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These medicines, which include olanzapine (zyprexa), risperidone (risperdal), quetiapine (seroquel), ziprasidone (geodon), and
aripiprazole (abilify), are called atypical
antipsychotics or mood stabilizers. They were developed in the 1990’s
to treat schizophrenia, and represented a major advancement for this
disorder because they had far fewer side effects than the older antipsychotics. Later it was
discovered that these medications are not just antipsychotics
but also work to stabilize mood. In
fact, they help with both the depressive and manic symptoms of bipolar
disorder, and several of them are FDA-approved for this use.
These
medicines also relieve agitation, insomnia and mood swings, and when added
to other psychiatric medications they can help treat depression,
post-traumatic stress disorder, borderline personality disorder and
obsessive compulsive disorder.
Although
the atypicals can be very helpful, there are a
few important risks you should be aware of in taking them:
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Some of the atypicals can cause
weight gain.
·
They can rarely cause diabetes and changes in cholesterol.
·
Very rarely, they may cause tardive
dyskinesia, a problem of muscle twitching that
may not go away after the medicine is stopped.
These effects are described in more detail below.
How do they work?
Generally, these medicines
relieve psychiatric conditions by reducing excess dopamine and enhancing
serotonin in the brain.
What types are available and how are they taken?
These medicines can be taken
with or without food. If they make
you drowsy, it is best to take them at night. If you miss a dose, ask yourself if you
are closer to the dose you missed or to your next dose. If you are closer to your next dose, just
wait and take it then, otherwise it’s ok to take the dose you
missed.
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Name (Brand)
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Strengths
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typical dosage
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Approximate price
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Risperidone (Risperdal)
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Tablets: 0.25, 0.5, 1, 2, 3, 4mg.
M-Tab (dissolving tablet): 0.5, 1, 2mg.
Liquid 1 mg/ml.
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Taken once a day (0.25-16mg daily).
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Tab: 30 of: 0.25mg ($82), 0.5mg ($88), 1mg ($85), 2mg
($147), 3mg ($168), 4mg ($232).
M-Tab: 28 of 1mg: $113.
Liquid: 2 bottles (30 ml each): $212.
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Olanzapine (Zyprexa)
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Tabs: 2.5, 5, 7.5, 10, 15, 20mg.
Zydis (dissolving tablet):
5, 10, 15, 20mg.
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Taken once a day (2.5-20mg daily).
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Tab: 30 of: 2.5mg ($149), 5mg ($180), 7.5mg ($194),
10mg ($263), 20mg ($510).
Zydis : 5mg ($224), 10mg ($322), 15mg ($467), 20mg ($602).
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Quetiapine (Seroquel)
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Tabs: 25, 100, 200, 300mg
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Taken 1-3 time a day (25-800mg daily).
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60 of: 25mg ($95), 100mg ($168), 200mg ($315), 300mg
($389).
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Ziprasidone (Geodon)
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Capsules: 20, 40, 60 and 80mg.
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Taken twice a day (20-160mg daily).
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60 of: 20mg ($244), 40mg ($252), 60mg ($274), 80mg
($285)
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Aripiprazole
(Abilify)
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Tabs: 5, 10, 15, 20, 30mg
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Taken once a day (5-30mg daily).
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30 of: 5mg ($280), 10mg ($276), 15mg ($276), 20mg
($381), 30mg ($381).
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How long will I need to take it for?
The atypicals can be used both to treat and prevent
symptoms, so how long you take them will depend on your goals. If you are
taking them for schizophrenia or schizoaffective disorder, the atypicals will continue to work after your symptoms
have gone away to prevent future symptoms, so long-term use may be helpful.
For bipolar disorder, there is also some evidence that the atypicals can prevent future mood swings, but since
there are other options to prevent mood swings whether or not you continue
to take them will also depend on any side effects you have.
What side effects can I expect?
Common side
effects:
Weight Gain: this
can affect up to half the people who take atypicals. Weight gain can sometimes be severe, so
it is important to diet
and exercise while taking these medicines. Weight gain is worse with olanzapine (Zyprexa), while aripirazole
(Abilify) does not appear to cause weight gain.
Akathisia: a feeling of
inner-restlessness, like you have to “keep moving.” This side
effect is very rare with ziprasidone (Geodon), quetiapine (Seroquel) and aripiprazole (Abilify).
Muscle Dystonia: sudden muscle
contractions and rigidity, especially of the head and neck. This is very
rare with aripiprazole (Abilify) and quetiapine (Seroquel).
EPS Symptoms: stiffness or slowing of the muscles. These symptoms are very rare with aripiprazole (Abilify)
and quetiapine (Seroquel).
Hypotension: these medicines can lower blood pressure,
especially in the beginning of treatment, which can lead to dizziness,
rapid heart rate and falls (especially when standing up).
Fatigue and drowsiness: this often improves after the first few days of
treatment.
Elevated prolactin hormone: this can cause menstrual irregularities, breast
engorgement and breast milk secretion. If you have been diagnosed with
breast cancer, high prolactin levels may
interfere with recovery. This side
effect is worse with risperidone (Risperdal) and occurs very rarely with aripiprazole (Abilify)
and quetiapine (Seroquel).
Other common side effects (these often improve with
time or with lower doses):
Anxiety, constipation, nausea, stomach discomfort, rash, vivid dreams,
increased sleeping, trouble with reading and close vision, reduced or
increased salivation, changes in urination, incontinence of urine,
diarrhea, excessive menstrual bleeding, diminished sexual desire, erectile
dysfunction, ejaculatory dysfunction, and trouble achieving orgasm, sun
sensitivity.
Rare but serious side effects:
Diabetes
Mellitus: there is evidence that
atypicals can increase the rates of diabetes,
particularly in people who are already at risk. The rate of diabetes on these medicines
is not known but appears to be low. Sometimes diabetes can come on
suddenly, causing high glucose levels (hyperglycemia), increased urination,
and even coma and death.
Elevations of
cholesterol or triglycerides:
these can increase the risk of heart disease and stroke.
Tardive Dyskinesia: this is a condition of unwanted muscle
movements, particularly of the facial muscles, tongue, fingers and toes. It
is a rare side effect of older antipsychotic drugs and has been extremely
rare with the atypicals. Those at greater risk include people who
have taken older antipsychotic drugs and elderly women. This condition may not go away after the
drug is stopped and there are no known treatments for it.
Neuroleptic
Malignant Syndrome: this
reaction occurred rarely with older antipsychotic drugs and is thought to
be even more rare with the atypicals. Symptoms include fever, rigid muscles,
confusion, sweating, and unstable heart rhythms or blood pressure. This condition is treatable but can
potentially be fatal.
Cerebrovascular
accidents and stroke: elderly
patients with dementia may be at slightly increased risk of these when
taking atypicals.
Other rare side effects:
Trouble with
swallowing, body temperature disruption, seizures (less than 1%), priapism (sustained, painful penis erections),
elevations of liver enzymes, increased skin pigmentation.
Atypicals can increase
the heart’s QT interval (a measure on heart EKGs); in people with
heart conditions this can rarely lead to serious arrhythmias. This problem may be worse for ziprasidone (Geodon) and does
not appear to occur with aripiprazole (Abilify).
Warning: The following symptoms may be early signs of a serious
side effect; stop the medicine and call me or go to your emergency room if
the occur: increased urination, extreme weakness,
unwanted muscle twitching in your face or elsewhere, fever, confusion,
rigid muscles.
Precautions
Since these medicines may cause drowsiness or low
blood pressure, Make sure you know how you react to it before you drive,
use machines, or do anything else that could be dangerous if you are not
alert, well-coordinated, or able to see well.
Pregnancy:
Atypicals are category-C drugs and
should be avoided if possible during pregnancy, especially during the first
trimester.
Breast-feeding: Atypicals come
out in breast milk. Talk to your
doctor if you plan to breast-feed while taking it.
Children: Atypicals
have not been well-studied in children.
Older adults: Atypicals may be removed from the body more slowly in
people after age 65, so lower dosages may be needed. Elder adults may also have more
difficulty with side effects from these medicines.
Medical problems that can worsen with atypicals:
- Diabetes
(personal or family history of this)
- High
cholesterol or other problems with blood-lipids
- Heart
disease (these medicines may cause changes in heart rate, blood
pressure, or EKG that put people with heart disease at risk for heart
arrhythmias).
- Seizures
- Obesity
- Breast
Cancer
- Parkinson’s
disease
- Liver
disease
- Enlarged
prostate
- Glaucoma
(narrow angle glaucoma)
- Conditions
impacting gut motion (e.g., paralytic ileus)
Medical problems that may affect the
dosing of atypicals:
Drug Interactions
These vary for each medication. Make sure your doctors know if you are
taking other prescribed or over-the-counter medication. You can look up some of the drug
interactions for specific atypicals at this site:
Index of Drug
Information.
Alcohol and Street Drugs
Although these do not interact
directly with atypical antipsychotics, they may
worsen the side effects or worsen the symptoms of psychiatric conditions.
Nicotine
Although smoking can lower the levels of certain atypical antipsychotics (e.g. olanzapine),
this does not generally cause problems in treatment.
Storage
- Keep
out of the reach of children.
- Store
away from heat and direct light.
- Do
not store in the bathroom, near the kitchen sink, or in other damp
places. Heat or moisture may cause the medicine to break down.
- Do
not keep outdated medicine or medicine no longer needed. Be sure that
any discarded medicine is out of the reach of children.
Updated 9/18/4 by Chris Aiken,
M.D.
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