FLUPHENAZINE Dana Bartlett, RN, BSN, MSN, MA, CSPI Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Rocky Mountain Poison Control Center. ABSTRACT Fluphenazine is an antipsychotic that is used for the treatment of patients who have a psychotic disorder. It is used off-label to treat chorea associated with Huntington’s disease, chronic tic disorders, and psychosis and agitation associated with dementia. Fluphenazine is a piperazine phenothiazine. The phenothiazines are a class of medications that are used as antiemetics and to treat psychiatric disorders. Fluphenazine’s mechanism of action is not completely understood but its antipsychotic effect is likely mediated through selective blockade of dopamine receptors in the brain. Fluphenazine may also affect peripheral alpha-adrenergic receptors, histamine receptors, and muscarinic receptors but fluphenazine’s ability to block these receptors is considered limited. Policy Statement 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 2.5 hours. Statement of Learning Need Health clinicians need to know the indications, uses, contraindications and potential side effects of fluphenazine. An awareness of fluphenazine benefits and risks in oral and depot forms is necessary for clinicians to prescribe and monitor outcomes safely, and to prevent both side effects and relapse of symptoms in the setting of chronic mental illness. Course Purpose To inform health clinicians of practical learning points for the use of fluphenazine that clinicians can include in everyday practice, as well as the potential for side effects or overdose that may occur with fluphenazine. Target Audience 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Dana Bartlett, RN, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – All have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 1. Fluphenazine is a piperazine phenothiazine and a first-generation 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com a. anticonvulsant. b. antipsychotic. c. mood stabilizer. d. antidepressant. 2. Fluphenazine should be used cautiously in patients who have asthma, glaucoma or other visual problems because a. of its cholinergic effects. b. it stimulates the neurotransmitter acetylcholine. c. it has a high potential to cause anticholinergic effects. d. of its possible anticholinergic effects. 3. Fluphenazine has an off-label use for the treatment of a. chorea associated with Huntington’s disease. b. anticholinergic symptoms. c. severe central nervous system (CNS) depression. d. subcortical brain damage. 4. If a patient has hepatic impairment, a. fluphenazine should be used cautiously. b. the adult dosage for fluphenazine may still be used. c. using fluphenazine is contraindicated. d. there are no specific dosing recommendations for fluphenazine. 5. A US Box Warning warns ___________________, who receive antipsychotics (such as fluphenazine) for the treatment of dementia-related psychosis, that they are at an increased risk for death. a. elderly patients b. renally impaired patients c. patients with hepatic impairment d. patients with Huntington’s chorea Introduction 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Fluphenazine is an antipsychotic that is used for the treatment of patients who have a psychotic disorder. Antipsychotic medications are typically the initial treatment for schizophrenia and fluphenazine has been successfully used to treat delusions and hallucinations. Fluphenazine is widely used to treat psychosis and may be administered in an oral and intramuscular (long acting) form. There are extensive possible adverse effects, which need to be reviewed with the patient when studying the drug profile and evaluating risks to the patient. Pharmacological Profile The information presented here is summarized from prescribing information and current published information relative to the basic pharmacological profile of fluphenazine. The clinical pearls section of drug use, which includes in-depth information on topics initially covered in the basic pharmacological profile, and a review of fluphenazine overdose will be covered in the next sections. Category First generation, typical antipsychotic; phenothiazine derivative.2 Mechanism of Action Fluphenazine is a piperazine phenothiazine. The phenothiazines are a class of medications that are used as antiemetics and to treat psychiatric disorders. Fluphenazine’s mechanism of action is not completely understood, but its antipsychotic effect is likely mediated through selective blockade of dopamine receptors in the brain. Phenothiazines have some effect on peripheral alpha-adrenergic receptors, histamine receptors, and muscarinic 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com receptors but fluphenazine’s ability to block these receptors is considered limited.2 Labeled Use Treatment of patients who have a psychotic disorder.2 Off-Label Uses Chorea of Huntington’s disease, chronic tic disorders, and psychosis and agitation associated with dementia.2 Dosing Oral Tablets: The initial dose is 2.5 mg – 10 mg a day given in three-four divided doses. The maintenance dose is 1 mg – 5 mg a day and may be given as one dose.2 Intramuscular Injection - Fluphenazine Hydrochloride: Initial dose is 1.25 mg, however some patients may need 2.5 mg – 10 mg a day and divided doses should be used every 6-8 hours. When the symptoms have stabilized, a switch may be made to the oral tablets.2 IM Injection - Fluphenazine Decanoate: Intramuscular (IM) or subcutaneous (SQ) injection, 6.25 mg – 25 mg every 2 weeks. Once the patient has stabilized the effects of a dose may last for 4 - 6 weeks.2 Fluphenazine decanoate 12.5 mg given every three weeks is approximately equivalent to 10 mg of oral fluphenazine hydrochloride given daily.2 Available Forms 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com ● Oral concentrate: 5 mg/mL ● Oral elixir: 2.5 mg/5 mL ● Oral tablets: 1 mg, 2.5 mg, 5 mg, and 10 mg ● Fluphenazine decanoate injection: 25 mg/mL ● Fluphenazine hydrochloride injection: 2.5 mg/mL All of the above are generic names for fluphenazine. The brand name is Prolixin. US Boxed Warning Elderly patients who receive antipsychotics for the treatment of dementia- related psychosis are at an increased risk for death. 2 Analyses of 17 placebo-controlled trials (most of the patients were taking atypical antipsychotics) found that the risk of death in the treated patients was 1.6 – 1.7 times that of the patients who received a placebo. The rate of death in the patients receiving an antipsychotic was 4.5%, for the placebo group it was 2.6%. Most of the deaths appeared to be from cardiovascular causes. Contraindications Contraindications include hypersensitivity to fluphenazine or to any of the components of the product. Fluphenazine is contraindicated if the patient has a blood dyscrasia, is comatose or has severe central nervous system (CNS) depression. Fluphenazine is also contraindicated if the patient is receiving large amounts of hypnotics, has hepatic disease, or subcortical brain damage. 2 Dosing Adjustment: Geriatric Patients 7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Oral: The initial dose should be 1 to 2.5 mg daily.2 The antipsychotics are identified by the Beers criteria as potentially inappropriate for patients 65 years or older.2 This issue will be discussed further in the Clinical Pearls section. Dosing Adjustment: Hepatic Impairment The use of fluphenazine is contraindicated if the patient has hepatic impairment.2 Dosing Adjustment: Renal Impairment There are no specific dosing recommendations for fluphenazine for patients who have renal impairment.2 Adverse Effects The incidence of the adverse effects of fluphenazine has not been reported in the prescribing information. Adverse