Antipsychotics for acute agitation

[chrish0204]

I am an RN in an acute, locked psychiatric facility. We often get orders from prescribers for PRN zyprexa (usually ODT). I haven't been working in psych very long and I have been wondering about a couple of issues; none of my texts seem to address this specifically so I figured I'd pose it to everyone here:

1) I'd say 97% of the time the order is for PRN zyprexa zydis (either 5 or 10mg). Very occasionally there will be a PRN order for risperdal M-tabs. Is the preference for zyprexa for agitation just peculiar to the prescribers at my particular facility, or is it actually more effective for reducing agitation in psychotic patients than risperdal (or any other drug, for that matter)?

2) When a patient is given an antipsychotic (of any kind) for acute agitation (or bad AH, or whatever), what is actually happening pharmacologically? Is the patient basically just getting sedated only, because of the antihistamine effect, or is there actually some "antipsychotic" effect happening with dopamine receptors and whatnot? I've always assumed the former to be true, because it can take so long for patients to improve psychotic symptoms with these drugs (i.e., weeks rather than minutes or hours).

And, while I am picking your brains:

3) Patients regularly tell me that weight gain is a huge reason they don't want to take their [insert medication here]. At my facility, the go-to antipsychotics are zyprexa and risperdal. I have always wondered why we don't use geodon more, since it doesn't cause as much weight gain as some of the other atypicals. I understand there are some serious cardiac risks with geodon, but what opinion does everyone have on the risk of noncompliance because of weight gain vs. a small but potentially serious cardiac event?

Thanks for any input.

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[splik]

1) I'd say 97% of the time the order is for PRN zyprexa zydis (either 5 or 10mg). Very occasionally there will be a PRN order for risperdal M-tabs. Is the preference for zyprexa for agitation just peculiar to the prescribers at my particular facility, or is it actually more effective for reducing agitation in psychotic patients than risperdal (or any other drug, for that matter)?

olanzapine is more sedating and thus is preferred in the acute situation by alot of people.

2) When a patient is given an antipsychotic (of any kind) for acute agitation (or bad AH, or whatever), what is actually happening pharmacologically? Is the patient basically just getting sedated only, because of the antihistamine effect, or is there actually some "antipsychotic" effect happening with dopamine receptors and whatnot? I've always assumed the former to be true, because it can take so long for patients to improve psychotic symptoms with these drugs (i.e., weeks rather than minutes or hours).

well blocking dopamine receptors has a calming effect without necessarily sedating, and this effect is acute. even non-sedating drugs e.g. abilify have been used in agitation and do have a calming effect, but as stated above if someone requires a chemical for agitation often sedation is not a bad thing.

And, while I am picking your brains:

3) Patients regularly tell me that weight gain is a huge reason they don't want to take their [insert medication here]. At my facility, the go-to antipsychotics are zyprexa and risperdal. I have always wondered why we don't use geodon more, since it doesn't cause as much weight gain as some of the other atypicals. I understand there are some serious cardiac risks with geodon, but what opinion does everyone have on the risk of noncompliance because of weight gain vs. a small but potentially serious cardiac event?

part of it is different hospitals and different prescribers have different preferences. geodon is more expensive and many insurance companies will not cover it in the first instance so there is no point of starting it for those pts. The risk of QTc prolongation (i.e. cardiac risk) seems to be more theoretical and has not borne out in practice for the most part. older antipsychotics like droperidol, pimozide and thiorizadine were much more likely to have this risk. some people thing that ziprasidone is just less effective than olanzapine or risperidone and thus are less inclined to use it. generally, the less weight gain and sedation, the less effective the antipsychotic.

 

[vistaril]

olanzapine is more sedating and thus is preferred in the acute situation by alot of people.



well blocking dopamine receptors has a calming effect without necessarily sedating, and this effect is acute. even non-sedating drugs e.g. abilify have been used in agitation and do have a calming effect, but as stated above if someone requires a chemical for agitation often sedation is not a bad thing.

And, while I am picking your brains:



part of it is different hospitals and different prescribers have different preferences. geodon is more expensive and many insurance companies will not cover it in the first instance so there is no point of starting it for those pts. The risk of QTc prolongation (i.e. cardiac risk) seems to be more theoretical and has not borne out in practice for the most part. older antipsychotics like droperidol, pimozide and thiorizadine were much more likely to have this risk. some people thing that ziprasidone is just less effective than olanzapine or risperidone and thus are less inclined to use it. generally, the less weight gain and sedation, the less effective the antipsychotic.

the last sentence is ridiculous and there is little evidence base for it.

 

[whopper]

CATIE showed Geodon's QT prolongation wasn't as big a deal as originally thought. That said, I still don't like to give it first choice because 1) the FDA documentation, even if it's in error still has it as higher risk. If that patient developed a cardiac event, it's going to look damning against you if that patient develops a cardiac event. 2) The price comparisons 3) Sedation is sometimes needed and several antipsychotics stop agitation, not because they improved the psychosis or anger but because the patient becomes sedated.

Old FDA warnings not being corrected can be a problem. E.g. The data that pushed for the FDA warnings with Wellbutrin and seizure are allegedly based on bad data, and there's warnings against it for someone with a seizure disorder. Fine, but you practice long enough in this field, you'll get someone with a seizure disorder that may need to placed on it.

As for weight gain, Zyprexa causes it in several patients but there is data that if injected, the effect isn't as bad because it bypasses the GI system.

 

[BobA]

the last sentence is ridiculous and there is little evidence base for it.

There is a Cochrane review that found for mania ziprasidone is less effective than haldol.

Other Cochrane reveiws found that Haldol=olanzapine=risperdal in treatment of mania. Therefore, one can conclude that ziprasidone is probably less effective than the other three for mania.

However, I agree that ziprasidone is underused. The risk of ziprasidone->QTc prolongation -> torsades->death is VASTLY over estimated.Just see the ZODIAC study

 

[BobA]

3) Patients regularly tell me that weight gain is a huge reason they don't want to take their [insert medication here]. At my facility, the go-to antipsychotics are zyprexa and risperdal. I have always wondered why we don't use geodon more, since it doesn't cause as much weight gain as some of the other atypicals. I understand there are some serious cardiac risks with geodon, but what opinion does everyone have on the risk of noncompliance because of weight gain vs. a small but potentially serious cardiac event?

Thanks for any input.

It is interesting that patients say they stop taking medicines because of weight gain - and I can be sympathetic with that myself. I'd HATE to take a medicine that made me gain tons of weight. HOWEVER, in the CATIE study (our best study of schizophrenia) patients stayed on Zyprexa the longest even though they gained the most weight on that medication. CATIE authors speculate that it was because of the greater reduction in symptoms on rating scales that was also achieved from zyperxa.

As a side note, both zydis and M-tabs are gastricly absorbed and so they are NOT really faster than just giving a pill. They do, however, help with compliance because they can't be easily cheeked.

 

[strangeglove]

Also, weight gain is kind-of a non-issue if you are giving the medication as a PRN for agitation, unless we're talking about daily injections in a long-term hospitalization.

 

[vistaril]

There is a Cochrane review that found for mania ziprasidone is less effective than haldol.

that is not what his last sentence said.