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For Personal Use Only SedatiWITH ANTIi ® Dowden Health Media CopyrightFor personal use only Initiate the antipsychotic at a reasonable, not overly high dose, then use a nonantipsychotic to help control insomnia, anxiety, and agitation For mass reproduction, content licensing and permissions contact Dowden Health Media. pSYCHIATRY i PSYCHOTICSon edation is a frequent side effect of antipsychot- ics, especially at relatively high doses. Antipsy- S chotics’ sedative effects can reduce agitation in acute psychosis and promote sleep in insomnia, but Manage, don’t long-term sedation may: • interfere with schizophrenia patients’ efforts to go accept adverse to work or school or engage in normal socialization • prevent improvement from psychosocial training, psychiatric rehabilitation, and other treatments. ‘calming’ eff ect This article discusses how to manage acute psycho- sis without oversedation and ways to address persistent sedation and chronic insomnia with less-sedating anti- Del D. Miller, PharmD, MD Professor of psychiatry psychotics or adjunctive medications. University of Iowa Carver College of Medicine Iowa City Neurobiology or psychopharmacology? Many patients experience only mild, transient som- nolence at the beginning of antipsychotic treatment, and most develop some tolerance to the sedating ef- fects with continued administration. Others may have persistent daytime sedation that interferes with nor- mal functioning. Sedation is especially common in elderly patients re- ceiving antipsychotics. Compared with younger patients, older patients receiving the same doses of the same med- ications become more heavily sedated for longer periods of time. The resulting sedation can impair arousal levels during the day and increase the risk of falls. continued MANLEY MATT Current Psychiatry 2007 Vol. 6, No. 8 © 39 Table 1 Antipsychotics’ potency, dosages, and sedative properties Relative Common dosage Medication potency (mg)* (mg/d) Sedation First-generation antipsychotics Chlorpromazine 100.0 300 to 600 Moderate Sedation Fluphenazine 1.0 to 2.0 4 to 20 Mild Haloperidol 2.0 5 to 20 Mild Second-generation antipsychotics Aripiprazole 7.5 15 to 30 Mild Clozapine 50.0 250 to 500 Marked Olanzapine 4.0 15 to 30 Moderate Quetiapine 80.0 300 to 800 Moderate Risperidone 1.0 2 to 6 Mild Ziprasidone 20.0 80 to 160 Mild Clinical Point * Approximate dose equivalent to 100 mg of chlorpromazine Source: Data from reference 9. Choose the initial antipsychotic for Sedation can occur with fi rst-generation Effi cacy and sedation its eff ectiveness, antipsychotics (FGAs) and second-genera- Antipsychotics are thought to exert their rather than relying tion antipsychotics (SGAs), but it is seen effect by antagonism of postsynaptic do- on its side eff ects more commonly and tends to be more pamine D2 and serotonin 5HT2A receptors to control disease severe with low-potency FGAs than with and possibly other receptors in the brain. SGAs. Clinical challenges come with: Four SGAs—risperidone, olanzapine, que- manifestations • distinguishing between sedation and tiapine, and ziprasidone—act as dopamine negative symptoms of schizophrenia such D2 and 5HT2A antagonists. Aripiprazole as avolition, amotivation, withdrawal, and is a dopamine D2 partial agonist, sero- anhedonia tonin 5HT1A partial agonist, and serotonin • determining whether an individual’s 5HT2A antagonist.1 Effi cacy data compar- cognitive impairment is related to the anti- ing SGAs with each other and with FGAs psychotic’s sedative properties. vary, but all 5 of these SGAs have been Because the treatments are different, it shown to be effective antipsychotics.2-4 is important to try to distinguish negative They also generally cause less sedation symptoms and/or cognitive impairment than FGAs. related to schizophrenia’s neurobiology Patients with acute exacerbation of psy- from sedation related to the antipsychotic. chosis often have insomnia and frequently Ask patients if they nap during the day report paranoia that “something” will or just lie around, and if they want to do happen to them while they sleep. When things but can’t: treating agitated patients, many clinicians • If they want to do things but feel too consider calming effects and true antipsy- tired, this likely is sedation caused by the chotic effects to be one in the same, which antipsychotic. Treatment might be a dose is not correct. All available antipsychotics reduction. are, on average, equally effective in treat- • If they are not interested in doing ing acute psychotic symptoms but vary things, the likely cause is negative symp- considerably in the amount of sedation toms. Treatment might be a medication such they produce. Studies of short-acting in- as a selective serotonin reuptake inhibitor. jectable SGAs, such as ziprasidone and ar- • If they want to do things but can- ipiprazole, have shown that agitation and not organize themselves to be able to do acute symptoms can be controlled without them, this likely is cognitive impairment. signifi cant sedation.5,6 Treatment might be cognitive training or Antipsychotic effects are not immedi- Current Psychiatry 40 August 2007 remediation. ate and historically were thought to occur continued on page 43 continued from page 40 Table 2 Antipsychotics’ sedative eff ects by the numbers: pSYCHIATRY Equilibrium dissociation constants at brain receptors* CurrentPsychiatry.com Receptors Dopamine D2 Serotonin 5-HT2A Histamine H1 FGA Haloperidol 2.60 61.00 260.0 SGAs Aripiprazole 0.34 3.40 61.00 Clozapine 210.00 2.60 3.10 Olanzapine 20.00 1.50 0.10 Risperidone 3.80 0.15 5.20 Quetiapine 770.00 31.00 19.00 Ziprasidone 2.60 0.12 4.60 * Lower numbers are equivalent to higher receptor binding affi nity. Each antipsychotic’s sedative effect is determined by histamine H1 affi nity and the amount of drug that reaches H1 receptors in the CNS—which in turn is affected by the agent’s dosage and dopamine Clinical Point D2 receptor affi nity. FGA: fi rst-generation antipsychotic; SGAs: second-generation antipsychotics The combination Source: References 1,14,15 of H1 affi nity and over several weeks. Recent meta-analyses is in remission may support adherence the amount of suggest, however, that some antipsychot- and improve outcomes. drug reaching ic effects are evident within the fi rst week the histamine H1 7,8 of treatment. To avoid overmedication, Dosages and sedation. Not all FGAs have receptors determines therefore, it’s important to separate calm- the same sedative effect, nor do all SGAs ing effects from antipsychotic effects. (Table 1, page 40).9 In general, the high-mil- the sedative eff ect ligram, low-potency FGAs—such as chlor- Recommendations. Choose the initial promazine—produce more sedation than antipsychotic based on its effective- the low-milligram, high-potency FGAs— ness in treating the underlying disease, such as haloperidol and fl uphenazine.9 rather than relying on side effects—such This principle tends to hold true for the as sedation—to control disease manifes- SGAs as well. For example, the high-po- tations. Without sedation, patients are tency, low-dose SGA risperidone is less se- better able to engage in therapy; partici- dating than the lower-potency, high-dose pate in family, social, school, and work SGAs quetiapine and clozapine. activities; and increase their chances of Dose does not always determine seda- recovery. tion, however. Olanzapine, which is com- Initiate the antipsychotic at or titrate to a monly dosed at 15 to 30 mg/d, is more reasonable, not overly high dose—such as: sedating than ziprasidone, for which the • olanzapine, 10 to 20 mg/d usual range is 80 to 160 mg/d.3,10-12 • risperidone, 3 to 6 mg/d • ziprasidone, 100 to 140 mg/d • quetiapine, 400 to 600 mg/d Mechanism and sedation • aripiprazole, 15 mg/d. The mechanisms of antipsychotics’ thera- Continue the patient on that dose, and peutic and sedative properties appear to be use a nonantipsychotic such as a benzodi- different.13 The degree of sedation shows azepine to help control insomnia, anxiety, little relationship with the various anti- and agitation. Two to 4 weeks is generally psychotics’ potency at the dopamine D2 adequate, but some patients may need the receptor, which suggests that dopamine adjunctive therapy for several months. If D2 receptor antagonism is not involved in you initiate a more sedating antipsychotic causing sedation. acutely, switching to a less sedating agent Instead, the degree of sedation may be Current Psychiatry when the patient is stable and the illness associated with each antipsychotic’s affi nity Vol. 6, No. 8 43 Table 3 Normal sleep architecture, Sleep patterns in mental illness which can be disordered Sleep disturbances—including changes in in schizophrenia sleep patterns, insomnia, and excessive sleeping—occur frequently in patients Nonrapid eye movement (NREM) sleep with psychiatric disorders. The sleep pro- Stage 1 Drowsiness; represents transition cess itself (Table 3) is disrupted in patients Sedation between waking and sleeping with schizophrenia. Stage 2 Sleep deepens A study that examined sleep patterns in 40 patients with schizophrenia found lon- Stages 3 Deepest levels of NREM sleep; and 4 subjects are most diffi cult to ger sleep latency, more frequent arousals, arouse (slow-wave or delta sleep) and increased periods of wakefulness after sleep onset compared with controls with- Rapid eye movement (REM) sleep out a psychiatric disorder. Ratings of sleep Vivid dreams; pulse and respiration rates are higher and more variable than during effi ciency—ratio of sleep time to time in NREM
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