometimes fatal; discontinue therapy if DRESS suspectedCutaneous adverse reactions, such as Stevens-Johnson syndrome, reported; severe cutaneous adverse reactions are sometimes fatal; discontinue therapy if suspectedRare cases of priapism reportedFDA warning regarding off-label use for dementia in elderly (see Black Box Warnings)May cause orthostatic hypotensionSuicide attempt is inherent in psychotic illness or bipolar disorder, close supervision of high-risk patients should accompany drug therapyDopamine2 antagonists may elevate prolactin levels; long-standing hyperprolactinemia when associated with hypogonadism may lead to decreased bone densityLeukopenia/neutropenia and agranulocytosis reported; possible risk factors for leukopenia/neutropenia include preexisting low white blood cell (WBC) count and history of drug-induced leukopenia/neutropenia If patient has history of clinically significant low WBC count or drug-induced leukopenia/neutropenia, monitor complete blood count (CBC) frequently during first few months of therapy; discontinue drug at first sign of clinically significant WBC decline <1000/μL in absence of other causative factors, and continue monitoring WBC count until recoveryAntipsychotic agents have been associated with esophageal dysmotility and aspiration; use caution in patients at risk of pneumoniaMay cause QTc prolongation, which has been associated with development of malignant ventricular arrhythmias (torsade de pointes) and sudden death; discontinue therapy in patients with persistent QTc intervals >500 msec; avoid hypokalemia or hypomagnesemiaModerate to highly sedative; use caution when required to operate heavy machineryMay cause core body temperature regulation impairment; use caution with heat exposure, strenuous exercise, dehydration, or taking medications with anticholinergic effectsMake electrolyte imbalance corrections, especially hypomagnesemia or hypokalemia before and throughout therapy Use with caution in hepatic impairmentINTERACTIONSContraindicated (21)amiodaroneamoxapinearsenic trioxideastemizolecisapridecitalopramdisopyramideescitalopramgoserelinibutilideindapamideleuprolidepentamidinepimozideprocainamidequinidinesaquinavirsorafenibsotalolterfenadinetoremifeneSerious - Use Alternative (70)amisulprideamitriptylineamoxapineapomorphineartemether/lumefantrinebromocriptinecabergolinechlorpromazinecitalopramclarithromycinclomipraminedesipraminedofetilidedopaminedosulepindoxepindronedaronedroperidolepinephrineepinephrine racemiceribulinerythromycin baseerythromycin ethylsuccinateerythromycin lactobionateerythromycin stearatefluconazolefluphenazineformoterolhaloperidolhistrelinhydroxyzineimipramineitraconazoleketoconazolelevodopalisuridelofepraminelorcaserinlumefantrinemaprotilinemefloquinemethyldopamianserinmoxifloxacinnafarelinnilotinibnortriptylineoctreotideoctreotide (antidote)ondansetronpanobinostatperphenazinepimavanserinpramipexoleprochlorperazinepromazinepromethazineprotriptylineropinirolesertindolesodium oxybatethioridazinetrazodonetrifluoperazinetrimipraminetriptorelinumeclidinium bromide/vilanterol inhaledvandetanibvemurafenibvilanterol/fluticasone furoate inhaledMonitor Closely (309)abobotulinumtoxinaacarboseaclidiniumalbiglutidealbuterolalfentanilalprazolamamisulprideamitriptylineamobarbitalamoxapineanticholinergic/sedative combosarformoterolaripiprazolearmodafinilatracuriumatropineatropine iv/imaxitinibazelastineazithromycinbaclofenbambuterolbedaquilinebelladonna alkaloidsbelladonna and opiumbenazeprilbenperidolbenzphetaminebrompheniraminebuclizinebuprenorphinebuprenorphine buccalbutabarbitalbutalbitalbutorphanolcaffeinecarbamazepinecarbinoxaminecarisoprodolchloral hydratechlordiazepoxidechlorpheniraminechlorpromazinechlorpropamidechlorzoxazonecimetidinecinnarizineciprofloxacincisatracuriumclarithromycinclemastineclobazamclomethiazoleclomipramineclonazepamclonidineclorazepateclozapinecodeinecrizotinibcyclizinecyclobenzaprinecyproheptadinedantrolenedarifenacindasatinibdesipraminedexchlorpheniraminedexfenfluraminedexmedetomidinedexmethylphenidatedextroamphetaminedextromoramidediamorphinediazepamdichlorphenamidedicyclominediethylpropiondifenoxin hcldimenhydrinatediphenhydraminediphenoxylate hcldipipanonedobutaminedolasetrondopaminedopexaminedosulepindoxepindoxylaminedroperidolenfluraneephedrineephedrine (pulmonary)epinephrineepinephrine racemicerythromycin baseerythromycin ethylsuccinateerythromycin lactobionateerythromycin stearateestazolamethanoletomidateexenatide injectable solutionexenatide injectable suspensionezogabinefenfluraminefesoterodineflavoxateflecainideflibanserinfluoxetinefluphenazineflurazepamfluvoxamineformoterolfoscarnetglimepirideglipizideglyburideglycopyrrolateglycopyrrolate inhaledguanabenzguanfacinehaloperidolhenbanehexobarbitalhomatropinehydrocodonehydromorphonehydroxyzinehyoscyaminehyoscyamine sprayiloperidoneimipramineincobotulinumtoxinaindacaterol, inhaledinsulin aspartinsulin degludecinsulin degludec/insulin aspartinsulin detemirinsulin glargineinsulin glulisineinsulin inhaledinsulin lisproinsulin nphinsulin regular humanipratropiumisoproterenolitraconazoleivacaftorketoconazoleketotifen, ophthalmiclapatiniblenvatiniblevalbuterollevofloxacinlevorphanolliraglutidelisdexamfetaminelofepraminelofexidinelomitapideloprazolamlorazepamlormetazepamloxapineloxapine inhaledlurasidonemaprotilinemaravirocmarijuanameclizinemelatoninmepenzolatemeperidinemephobarbitalmeprobamatemetaproterenolmetaxalonemetforminmethadonemethamphetaminemethocarbamolmethscopolaminemethylenedioxymethamphetaminemethylphenidatemetoclopramidemianserinmidazolammidodrinemifepristonemiglitolmirtazapinemodafinilmorphinemotherwortmoxonidinenabilonenalbuphinenateglinidenefazodonenorepinephrinenortriptylineofloxacinolanzapineolodaterol inhaledonabotulinumtoxinaopium tinctureorphenadrineosimertiniboxazepamoxybutyninoxybutynin topicaloxybutynin transdermaloxycodoneoxymorphonepaliperidonepancuroniumpapaveretumpapaverineparoxetinepasireotidepazopanibpentazocinepentobarbitalperphenazinephendimetrazinephenobarbitalphenterminephenylephrinephenylephrine popholcodinepimozidepioglitazonepirbuterolposaconazolepralidoximepramlintideprimidoneprochlorperazinepromethazinepropanthelinepropofolpropylhexedrineprotriptylinepseudoephedrinequazepamquetiapinequinineramelteonranolazinerapacuroniumrepagliniderifabutinrifampinrilpivirinerimabotulinumtoxinbrisperidonerocuroniumromidepsinrosiglitazonesalmeterolsaxagliptinscopolaminescullcapsecobarbitalsertindolesertralineshepherd's pursesitagliptinsolifenacinst john's wortsufentanilsulfamethoxazolesulpiridetapentadoltelavancintelithromycintemazepamterbutalineterfenadinetetrabenazinethioridazinethiothixenetiotropiumtolazamidetolbutamidetolterodinetopiramatetramadoltrazodonetriazolamtriclofostrifluoperazinetrimethoprimtrimipraminetriprolidinetropisetrontrospium chloridetubocurarinevecuroniumvenlafaxinevoriconazolexylometazolineyohimbineziconotidezotepineMinor (77)amobarbitalaprepitantarmodafinilartemether/lumefantrineatazanavirbosentanbrimonidinebudesonidebutabarbitalbutalbitalchasteberryclobetasoneconivaptancortisonecyclosporinedarifenacindarunavirdasatinibdelavirdinedexamethasonedhea, herbaldiltiazemefavirenzeslicarbazepine acetateethanolethotoinetravirineeucalyptusfluconazolefludrocortisonefosamprenavirfosphenytoingrapefruitgriseofulvinhexobarbitalhydrocortisoneindinavirisoniazidlapatiniblumefantrinemarijuanamephobarbitalmethylprednisolonemetronidazolemibefradilmiconazole vaginalmodafinilnafcillinnelfinavirnevirapinenifedipinenilotiniboxcarbazepineoxiconazolepentobarbitalphenobarbitalphenytoinposaconazoleprednisoloneprednisoneprimidonequinupristin/dalfopristinrifapentineritonavirrufinamideruxolitinibsagesecobarbitalsitaxentantelithromycintopiramatetriamcinolonetroglitazonetroleandomycinverapamilvoriconazolezafirlukast ................
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