Download Commonly Used Psychotropic Medications

COMMONLY USED PSYCHOTROPIC DRUGS
po = by mouth; prn = as needed; qd = 1x/day; bid = 2x/day; tid = 3x/day; qid = 4x/day;
qod = every other day; qhs = at bedtime; qac = before meals;
= on WalMart’s $4 Rx plan, however not all dosages may be covered
NAME
DOSE
IMPORTANT CLINICAL INFORMATION
Commonly used Antidepressants and Antianxiety Medications
Start: 100mg bid titrating to 150 mg bid or tid
SR or XL preparation is longer acting (bid dosing)
Seizure risk ; Stimulating; not good for anxiety
20 – 60mg qam (Start: 20mg qam)
Less GI distress than other SSRIs; No clinical CYP 450 interactions
Duloxetine (Cymbalta)
20 – 30mg bid (Start: 20 mg bid)
Side effect profile like SSRIs and venlafaxine
Escitalopram (Lexapro)
10 – 20mg qam (Start: 10 mg qam)
Less GI distress than other SSRIs; No clinical CYP 450 interactions
20 – 80mg qam (Start: 10 – 20mg qam)
More stimulating than other SSRIs; Long half life prevents withdrawal
Bupropion (Wellbutrin)
Citalopram (Celexa)
Fluoxetine (Prozac)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Sertraline (Zoloft)
30 – 45mg qhs (Start: 15mg qhs)
Sedating and appetite promoting; Neutropenia risk (1 in 1000)
20 – 50mg qhs (Start: 10 – 20mg qhs)
Anticholinergic, sedating, withdrawal syndrome
50 – 200mg qam (Start: 25 – 50mg qam )
No clinical CYP 450 interactions
Trazodone (Desyrel)
50 – 150mg qhs for sleep (Start: 25mg qhs)
Commonly used as sleep aid; Priapism risk
Venlafaxine (Effexor)
Start: 37.5 – 75mg bid with titration to 300 – 375mg daily
XR preparation is longer acting (once daily dosing)
Side effects like SSRIs; HTN and withdrawal risk
Commonly used Antianxiety and Sleep (Hypnotic) Medications
Alprazolam (Xanax)
Start: 0.25mg – 0.5mg tid
Indicated for panic disorder and anxiety; Equivalent dose: 0.5mg
Start: 0.25 – 0.5mg bid with doses up to 1 – 4mg in panic disorder and up to
20mg divided bid for seizures
Start: 2 – 10mg bid to qid with doses varying widely based on the reason for
use
Indicated for panic disorder and seizure disorder; Has been effective in mania
Onset: intermediate; Elimination: 18 – 50 hrs; Equivalent dose: 0.25mg
Many indications including anxiety, seizures, alcohol withdrawal, & muscle spasm
Onset: fast; Elimination: 30 – 100 hrs; Equivalent dose: 5mg
Oxazepam (Serax)
Start: 10mg bid or tid for anxiety. Insomnia: start with 15 mg at bedtime.
Indicated for alcohol withdrawal and anxiety; Equivalent dose: 15mg
Lorazepam (Ativan)
Anxiety: 2 – 3mg bid or tid
Indicated for insomnia, anxiety, pre-anesthesia, and status epilepticus
Safer in liver disease; Equivalent dose: 1mg
Start: 1 – 2mg at bedtime titrated to 3mg
Approved for long term use; no evidence of dependence over six month treatment
Start: 5mg at bedtime titrated to 10mg
Short half life of 2-3 hours.
Clonazapam (Klonopin)
Diazepam (Valium)
Eszopiclone (Lunesta)
Zolpidem (Ambien)
Zaleplon (Sonata)
Ramelteon (Rozerem)
Start: 10mg titrated to 20mg
Essentially like zolpidem; Has a very short half life of one hour.
Start: 8mg at bedtime
Melatonin receptor agonist; Appears safe for long term use in insomnia
Commonly used Antimanic Medications (Mood Stabilizers)
Lithium
Valproic Acid
Lamotrigine (Lamictal)
Start: 150 – 300mg bid with doses up to 1200 – 1500mg daily based on renal
function
Start: 250mg bid with end dose of 1000 – 2000mg divided bid
(max dose: 60mg/kg/day divided bid)
Start: 25mg daily for two weeks then 50mg daily for two weeks with a final
dose of 200 – 400mg once or divided.
Black box warning: toxicity and the need to check levels; Level established (0.5 - 1.2 meq/L)
Black box warning: hepatotoxicity, pancreatitis, and teratogenicity; Therapeutic levels (80-120mcg/mL)
Black box warning due to rash.
No therapeutic drug levels
Commonly used Antipsychotic Medications
Hyperprolactinemia common; Decanoate (injection) preparation available.
Orally dissolvable tablet excellent for acute agitation
Risperidone (Risperdal)
Start: 0.5 – 1mg qhs or bid titrating to 4 – 6mg daily or bid
Olanzapine (Zyprexa)
Start: 5 – 10mg daily titrating to 15 – 30mg daily once or divided bid
Sedation, weight gain, and metabolic complications are common.
Quetiapine (Seroquel)
Start: 20mg bid titrating to 400 – 600mg daily divided bid (max dose:
800mg)
Very sedating with a low incidence of extrapyramidal side effects.
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Start: 20mg bid titrating to 40 – 80mg bid
Black box warning for QT prolongation
Start:10 – 15mg daily titrating to 15 – 30mg daily
May have less metabolic complications than other atypicals
Also has an indication for bipolar disorder
Most effective antipsychotic for treatment refractory patients
Agranulocytosis, orthostasis, tachycardia, weight gain, and drooling
Classic typical, high potency neuroleptic. Causes Parkinsonian symptoms (EPS).
Comes in an elixir and can be given PO, IM. Long acting (depot) form available.
Clozapine (Clozaril)
Start: 12.5 daily or bid titrating slowly to 300-450mg daily in divided doses
(max dose: 900mg)
Haloperidol (Haldol)
Start: 0.5 to 5mg daily or bid titrating to 5- 20 mg daily
Prazosin (Vasoflex )
Start: 1mg at bedtime (titrate slowly as needed to effect)
Orthostatic hypertension– Patient should move slowly from resting to standing
COMMONLY USED PSYCHOTROPIC DRUGS
po = by mouth; prn = as needed; qd = 1x/day; bid = 2x/day; tid = 3x/day; qid = 4x/day;
qod = every other day; qhs = at bedtime; qac = before meals;
= on WalMart’s $4 Rx plan, however not all dosages may be covered
NAME
DOSE
IMPORTANT CLINICAL INFORMATION
Commonly used Antidepressants and Antianxiety Medications
Start: 100mg bid titrating to 150 mg bid or tid
SR or XL preparation is longer acting (bid dosing)
Seizure risk ; Stimulating; not good for anxiety
20 – 60mg qam (Start: 20mg qam)
Less GI distress than other SSRIs; No clinical CYP 450 interactions
Duloxetine (Cymbalta)
20 – 30mg bid (Start: 20 mg bid)
Side effect profile like SSRIs and venlafaxine
Escitalopram (Lexapro)
10 – 20mg qam (Start: 10 mg qam)
Less GI distress than other SSRIs; No clinical CYP 450 interactions
20 – 80mg qam (Start: 10 – 20mg qam)
More stimulating than other SSRIs; Long half life prevents withdrawal
Bupropion (Wellbutrin)
Citalopram (Celexa)
Fluoxetine (Prozac)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Sertraline (Zoloft)
30 – 45mg qhs (Start: 15mg qhs)
Sedating and appetite promoting; Neutropenia risk (1 in 1000)
20 – 50mg qhs (Start: 10 – 20mg qhs)
Anticholinergic, sedating, withdrawal syndrome
50 – 200mg qam (Start: 25 – 50mg qam )
No clinical CYP 450 interactions
Trazodone (Desyrel)
50 – 150mg qhs for sleep (Start: 25mg qhs)
Commonly used as sleep aid; Priapism risk
Venlafaxine (Effexor)
Start: 37.5 – 75mg bid with titration to 300 – 375mg daily
XR preparation is longer acting (once daily dosing)
Side effects like SSRIs; HTN and withdrawal risk
Commonly used Antianxiety and Sleep (Hypnotic) Medications
Alprazolam (Xanax)
Start: 0.25mg – 0.5mg tid
Indicated for panic disorder and anxiety; Equivalent dose: 0.5mg
Start: 0.25 – 0.5mg bid with doses up to 1 – 4mg in panic disorder and up to
20mg divided bid for seizures
Start: 2 – 10mg bid to qid with doses varying widely based on the reason for
use
Indicated for panic disorder and seizure disorder; Has been effective in mania
Onset: intermediate; Elimination: 18 – 50 hrs; Equivalent dose: 0.25mg
Many indications including anxiety, seizures, alcohol withdrawal, & muscle spasm
Onset: fast; Elimination: 30 – 100 hrs; Equivalent dose: 5mg
Oxazepam (Serax)
Start: 10mg bid or tid for anxiety. Insomnia: start with 15 mg at bedtime.
Indicated for alcohol withdrawal and anxiety; Equivalent dose: 15mg
Lorazepam (Ativan)
Anxiety: 2 – 3mg bid or tid
Indicated for insomnia, anxiety, pre-anesthesia, and status epilepticus
Safer in liver disease; Equivalent dose: 1mg
Start: 1 – 2mg at bedtime titrated to 3mg
Approved for long term use; no evidence of dependence over six month treatment
Start: 5mg at bedtime titrated to 10mg
Short half life of 2-3 hours.
Clonazapam (Klonopin)
Diazepam (Valium)
Eszopiclone (Lunesta)
Zolpidem (Ambien)
Zaleplon (Sonata)
Ramelteon (Rozerem)
Start: 10mg titrated to 20mg
Essentially like zolpidem; Has a very short half life of one hour.
Start: 8mg at bedtime
Melatonin receptor agonist; Appears safe for long term use in insomnia
Commonly used Antimanic Medications (Mood Stabilizers)
Lithium
Valproic Acid
Lamotrigine (Lamictal)
Start: 150 – 300mg bid with doses up to 1200 – 1500mg daily based on renal
function
Start: 250mg bid with end dose of 1000 – 2000mg divided bid
(max dose: 60mg/kg/day divided bid)
Start: 25mg daily for two weeks then 50mg daily for two weeks with a final
dose of 200 – 400mg once or divided.
Black box warning: toxicity and the need to check levels; Level established (0.5 - 1.2 meq/L)
Black box warning: hepatotoxicity, pancreatitis, and teratogenicity; Therapeutic levels (80-120mcg/mL)
Black box warning due to rash.
No therapeutic drug levels
Commonly used Antipsychotic Medications
Hyperprolactinemia common; Decanoate (injection) preparation available.
Orally dissolvable tablet excellent for acute agitation
Risperidone (Risperdal)
Start: 0.5 – 1mg qhs or bid titrating to 4 – 6mg daily or bid
Olanzapine (Zyprexa)
Start: 5 – 10mg daily titrating to 15 – 30mg daily once or divided bid
Sedation, weight gain, and metabolic complications are common.
Quetiapine (Seroquel)
Start: 20mg bid titrating to 400 – 600mg daily divided bid (max dose:
800mg)
Very sedating with a low incidence of extrapyramidal side effects.
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Start: 20mg bid titrating to 40 – 80mg bid
Black box warning for QT prolongation
Start:10 – 15mg daily titrating to 15 – 30mg daily
May have less metabolic complications than other atypicals
Also has an indication for bipolar disorder
Most effective antipsychotic for treatment refractory patients
Agranulocytosis, orthostasis, tachycardia, weight gain, and drooling
Classic typical, high potency neuroleptic. Causes Parkinsonian symptoms (EPS).
Comes in an elixir and can be given PO, IM. Long acting (depot) form available.
Clozapine (Clozaril)
Start: 12.5 daily or bid titrating slowly to 300-450mg daily in divided doses
(max dose: 900mg)
Haloperidol (Haldol)
Start: 0.5 to 5mg daily or bid titrating to 5- 20 mg daily
Prazosin (Vasoflex )
Start: 1mg at bedtime (titrate slowly as needed to effect)
Orthostatic hypertension– Patient should move slowly from resting to standing
Provide d by Mental H ealth Infrastructure a nd Train ing (MHIT) Project an d REACH NOLA (w ww.reac hno la.org)
MAXIMUM THERAPEUTIC DOSES (mg PER DAY)
COMMONLY USED ANTIDEPRESSANTS
OF
(Medication "failures" are often due to inadequate dosing*)
Bupropion (Wellbutrin)
450mg
Citalopram (Celexa)
60mg
Duloxetine (Cymbalta)
60mg
Escitalopram (Lexapro)
30mg
Fluoxetine (Prozac)
60mg
Mirtazapine (Remeron)
60mg
Paroxetine (Paxil)
60mg
Sertraline (Zoloft)
200mg
Venlafaxine (Effexor)
300mg
*Treat at the maximum tolerated therapeutic dose for 6 to 8 weeks before switching.
GOOD REASONS
•
•
•
•
TO
STOP
A
MEDICATION
Intolerable side effects
Dangerous interactions with other necessary medications
It was never "indicated" to begin with (wrong diagnosis or wrong medicine for diagnosis)
It has been at the maximum therapeutic dose for 6 to 8 weeks with no results
Originally created by Alex Thompson, MD, MPH, MBA and Stephen Thielke, MD, MPH
University of Washington
MAXIMUM THERAPEUTIC DOSES (mg PER DAY)
COMMONLY USED ANTIDEPRESSANTS
OF
(Medication "failures" are often due to inadequate dosing*)
Bupropion (Wellbutrin)
450mg
Citalopram (Celexa)
60mg
Duloxetine (Cymbalta)
60mg
Escitalopram (Lexapro)
30mg
Fluoxetine (Prozac)
60mg
Mirtazapine (Remeron)
60mg
Paroxetine (Paxil)
60mg
Sertraline (Zoloft)
200mg
Venlafaxine (Effexor)
300mg
*Treat at the maximum tolerated therapeutic dose for 6 to 8 weeks before switching.
GOOD REASONS
•
•
•
•
TO
STOP
A
MEDICATION
Intolerable side effects
Dangerous interactions with other necessary medications
It was never "indicated" to begin with (wrong diagnosis or wrong medicine for diagnosis)
It has been at the maximum therapeutic dose for 6 to 8 weeks with no results
Originally created by Alex Thompson, MD, MPH, MBA and Stephen Thielke, MD, MPH
University of Washington
Provide d by Mental H ealth Infrastructure a nd Train ing (MHIT) Project an d REACH NOLA (w ww.reac hno la.org)