NURS 660 Exam1 QUESTIONS AND WELL
EXPLAINED ANSWERS|AGRADE
1. Know the following medications, including their most commonly expected side
effects, drug interactions, potentially serious adverse events, FDA indications, and
lab work that should be monitored prior to starting and while on the medication:
❖ First Generation Antipsychotic Drug
▪ Typical
▪ D2 receptor antagonist
❖ Second Generation Antipsychotic Drug
▪ Atypical
▪ Serotonin and Dopamine receptor antagonist
D2 antagonist
5HT2A/D2 antagonist
D2/5HT1A partial agonist
5HT2A antagonist ❖ The “-pines
(atypical):
▪ Tend to be heavily sedating
▪ Tend to work heavily on other receptor sites: Alpha, Histamine or even some
Muscarinic receptors
▪ Highest risk for weight gain d/t their actions on 5HT2C in addition to H1
❖ The many -dones and a -rone (atypical)
▪ Within the dones and the rone, we have 3 out of 5 in psychiatry that must
take with food Ziprasidone Lurasidone Lumateperone
❖ Two - pips and a -rip
▪ Aripiprazole, Brexpiprazole, and Cariprazine
▪ Common theme between all 3 drugs is that they are D2 and
5HT1A partial agonists – really different from all the other ones
Not sedating
Typically, don’t have a lot of weight gain associated
Not likely to increase prolactin and if anything, they could decrease
prolactin
The most common side effect is akathisia
o Aripiprazole (Abilify)
▪ Atypical
1
, ▪ Not likely to increase prolactin and if anything, they could decrease
prolactin
▪ Not sedating
▪ Very effective in treating depression
▪ Biggest side effects patients complain about is akathisia
o Brexpiprazole (Rexulti)
▪ Atypical
▪ Lesser incidence of akathisia
▪ More anxiolytic qualities
▪ Approved to treat schizophrenia and also approved as add-on therapy
to treat major depressive disorder but has not been approved to treat
bipolar type depression
o Chlorpromazine (Thorazine)
▪ First generation (D2 receptor antagonist)
▪ Low potency dopamine 2 antagonist
▪ Has a wide range of side effects because of those various different receptor
actions
▪ Risk for photosensitivity
▪ Pigmentation changes in skin and eyes
▪ The only 1st generation antipsychotic that is associated with significantly
lowering the seizure threshold
▪ Pigment changes in the skin and the eyes, it’s kind of this blue grayish color.
It occurs with prolonged use and definitely, if it’s at high doses for a long period of
time, any kind of sun-exposed skin can turn this weird blue-gray color. It is not
permanent. o Clozapine (Clozaril)
▪ First atypical agent that was discovered (2nd generation drug)
▪ Most effect option to treat schizophrenia; treat treatment- resistant
schizophrenia (drug of last resort when all else has been tried & nothing
works) ▪ Unique thing:
Only 2 drugs that have been shown to reduce suicide- associated
with schizophrenia
▪ Important to know
Metabolized and it’s a substrate of CYP1A2 (remember smoking is
an inducer in CYP1A2)
Smoking will speed up the metabolism of clozapine which means it
can lower your clozapine levels with it’s important to have a
therapeutic level of clozapine for it to have a therapeutic effect. It
has a therapeutic range, so anything above that can lead to
clozapine toxicity and can lead to life-threatening side effects.
2
, Do not want to give Luvox with clozapine as it could increase
clozapine levels which could lead to clozapine toxicity,
seizure
Lowest risk of EPS, it doesn’t cause tardive dyskinesia, and doesn’t
elevate prolactin
Initially you want to monitor their blood pressure carefully, be
mindful of their cardiac status, watch their heart rate,
temperature
➢ The first 6 weeks of treatment, highest risk for developing
myocarditis
➢ Long run of course of treatment, risk factor for
cardiomyopathy. EKG
▪ Clozapine – concerns with agranulocytosis
Enroll the patient into a risk evaluation management program, the
Clozapine Rims site
Before starting clozapine, you have to check an absolute neutrophil
count to make sure that it is therapeutic (greater than 1500)
➢ Check weekly for the 1st six months and then every other
week for the next 6 months and then every
month for the rest of the patient’s life
▪ Most common side effects
Sedation and weight gain
Drooling and salivation
➢ Do not give them Cogentin or Benadryl to try to dry them up
because the other receptors that works on it really affects
the cholinergic system heavily, putting them at risk for
constipation potentially severe enough that could cause an
ileus leading to bowel obstruction
➢ Preferred treatment for excessive drooling: localize
atropine drops
Other side effects: constipation, orthostatic hypotension
▪ Clozapine – most concerned diabetic ketoacidosis
▪ Used for treatment resistance schizophrenia and suicidal thoughts or
behaviors
▪ What might that look like or what might the patient come in talking about
that would make you worry
▪ Sign & symptoms of maybe having an infection or agranulocytosis
Fever
Malaise
Flu-like symptoms
▪ When combining Clozapine & Luvox
Luvox is a 5HT1A inhibitor, so it can make your clozapine levels high
3
, ▪ Luvox increases clozapine level
▪ What can decrease clozapine level
Smoking – it’s not the nicotine that decreases clozapine, it is the
smoke itself. It is SMOKE the issue NOT the substance
▪ Seizures
When do you expect seizures to happen?
➢ Not so much the timing per se but the level of clozapine
➢ Can happen whenever, it would depend on what dose they’re
on, and then it might depend on if anything is inhibiting or
inducing the Clozapine
➢ Clozapine level
▪ Cardiac effects
Myocarditis – early; present the 1st 6 weeks
➢ Acute inflammatory effects would be more based in part on
just the kind of initial titrating part
Cardiomyopathy – shows later o
Deutetrabenazine o Haloperidol (Haldol)
▪ First generation (D2 receptor antagonist)
▪ High potency dopamine 2 antagonist
▪ Lacks anticholinergic activity
▪ High risk for EPS/TD
▪ Prolonged QTc risk (IV administration)
▪ Possible hypotension side effect not super sedating on its own o
Lurasidone (Latuda)
▪ Must be taken with food (350 calories)
▪ Once a day dosing
▪ Atypical
▪ Side Effects
Less problematic as far as weight gain goes, not that sedating
Higher risk for EPS
▪ Major substrate of the CYP3A4 pathway
Use caution with inducers because they will drastically decrease your
lurasidone levels
➢ Some inducers include Tegretol, St. john’s wart
Use caution with inhibitors like grapefruit, can increase lurasidone
levels up to 8-fold
o Lumateperone (Caplyta)
▪ Must be taken with food – no calorie specification
▪ “newest” antipsychotic medication
▪ Atypical
4
EXPLAINED ANSWERS|AGRADE
1. Know the following medications, including their most commonly expected side
effects, drug interactions, potentially serious adverse events, FDA indications, and
lab work that should be monitored prior to starting and while on the medication:
❖ First Generation Antipsychotic Drug
▪ Typical
▪ D2 receptor antagonist
❖ Second Generation Antipsychotic Drug
▪ Atypical
▪ Serotonin and Dopamine receptor antagonist
D2 antagonist
5HT2A/D2 antagonist
D2/5HT1A partial agonist
5HT2A antagonist ❖ The “-pines
(atypical):
▪ Tend to be heavily sedating
▪ Tend to work heavily on other receptor sites: Alpha, Histamine or even some
Muscarinic receptors
▪ Highest risk for weight gain d/t their actions on 5HT2C in addition to H1
❖ The many -dones and a -rone (atypical)
▪ Within the dones and the rone, we have 3 out of 5 in psychiatry that must
take with food Ziprasidone Lurasidone Lumateperone
❖ Two - pips and a -rip
▪ Aripiprazole, Brexpiprazole, and Cariprazine
▪ Common theme between all 3 drugs is that they are D2 and
5HT1A partial agonists – really different from all the other ones
Not sedating
Typically, don’t have a lot of weight gain associated
Not likely to increase prolactin and if anything, they could decrease
prolactin
The most common side effect is akathisia
o Aripiprazole (Abilify)
▪ Atypical
1
, ▪ Not likely to increase prolactin and if anything, they could decrease
prolactin
▪ Not sedating
▪ Very effective in treating depression
▪ Biggest side effects patients complain about is akathisia
o Brexpiprazole (Rexulti)
▪ Atypical
▪ Lesser incidence of akathisia
▪ More anxiolytic qualities
▪ Approved to treat schizophrenia and also approved as add-on therapy
to treat major depressive disorder but has not been approved to treat
bipolar type depression
o Chlorpromazine (Thorazine)
▪ First generation (D2 receptor antagonist)
▪ Low potency dopamine 2 antagonist
▪ Has a wide range of side effects because of those various different receptor
actions
▪ Risk for photosensitivity
▪ Pigmentation changes in skin and eyes
▪ The only 1st generation antipsychotic that is associated with significantly
lowering the seizure threshold
▪ Pigment changes in the skin and the eyes, it’s kind of this blue grayish color.
It occurs with prolonged use and definitely, if it’s at high doses for a long period of
time, any kind of sun-exposed skin can turn this weird blue-gray color. It is not
permanent. o Clozapine (Clozaril)
▪ First atypical agent that was discovered (2nd generation drug)
▪ Most effect option to treat schizophrenia; treat treatment- resistant
schizophrenia (drug of last resort when all else has been tried & nothing
works) ▪ Unique thing:
Only 2 drugs that have been shown to reduce suicide- associated
with schizophrenia
▪ Important to know
Metabolized and it’s a substrate of CYP1A2 (remember smoking is
an inducer in CYP1A2)
Smoking will speed up the metabolism of clozapine which means it
can lower your clozapine levels with it’s important to have a
therapeutic level of clozapine for it to have a therapeutic effect. It
has a therapeutic range, so anything above that can lead to
clozapine toxicity and can lead to life-threatening side effects.
2
, Do not want to give Luvox with clozapine as it could increase
clozapine levels which could lead to clozapine toxicity,
seizure
Lowest risk of EPS, it doesn’t cause tardive dyskinesia, and doesn’t
elevate prolactin
Initially you want to monitor their blood pressure carefully, be
mindful of their cardiac status, watch their heart rate,
temperature
➢ The first 6 weeks of treatment, highest risk for developing
myocarditis
➢ Long run of course of treatment, risk factor for
cardiomyopathy. EKG
▪ Clozapine – concerns with agranulocytosis
Enroll the patient into a risk evaluation management program, the
Clozapine Rims site
Before starting clozapine, you have to check an absolute neutrophil
count to make sure that it is therapeutic (greater than 1500)
➢ Check weekly for the 1st six months and then every other
week for the next 6 months and then every
month for the rest of the patient’s life
▪ Most common side effects
Sedation and weight gain
Drooling and salivation
➢ Do not give them Cogentin or Benadryl to try to dry them up
because the other receptors that works on it really affects
the cholinergic system heavily, putting them at risk for
constipation potentially severe enough that could cause an
ileus leading to bowel obstruction
➢ Preferred treatment for excessive drooling: localize
atropine drops
Other side effects: constipation, orthostatic hypotension
▪ Clozapine – most concerned diabetic ketoacidosis
▪ Used for treatment resistance schizophrenia and suicidal thoughts or
behaviors
▪ What might that look like or what might the patient come in talking about
that would make you worry
▪ Sign & symptoms of maybe having an infection or agranulocytosis
Fever
Malaise
Flu-like symptoms
▪ When combining Clozapine & Luvox
Luvox is a 5HT1A inhibitor, so it can make your clozapine levels high
3
, ▪ Luvox increases clozapine level
▪ What can decrease clozapine level
Smoking – it’s not the nicotine that decreases clozapine, it is the
smoke itself. It is SMOKE the issue NOT the substance
▪ Seizures
When do you expect seizures to happen?
➢ Not so much the timing per se but the level of clozapine
➢ Can happen whenever, it would depend on what dose they’re
on, and then it might depend on if anything is inhibiting or
inducing the Clozapine
➢ Clozapine level
▪ Cardiac effects
Myocarditis – early; present the 1st 6 weeks
➢ Acute inflammatory effects would be more based in part on
just the kind of initial titrating part
Cardiomyopathy – shows later o
Deutetrabenazine o Haloperidol (Haldol)
▪ First generation (D2 receptor antagonist)
▪ High potency dopamine 2 antagonist
▪ Lacks anticholinergic activity
▪ High risk for EPS/TD
▪ Prolonged QTc risk (IV administration)
▪ Possible hypotension side effect not super sedating on its own o
Lurasidone (Latuda)
▪ Must be taken with food (350 calories)
▪ Once a day dosing
▪ Atypical
▪ Side Effects
Less problematic as far as weight gain goes, not that sedating
Higher risk for EPS
▪ Major substrate of the CYP3A4 pathway
Use caution with inducers because they will drastically decrease your
lurasidone levels
➢ Some inducers include Tegretol, St. john’s wart
Use caution with inhibitors like grapefruit, can increase lurasidone
levels up to 8-fold
o Lumateperone (Caplyta)
▪ Must be taken with food – no calorie specification
▪ “newest” antipsychotic medication
▪ Atypical
4
