pocket psiquiatry guide[1]
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ACP Formulary
and Pocket Guide To
Psychopharmacology
Virg
Volu
200
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The Office of Health and Quality Care in the VirginiaDepartment of Mental Health, Mental Retardationand Substance Abuse Services (DMHMRSAS or
Department) is pleased to present the publication of thefirst Formulary Pocket Guide (FPG) for the AfterCarePharmacy (ACP). This FPG provides a listing of medications
currently available for use through the DMHMRSASAfterCare Pharmacy. This FPG may not have all medicationsavailable on the market, as new medications come to marketrapidly, however we believe that what is on the formulary doesnot limit the quality of care provided to our clients. The FPGis intended to summarize guidelines and provide a referencethat includes charts and tables to enable the reader to havequick access to important information on medication use,
dosing and cost information. However, the use of the FPG isnot intended to replace sound clinical judgment.
Cost data have been included in the pocket guide. These fig-ures have been supplied for your information and not meant
to be utilized to formulate pharmacodations solely based on cost. These fto contribute to the informed decisisupports best practice values and pcomes, as an effective formulary shoucost effective drug therapy.
The FPG will be made available on SAS intranet and any updates will be aLook for additional information in th
We are interested in your feedback content of the FPG. Please notify us wimprovement, omissions or further into this Guide. Please send in your sugof Michele Thomas, Pharm.D., BCPPOffice of Health and Quality Care. Drby phone at (804) 786-9489, (804) [email protected].
James Evans MD. Medical Director;VA. DMHMRSAS
Michele Thomas Pharm.D., BCPPClinical PsychopharmacologistCentral State HospitalVA. DMHMRSAS
VA. DMHMRSAS Pharmacy Task F
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Pages
2 . . . . .ACP Therapeutic Class:Alcohol Deterrents-Insomnia
3 . . . . .ACP Therapeutic Class:Depression
4 . . . . .ACP Therapeutic Class: Psychosis & Potency Table
5 . . . . .Use of Cost Guide
6-7 . . . .ACP Formulary: Antianxiety Medications
8-9 . . . .ACP Formulary: Bipolar Disorders Medications
10 . . . .ACP Formulary: Side Effect Medications
11-15 . .ACP Formulary: Antidepressant Medications
16-20 . .ACP Formulary: Antipsychotic Medications
21 . . . .Common Antipsychotic Adverse Effects: Comparison
22 . . . .Anticholinergic Effects of Common Psychotropics
23-26 . .NASMHPD Psychiatric PolypharmacyRecommendations [abbreviated]
27-29 . .Antipsychotic Switch Methods
Pages
30-31 . .Conventional Antipsychot
31-39 . .Antipsychotic Dosing [Ad
Principles40-41 . .Treatment Resistance
41 . . . .Antipsychotic efficacy & w
42 . . . .Receptor Interactions & E
43 . . . .Clinical Signs of Excess BSecond Generation Antips
44 . . . .Mood Stabilizer / Anticon
45 . . . .Important Web links46-51 . .Generic / Trade Names of
Psychotropic Agents
52 . . . .Disclaimer
53-56 . .Notes / Important Phone
TABLE OF CONTENTS
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GENERIC NAME RELATIVE COST BRAND NAME
ALCOHOLDETERRENTS
disulfiram $$ ANTABUSE
ANXIETY
alprazolam $ XANAX
chlordiazepoxide $ LIBRIUM
diazepam $ VALIUM
hydroxyzine pamoate $ VISTARIL
buspirone $-$$ BUSPAR
lorazepam $-$$ ATIVAN
oxazepam $$$-$$$$ SERAX
GENERIC NAME RELATIVE COST
BIPOLAR DISORDERS
carbamazepine $
clozapine $lithium carbonate $
lithium carbonateext-rel tabs $
valproic acid $
lamotrigine $$
divalproex sodiumdelayed-rel $-$$
olanzapine $$$-$$$$
quetiapine $$$-$$$$
risperidone $$$-$$$$
topiramate $$$-$$$$
INSOMNIA
hydroxyzine pamoate $
temazepam $
2
ACP SUMMARY: FORMULARY BY DRUG "THERAPEUTIC" CL
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GENERIC NAME RELATIVE COST BRAND NAME
DEPRESSION
amitriptyline $ ELAVIL
amitriptyline /perphenazine $ TRIAVIL
amoxapine $ ASENDIN bupropion $ WELLBUTRIN
clomipramine $ ANAFRANIL
desipramine $ NORPRAMIN
doxepin $ SINEQUAN
fluoxetine $ PROZAC
imipramine HCL $ TOFRANIL
maprotiline $ LUDIOMIL
nortriptyline $ PAMELOR
protryptylline $ VIVACTIL
tranylcypromine $ PARNATE
trazodone $ DESYREL
nefazodone $$ SERZONE
GENERIC NAME RELATIVE CO
fluvoxamine $$
escitalopram $$$
mirtazapine $$$$
bupropion ext-rel $$$$sertraline $$$$
paroxetine $$$$
venlafaxine ext-rel $$$$
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ACP SUMMARY: FORMULARY BY DRUG "THERAPEUTIC" CLAGENERIC NAME RELATIVE COST BRAND NAME
PSYCHOSIS
chlorpromazine $ THORAZINE
clozapine $ CLOZARIL
fluphenazine decanoate $ PROLIXIN haloperidol $ HALDOL
haloperidol decanoate $ HALDOLDECANOATE
loxapine $ LOXITANE
perphenazine $ TRILAFON
thioridazine $ MELLARIL
thiothixene $ NAVANE
trifluoperazine $ STELAZINE
ziprasidone $$ GEODON
quetiapine $-$$$ SEROQUEL
risperidone $-$$$ RISPERDAL
olanzapine $$-$$$ ZYPREXA
aripiprazole $$$-$$$$ ABILIFY
risperidone long-acting injection $$$$ RISPERDAL
Potency Table:
Conventional AntipsychoHigh-Potency Mid-Potency Conventional Conventional
Haloperidol Perphenazine
Fluphenazine Loxapine
Trifluoperazine Molindone
Thiothixene
CONSTA
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The following tables on the upcoming pages representthe Virginia DMHMRSAS AfterCare Pharmacy (Va.DMHMRSAS ACP) drug prices, and cost comparisons.
Repacks are unit of use quantities repackaged at the ACP.
Available quantities are bottles of 30, 60, 90, and 120.
Cost Comparisons are per unit (tab, cap, etc.).
The Cost Guide is differentiated in two ways. First, bycolor (light green being the lowest cost, red being thehighest cost) and by the number of dollar signs withinthe color scheme. Each dollar sign represents the relative
cost of the product within the therapeutic class; the moredollars signs, the more cost, the less dollar signs, the lowerthe cost within each respective color/class. Note: costsreflect prices at time of printing & may differ slightly fromthe exact price due to rounding and/or contract negotiations.
Color Key Definition and
Green - Lowest cost (m
Yellow - Medium cost (m
Orange - Moderate cost (m
Red - Highest cost (m
Aftercare Pharmacy
Capsule
Cost per unit
Generic Available
Manufacturer
Milliter (volume)
Stock Bottle; used for cost com
Tablet
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ACP ACP ACP
NAME TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
Continued on next page
VA. DMHMRSAS (ACP) FORMULARY: ANTIANXIETY MEDS
ALPRAZOLAM ALPRAZOLAM 0.25MG TABLET ALPHARMA G 4.83 5.92 7.00
ALPRAZOLAM ALPRAZOLAM 0.5MG TABLET ALPHARMA G 5.03 6.32 7.60
ALPRAZOLAM ALPRAZOLAM 1MG TABLET ALPHARMA G 5.14 6.53 7.93
AMITRIPTYLINE AMITRIP/PERPHEN 10-2 MYLANHCL/PERPHENAZINE TABLET PHARMACEUTICALS G 5.43 7.10 8.78
AMITRIPTYLINE AMITRIP/PERPHEN 25-2 MYLANHCL/PERPHENAZINE TABLET PHARMACEUTICALS G 5.70 7.66 9.61
AMITRIPTYLINE AMITRIP/PERPHEN 25-4 MYLANHCL/PERPHENAZINE TABLET PHARMACEUTICALS G 6.16 8.57 10.98
BUSPIRONE HCL BUSPIRONE HCL5MG RANBAXYTABLET PHARMACEUTICALS INC G 5.00 6.26 7.51
BUSPIRONE HCL BUSPIRONE HCL 10MG TABLET IVAX PHARMACEUTICALS G 5.41 7.07 8.73
CHLORDIAZEPOXIDEHCL CHLORDIAZEPOXIDE 10MG CAP "WATSON PHARMA, INC." G 4.91 6.06 7.22
CHLORDIAZEPOXIDEHCL CHLORDIAZEPOXIDE 25MG CAP "WATSON PHARMA, INC." G 5.37 6.98 8.60
CHLORDIAZEPOXIDEHCL CHLORDIAZEPOXIDE 5MG CAP "WATSON PHARMA, INC." G 5.69 7.63 9.57
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ACP ACP ACP
NAME TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
CLONAZEPAM CLONAZEPAM 0.5MG TABLET CARACOPHARMACEUTICAL LABS G 4.22 4.68 5.15
CLONAZEPAM CLONAZEPAM 1MG TABLET CARACOPHARMACEUTICAL LABS G 4.56 5.37 6.18
CLONAZEPAM CLONAZEPAM 2MG TABLET CARACOPHARMACEUTICAL LABS G 5.01 6.27 7.53
DIAZEPAM DIAZEPAM 2MG TABLET IVAX PHARMACEUTICALS G 4.38 5.01 5.63
DIAZEPAM DIAZEPAM 5MG TABLET BARR LABS G 4.53 5.31 6.09
DIAZEPAM DIAZEPAM 10MG TABLET IVAX PHARMACEUTICALS G 4.63 5.51 6.39
HYDROXYZINEPAMOATE HYDROXYZINE PAM 25MG CAP IVAX PHARMACEUTICALS G 4.89 6.02 7.16
HYDROXYZINE
PAMOATE HYDROXYZINE PAM 50MG CAP EON LABS G 5.59 7.43 9.27LORAZEPAM LORAZEPAM 1MG TABLET MYLAN
PHARMACEUTICALS G 5.23 6.71 8.19
LORAZEPAM LORAZEPAM 0.5MG TABLET "WATSON PHARMA, INC." G 5.32 6.89 8.46
LORAZEPAM LORAZEPAM 2MG TABLET "WATSON PHARMA, INC." G 7.18 10.62 14.05
OXAZEPAM OXAZEPAM 10MG CAPSULE IVAX PHARMACEUTICALS G 8.18 12.61 17.04
OXAZEPAM OXAZEPAM 15MG CAPSULE IVAX PHARMACEUTICALS G 10.83 17.92 25.00
OXAZEPAM OXAZEPAM 30MG CAPSULE IVAX PHARMACEUTICALS G 18.33 32.90 47.48
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VA. DMHMRSAS (ACP) FORMULARY: BIPOLAR DISORDER M
CARBAMAZEPINE CARBAMAZEPINE 200MG MAJORTABLET PHARMACEUTICALS G 5.16 6.57 7.98
CLOZAPINE CLOZAPINE 25MG TABLET IVAX PHARMACEUTICALS G 12.41 21.06 29.72
CLOZAPINE CLOZAPINE 100MG TABLET IVAX PHARMACEUTICALS G 26.25 48.75 71.25DIVALPROEX SODIUM DEPAKOTE 250MG TABLET EC "ABBOTT
LABORATORIES, PPD" 30.83 57.92 85.00
DIVALPROEX SODIUM DEPAKOTE ER 500MG TAB SA "ABBOTTLABORATORIES, PPD" 51.39 99.02 146.66
DIVALPROEX SODIUM DEPAKOTE 500MG TABLET EC "ABBOTTLABORATORIES, PPD" 53.70 103.64 153.59
LAMOTRIGINE LAMICTAL 25MG TABLET GSK (GLAXOSMITHKLINE) 78.83 153.90 228.98
LAMOTRIGINE LAMICTAL 100MG TABLET GSK (GLAXOSMITHKLINE) 83.44 163.13 242.83
LAMOTRIGINE LAMICTAL 150MG TABLET GSK (GLAXOSMITHKLINE) 87.50 171.24 254.99
LAMOTRIGINE LAMICTAL 200MG TABLET GSK (GLAXOSMITHKLINE) 91.53 179.31 267.09
LITHIUM CARBONATE LITHIUM CARBONATE 300MGCAP ROXANE LABS INC G 5.04 6.33 7.62
LITHIUM CARBONATE LITHIUM CARBONATE 300MGTAB ROXANE LABS INC 8.46 13.18 17.89
OLANZAPINE ZYPREXA 7.5MG TABLET ELI LILLY & CO 199.28 394.82 590.35
OLANZAPINE ZYPREXA 10MG TABLET ELI LILLY & CO 248.14 492.54 736.93
OLANZAPINE ZYPREXA 2.5MG TABLET ELI LILLY & CO 139.88 276.01 412.14
OLANZAPINE ZYPREXA 5MG TABLET ELI LILLY & CO 164.53 325.31 486.09
ACP ACP ACP
NAME TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
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ACP ACP ACP
NAME TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 25MG TABLET PHARMACEUTICALS 44.64 85.52 126.41
QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 100MG TABLET PHARMACEUTICALS 78.08 152.42 226.75
QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 300MG TABLET PHARMACEUTICALS 184.08 364.40 544.73
QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 200MG TABLET PHARMACEUTICALS 144.06 284.37 424.68
RISPERIDONE RISPERDAL 1MG TABLET JOHNSON& JOHNSON HCS 89.22 174.70 260.17
RISPERIDONE RISPERDAL 2MG TABLET JOHNSON& JOHNSON HCS 137.59 271.43 405.27
RISPERIDONE RISPERDAL 4MG TABLET JOHNSON& JOHNSON HCS 223.11 442.47 661.83
RISPERIDONE RISPERDAL 3MG TABLET JOHNSON& JOHNSON HCS 168.66 333.57 498.48
TOPIRAMATE TOPAMAX 100MG TABLETJOHNSON& JOHNSON HCS
103.14 202.52 301.91TOPIRAMATE TOPAMAX 200MG TABLET JOHNSON& JOHNSON HCS 120.11 236.46 352.82
TOPIRAMATE TOPAMAX 25MG TABLET JOHNSON& JOHNSON HCS 44.55 85.35 126.15
VALPROIC ACID VALPROIC ACID 250MGCAPSULE UPSHER SMITH LABS G 8.78 13.80 18.83
*Lower doses required if co-administered with valproate
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ACP ACP ACP
NAME TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
VA. DMHMRSAS (ACP) FORMULARY: "SIDE EFFECT" MEDICA
AMANTADINE HCL AMANTADINE 100MG CAPSULE UPSHER SMITH LABS G 9.33 14.92 20.50
BENZTROPINEMESYLATE BENZTROPINE MES 1MG TABLET PAR PHARMACEUTICALS G 5.15 6.55 7.94
BENZTROPINEMESYLATE BENZTROPINE MES 2MG TABLET PAR PHARMACEUTICALS G 5.74 7.74 9.73
DIPHENHYDRAMINE MARLEXHCL DIPHENHYDRAMINE 25MG CAPS PHARMACEUTICALS G 4.03 4.31 4.60
DIPHENHYDRAMINE MARLEXHCL DIPHENHYDRAMINE 50MG CAPS PHARMACEUTICALS G 4.09 4.43 4.76
LORAZEPAM LORAZEPAM 1MG TABLET MYLANPHARMACEUTICALS G 5.23 6.71 8.19
LORAZEPAM LORAZEPAM 0.5MG TABLET "WATSON PHARMA, INC." G 5.32 6.89 8.46
LORAZEPAM LORAZEPAM 2MG TABLET "WATSON PHARMA, INC." G 7.18 10.62 14.05PROCYCLIDINE MONARCHHYDROCHLORIDE KEMADRIN 5MG TABLET PHARMACEUTICALS 20.95 38.14 55.34
PROPRANOLOL HCL PROPRANOLOL 20MG TABLET "PLIVA, INC." G 4.47 5.18 5.90
PROPRANOLOL HCL PROPRANOLOL 40MG TABLET "PLIVA, INC." G 4.60 5.46 6.31
PROPRANOLOL HCL PROPRANOLOL 80MG TABLET "PLIVA, INC." G 4.84 5.93 7.02
TRIHEXYPHENIDYL WEST-WARDHCL TRIHEXYPHENIDYL 2MG TABLET PHARMACEUTICAL CO G 5.52 7.29 9.06
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ACP ACP ACP
NAME TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
VA. DMHMRSAS (ACP) FORMULARY: ANTIDEPRESSANTS
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10MG TAB "QUALITESTPHARMACEUTICALS, INC" G 4.21 4.66 5.12
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25MG TAB "QUALITEST
PHARMACEUTICALS, INC" G 4.27 4.80 5.32AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50MG TAB "QUALITEST
PHARMACEUTICALS, INC" G 4.38 5.00 5.63
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75MG TAB "QUALITESTPHARMACEUTICALS, INC" G 4.90 6.05 7.21
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 100MG TAB "QUALITESTPHARMACEUTICALS, INC" G 5.06 6.38 7.69
AMITRIPTYLINE HCL/PERPHENAZINE AMITRIP/PERPHEN 10-2 TABLET MYLAN PHARMACEUTICALS G 5.43 7.10 8.78
AMITRIPTYLINE HCL/PERPHENAZINE AMITRIP/PERPHEN 25-2 TABLET MYLAN PHARMACEUTICALS G 5.70 7.66 9.61
AMITRIPTYLINE HCL/PERPHENAZINE AMITRIP/PERPHEN 25-4 TABLET MYLAN PHARMACEUTICALS G 6.16 8.57 10.98
AMOXAPINE AMOXAPINE 50MG TABLET "WATSON PHARMA, INC." G 14.57 25.38 36.20
AMOXAPINE AMOXAPINE 100MG TABLET "WATSON PHARMA, INC." G 22.28 40.80 59.33
BUPROPION HCL BUPROPION HCL 75MG TABLET MYLAN PHARMACEUTICALS G 8.70 13.65 18.60
BUPROPION HCL BUPROPION HCL100MG TABLET MYLAN PHARMACEUTICALS G 9.57 15.39 21.21
VA DMHMRSAS (ACP) F l A tid t
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VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from previous page
ACP ACP ACP
NAME TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
BUPROPION HCL WELLBUTRIN SR 150MG TAB SA GSK (GLAXOSMITHKLINE) 55.41 107.06 158.72
BUPROPION HCL WELLBUTRIN SR 100MG TAB SA GSK (GLAXOSMITHKLINE) 51.95 100.14 148.34
CLOMIPRAMINE HCL CLOMIPRAMINE 25MG CAPSULE TARO PHARMACEUTICALS G 5.67 7.58 9.50
CLOMIPRAMINE HCL CLOMIPRAMINE 50MG CAPSULE TARO PHARMACEUTICALS G 6.58 9.41 12.24
CLOMIPRAMINE HCL CLOMIPRAMINE 75MG CAPSULE TARO PHARMACEUTICALS G 7.91 12.07 16.23
DESIPRAMINE HCL DESIPRAMINE 25MG TABLET EON LABS G 8.42 13.10 17.77
DESIPRAMINE HCL DESIPRAMINE 50MG TABLET EON LABS G 12.55 21.35 30.15
DESIPRAMINE HCL DESIPRAMINE 75MG TABLET EON LABS G 14.95 26.15 37.35
DESIPRAMINE HCL DESIPRAMINE 100MG TABLET EON LABS G 18.47 33.18 47.90
DOXEPIN HCL DOXEPIN 10MG CAPSULE PAR PHARMACEUTICALS G 4.72 5.69 6.67
DOXEPIN HCL DOXEPIN 25MG CAPSULE PAR PHARMACEUTICALS G 4.84 5.94 7.03
DOXEPIN HCL DOXEPIN 50MG CAPSULE PAR PHARMACEUTICALS G 5.33 6.91 8.49
DOXEPIN HCL DOXEPIN 75MG CAPSULE PAR PHARMACEUTICALS G 5.79 7.84 9.88
DOXEPIN HCL DOXEPIN 100MG CAPSULE PAR PHARMACEUTICALS G 6.40 9.05 11.70
ESCITALOPRAM FORESTOXALATE LEXAPRO 10MG TABLET PHARMACEUTICALS 57.59 111.42 165.26
ESCITALOPRAM FORESTOXALATE LEXAPRO 20MG TABLET PHARMACEUTICALS 59.93 116.11 172.29
VA DMHMRSAS (ACP) Formulary: Antidepressants ti d f b
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VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from above
ACP ACP ACP
NAME TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
FLUOXETINE HCL FLUOXETINE 20MG CAPSULE "PLIVA, INC." G 4.60 5.46 6.31
FLUOXETINE HCL FLUOXETINE 10MG CAPSULE "PLIVA, INC." G 4.68 5.61 6.54
FLUVOXAMINEMALEATE FLUVOXAMINE MAL 100MG TAB EON LABS G 16.01 28.26 40.52
IMIPRAMINE HCL IMIPRAMINE HCL 10MG TABLET PAR PHARMACEUTICALS G 7.98 12.21 16.44
IMIPRAMINE HCL IMIPRAMINE HCL 25MG TABLET PAR PHARMACEUTICALS G 9.04 14.33 19.62
IMIPRAMINE HCL IMIPRAMINE HCL 50MG TABLET PAR PHARMACEUTICALS G 11.60 19.46 27.31
MAPROTILINE HCL MAPROTILINE 25MG TABLET MYLAN PHARMACEUTICALS G 10.89 18.03 25.17
MAPROTILINE HCL MAPROTILINE 50MG TABLET MYLAN PHARMACEUTICALS G 14.28 24.81 35.34
MIRTAZAPINE REMERON 30MG SOLTAB ORGANON 67.33 130.91 194.49
MIRTAZAPINE REMERON 45MG SOLTAB ORGANON 71.50 139.25 207.00
NEFAZODONE HCL NEFAZODONE HCL 200MGTABLET IVAX PHARMACEUTICALS G 10.65 17.54 24.44
NEFAZODONE HCL NEFAZODONE HCL 100MGTABLET IVAX PHARMACEUTICALS G 10.71 17.67 24.62
NEFAZODONE HCL NEFAZODONE HCL 150MGTABLET IVAX PHARMACEUTICALS G 10.78 17.81 24.83
NEFAZODONE HCL NEFAZODONE HCL 250MGTABLET IVAX PHARMACEUTICALS G 11.06 18.37 25.68
VA DMHMRSAS (ACP) Formulary: Antidepressants continued from previous page
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Continued below
VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from previous page
ACP ACP ACP
NAME TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10MG CAP TEVA PHARMACEUTICALSUSA G 4.82 5.88 6.95
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25MG CAP "WATSON PHARMA, INC." G 5.08 6.40 7.73
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50MG CAP TEVA PHARMACEUTICALS
USA G 5.52 7.29 9.06
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75MG CAP TEVA PHARMACEUTICALSUSA G 6.00 8.25 10.51
PAROXETINE HCL PAROXETINE HCL 20MG TABLET MAJOR PHARMACEUTICALS G 49.56 95.36 141.17
PAROXETINE HCL PAROXETINE HCL 30MG TABLET MAJOR PHARMACEUTICALS G 50.95 98.15 145.35
PAROXETINE HCL PAROXETINE HCL 40MG TABLET MAJOR PHARMACEUTICALS G 52.61 101.48 150.34
PROTRIPTYLINE HCL VIVACTIL 5 MG TABLET ODYSSEYPHARMACEUTICALS 25.98 48.21 70.44
PROTRIPTYLINE HCL VIVACTIL 10MG TABLET ODYSSEYPHARMACEUTICALS 35.97 68.18 100.40
SERTRALINE HCL ZOLOFT 100MG TABLET PFIZER U.S. 72.71 141.68 210.64
TRANYLCYPROMINESULFATE PARNATE 10MG TABLET GSK (GLAXOSMITHKLINE) 21.99 40.22 58.46
TRAZODONE HCL TRAZODONE 50MG TABLET "PLIVA, INC." G 4.37 5.00 5.62
TRAZODONE HCL TRAZODONE 100MG TABLET "PLIVA, INC." G 4.98 6.21 7.44
VA DMHMRSAS (ACP) Formulary: Antidepressants continued from above
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VA. DMHMRSAS (ACP) Formulary: Antidepressants, continued from above
ACP ACP ACP
NAME TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
VENLAFAXINE HCL EFFEXOR XR 37.5MG CAP SA WYETH PHARMACEUTICALS 73.59 143.43 213.27
VENLAFAXINE HCL EFFEXOR XR 75MGCAPSULE SA WYETH PHARMACEUTICALS 81.99 160.23 238.47
VENLAFAXINE HCL EFFEXOR XR 150MGCAPSULE SA WYETH PHARMACEUTICALS 88.97 174.18 259.40
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VA. DMHMRSAS (ACP) FORMULARY: ANTIPSYCHOTICS
Continued below
ACP ACP ACP
GENERIC TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
ARIPIPRAZOLE ABILIFY 10MG TABLET BRISTOL-MYERS SQUIBB 267.14 530.53 793.91
ARIPIPRAZOLE ABILIFY 15MG TABLET BRISTOL-MYERS SQUIBB 267.14 530.53 793.91
ARIPIPRAZOLE ABILIFY 20MG TABLET BRISTOL-MYERS SQUIBB 376.23 748.72 1,121.20ARIPIPRAZOLE ABILIFY 30MG TABLET BRISTOL-MYERS SQUIBB 376.23 748.72 1,121.20
CHLORPROMAZINE CHLORPROMAZINE 25MGHCL TABLET UPSHER SMITH LABS G 6.76 9.76 12.77
CHLORPROMAZINE CHLORPROMAZINE 10MGHCL TABLET UPSHER SMITH LABS G 7.06 10.38 13.69
CHLORPROMAZINE CHLORPROMAZINE 50MGHCL TABLET UPSHER SMITH LABS G 7.36 10.96 14.57
CHLORPROMAZINE CHLORPROMAZINE 100MGHCL TABLET UPSHER SMITH LABS G 8.60 13.45 18.29
CHLORPROMAZINE CHLORPROMAZINE 200MGHCL TABLET UPSHER SMITH LABS G 9.75 15.75 21.75
CLOZAPINE CLOZAPINE 25MG TABLET IVAX PHARMACEUTICALS G 12.41 21.06 29.72
CLOZAPINE CLOZAPINE 100MG TABLET IVAX PHARMACEUTICALS G 26.25 48.75 71.25
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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from above
ACP ACP ACP
GENERIC TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
FLUPHENAZINE FLUPHENAZINE DECDECANOATE 25MG/ML 5ML VL SICOR PHARMACEUTICAL G NA NA NA
FLUPHENAZINE HCL FLUPHENAZINE 1MG TABLET PAR PHARMACEUTICALS G 5.19 6.64 8.08
FLUPHENAZINE HCL FLUPHENAZINE 2.5MG TABLET PAR PHARMACEUTICALS G 5.29 6.83 8.37FLUPHENAZINE HCL FLUPHENAZINE 5MG TABLET PAR PHARMACEUTICALS G 5.74 7.73 9.71
FLUPHENAZINE HCL FLUPHENAZINE 10MG TABLET PAR PHARMACEUTICALS G 6.44 9.14 11.83
HALOPERIDOL HALOPERIDOL 0.5MG TABLET MYLAN PHARMACEUTICALS G 5.08 6.40 7.73
HALOPERIDOL HALOPERIDOL 1MG TABLET MYLAN PHARMACEUTICALS G 5.83 7.91 9.99
HALOPERIDOL HALOPERIDOL 2MG TABLET MYLAN PHARMACEUTICALS G 6.59 9.42 12.26
HALOPERIDOL HALOPERIDOL 5MG TABLET MYLAN PHARMACEUTICALS G 6.89 10.02 13.16
HALOPERIDOL HALOPERIDOL DECDECANOATE 50MG/ML 1ML VL SICOR PHARMACEUTICAL G NA NA NA
HALOPERIDOL HALOPERIDOL DECDECANOATE 100MG/ML 1ML VL SICOR PHARMACEUTICAL G NA NA NA
HALOPERIDOL HALOPERIDOL DECDECANOATE 100MG/ML 5ML VL BEDFORD LABS G NA NA NA
HALOPERIDOL HALOPERIDOL DECDECANOATE 50MG/ML 5ML VL BEDFORD LABS G NA NA NA
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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from previous page
Continued below
ACP ACP ACP
GENERIC TRADE NAME VENDOR G
COSTREPACK30's
COSTREPACK60's
COSTREPACK90's
LOXAPINE SUCCINATE LOXITANE 5MG CAPSULE "WATSON PHARMA, INC." 34.45 65.15 95.85
LOXAPINE SUCCINATE LOXITANE 10MG CAPSULE "WATSON PHARMA, INC." 43.42 83.08 122.75
LOXAPINE SUCCINATE LOXITANE 25MG CAPSULE "WATSON PHARMA, INC." 63.68 123.62 183.55
LOXAPINE SUCCINATE LOXITANE 50MG CAPSULE "WATSON PHARMA, INC." 83.72 163.69 243.65
OLANZAPINE ZYPREXA 2.5MG TABLET ELI LILLY & CO 139.88 276.01 412.14
OLANZAPINE ZYPREXA 5MG TABLET ELI LILLY & CO 164.53 325.31 486.09
OLANZAPINE ZYPREXA 7.5MG TABLET ELI LILLY & CO 199.28 394.82 590.35
OLANZAPINE ZYPREXA 10MG TABLET ELI LILLY & CO 248.14 492.54 736.93
PERPHENAZINE PERPHENAZINE 2MG TABLET RICHMOND G 7.85 11.96 16.06
PERPHENAZINE PERPHENAZINE 4MG TABLET RICHMOND G 9.20 14.65 20.10
PERPHENAZINE PERPHENAZINE 8MG TABLET RICHMOND G 10.99 18.23 25.48
PERPHENAZINE PERPHENAZINE 16MG TABLET IVAX PHARMACEUTICALS G 12.33 20.92 29.50
QUETIAPINE SEROQUEL 25MG ASTRA/ZENECAFUMARATE TABLET PHARMACEUTICALS 44.64 85.52 126.41
QUETIAPINE SEROQUEL 100MG ASTRA/ZENECAFUMARATE TABLET PHARMACEUTICALS 78.08 152.42 226.75
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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from above
ACP ACP ACP
GENERIC TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 200MG TABLET PHARMACEUTICALS 144.06 284.37 424.68
QUETIAPINE ASTRA/ZENECAFUMARATE SEROQUEL 300MG TABLET PHARMACEUTICALS 184.08 364.40 544.73
RISPERIDONE RISPERDAL 1MG TABLET JOHNSON & JOHNSON HCS 89.22 174.70 260.17
RISPERIDONE RISPERDAL 2MG TABLET JOHNSON & JOHNSON HCS 137.59 271.43 405.27
RISPERIDONE RISPERDAL 3MG TABLET JOHNSON & JOHNSON HCS 168.66 333.57 498.48
RISPERIDONE RISPERDAL 4MG TABLET JOHNSON & JOHNSON HCS 223.11 442.47 661.83
RISPERIDONE RISPERDAL CONSTAMICROSPHERES 25MG SYR 2ML JOHNSON & JOHNSON HCS NA NA NA
RISPERIDONE RISPERDAL CONSTA
MICROSPHERES 37.5MG SYR 2ML JOHNSON & JOHNSON HCS NA NA NA
RISPERIDONE RISPERDAL CONSTAMICROSPHERES 50MG SYR 2ML JOHNSON & JOHNSON HCS NA NA NA
THIORIDAZINE HCL THIORIDAZINE 10MG TABLET MYLAN PHARMACEUTICALS G 7.08 10.41 13.74
THIORIDAZINE HCL THIORIDAZINE 25MG TABLET MYLAN PHARMACEUTICALS G 8.32 12.90 17.47
THIORIDAZINE HCL THIORIDAZINE 50MG TABLET MYLAN PHARMACEUTICALS G 9.58 15.40 21.23
THIORIDAZINE HCL THIORIDAZINE 100MG TABLET MYLAN PHARMACEUTICALS G 11.25 18.75 26.25
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VA. DMHMRSAS (ACP) Formulary: Antipsychotics, continued from previous page
ACP ACP ACP
GENERIC TRADE NAME VENDOR GCOSTREPACK30's
COSTREPACK60's
COSTREPACK90's
THIOTHIXENE THIOTHIXENE 1MG CAPSULE SANDOZ G 6.13 8.51 10.90
THIOTHIXENE THIOTHIXENE 2MG CAPSULE MYLAN PHARMACEUTICALS G 6.82 9.89 12.95
THIOTHIXENE THIOTHIXENE 5MG CAPSULE MYLAN PHARMACEUTICALS G 8.53 13.31 18.09
THIOTHIXENE THIOTHIXENE 10MG CAPSULE MYLAN PHARMACEUTICALS G 10.32 16.90 23.47
TRIFLUOPERAZINEHCL TRIFLUOPERAZINE 2MG TABLET MYLAN PHARMACEUTICALS G 8.13 12.51 16.89
TRIFLUOPERAZINEHCL TRIFLUOPERAZINE 5MG TABLET MYLAN PHARMACEUTICALS G 8.84 13.92 19.01
TRIFLUOPERAZINEHCL TRIFLUOPERAZINE 10MG TABLET MYLAN PHARMACEUTICALS G 9.75 15.75 21.75
ZIPRASIDONE HCL GEODON 20MG CAPSULE PFIZER U.S. 121.12 238.49 355.86
ZIPRASIDONE HCL GEODON 40MG CAPSULE PFIZER U.S. 121.12 238.49 355.86
ZIPRASIDONE HCL GEODON 60MG CAPSULE PFIZER U.S. 131.57 259.38 387.20
ZIPRASIDONE HCL GEODON 80MG CAPSULE PFIZER U.S. 131.57 259.38 387.20
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COMMON ANTIPSYCHOTIC ADVERSE EFFECTS: COMPARISON / SUM
EPS Sedation TD Anticholinergic Cardiovascular Sexual Dysfunct. Prolactin W
Chlorpromazine(Thorazine) +++ ++++ ++++ +++ +++ +++ +++
Haloperidol (Haldol) ++++ + ++++ + + + ++++
Loxapine (Loxitane) +++ ++ +++ + ++ +++ +++
Aripiprazole (Abilify) + + ? - + ? -
Clozapine (Clozaril) +/- ++++ - ++++ +++ + -
Olanzapine (Zyprexa) + ++ + ++ + - +
Quetiapine (Seroquel) - ++ ? + ++ - -
Risperidone (Risperdal) ++ + + + + + +++
Ziprasidone (Geodon) + ++ + + + - ++
- Not noted + Possible + Mild / Low ++ Moderate +++ High
Bezchlibnyk-Butler & Jeffries, Clinical Handbook Psychotropic Drugs, 10th ed.; Fuller & Sajatovic, DI Handbook for PsyPuzantian & Stimmel, "Review of Psychotropic Drugs", Pharmacy Practice News, 2003; PI's: AZ, BMS, Janssen, Lilly, Pfizer
21
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ANTICHOLINERGIC EFFECTS OF COMMON PSYCHOTROP
ANTIPSYCHOTICS
DRUG COMMONADVERSE EFFECTS
Haloperidol
Molindone
Fluphenazine +
Perphenazine +
Thiothixene +
Trifluoperazine +
Loxapine +
Mesoridazine ++
Chlorpromazine +++
Thioridazine +++
Clozapine +++
ANTICHOLINERGICS
DRUG COMMONADVERSE EFFECTS*
Diphenhydramine ++
Benztropine +++
Trihexyphenidyl ++++
ANTIDEPRESSA
DRUG
Trazodone
Fluoxetine
Amoxapine
Maprotiline
Desipramine
Nortriptyline
Imipramine
Doxepin
Amitriptyline
*Anticholinergic adverse effects are related toanticholinergic action (as related to atropine); higher the
value, higher the risk. Psychotropics bolded in red are
most anticholinergic in class. Be sure to monitor for
additive anticholinergic effects between agents.
** Common GI Adverse Effects: constipation, blurredvision, N&V, dry mouth
*** Common CNS Adverse Effects: stimulation,disorientation, confusion, hallucinations,
restlessness, cognitive impairment
****Common CV Ad
Bezchlibnyk-Butler & Jef
Drugs, 10th ed.; Fuller &
Ed; Puzantian & Stimme
Pharmacy Practice News
*NASMHPD PSYCHIATRIC POLYPHARMACY RECOMMENDATI
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23
NASMHPD PSYCHIATRIC POLYPHARMACY RECOMMENDATIA. Before adding a second medication to a regimen,the following are considered appropriate practices:
For most psychiatric disorders, at least 2-3 trials ofmonotherapy with chemically distinct classes of agentsshould be tried prior to treatment with multiple agents.
Actual practice will vary by disorder. When polypharmacy isto be used, accepted evidence-based guidelines, if available,should be followed.
After failing therapy on single agents, the patients psychi-atric diagnosis should be reevaluated before initiating therapy
with multiple medications.
Only one medication should be changed at a time. In orderto assess the adverse effects of & therapeutic response to a med-
ication, only one actual medication trial can be monitored &evaluated at any time.
The first thing a clinician should consider when a patientdoes not respond to a medication is whether the patient istaking the medication correctly, (if at all). Therefore, con-sider the patients current adherence to treatment beforeadding medications. To increase adherence, preferenceshould be given to the simplest effective treatment regimen.
Many psychiatric medications can bfew need more than twice a day do
A single medication should be giveffective dose to produce a therincludes at least 5 half-lives at a singblood concentration, plus additionclinical response & adverse effects.
O For antidepressants & anti-anweeks are often needed to evadverse effects.
O For antipsychotics and m
months may be required foresponse / adverse effects.
An important aspect of polypharmations. A majority of psychotropic kinetic drug interactions are due toSystem (CYP450). Clinically signiare involved in problematic drug spharmacotherapy. These interaction
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24
ing. Drug-drug interactions are preventable. A clinicianshould have a comprehensive understanding of the liverenzyme system, CYP450.
The prescriber & patient should define an acceptableresponse to the new medication & what type of response
would result in discontinuance of the new medication.
The patient should be educated on how long the medica-tion will take to reach its maximum effect & the effect thenew medication is expected to produce.
The patients functioning should be considered moreimportant than treatment of the patients symptoms. Forexample, the use of sedating medications may reduce some of the patients symptoms, but may unfavorably reduce the
patients functioning.
Consider treatment alternatives, such as the use ofpsychosocial interventions, before prescribing additionalmedication.
The patients total drug load shconsider the patients ability to adhemedication regimen.
The patients ability to pay for or oshould be considered when adding
All other remedies the patient is
be addressed, including OTC mremedies, herbal remedies & illicit
The frequency and duration of phyfor appropriate assessment of respodischarged or further medication ch
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B. During treatment with multiple medications,these considerations should guide therapy:
The principle of start low, go slow should be followed wheninitiating new medications, particularly in elderly, pediatricpatients or medically compromised patients.
Drug interactions should be anticipated & monitored whenan additional medication is added. If an interaction drug isadded, blood levels of interacting medications should bechecked where appropriate. For example, adding fluoxetine toclozapine has been associated with at least one reported deathin the literature secondary to potential drug interaction.
The prescriber should communicate with all health careproviders involved with the patient.
Interventions to improve adherence with & access to med-ication therapy need to be identified & implemented.
For patients in an inpatient facility who have had their med-ication dose or regimen recently changed, time should beallowed for appropriate assessment of response before thepatient is discharged or further medication changes are made.
Bioethnic differences should be considered when assessing apatients response to medications.
C. After the patient has been usingconsider the following points when mon
Discontinuing medications that doresponse.
Cross-tapers initiated to switch theication to another should be compl
Patients who are using multiple mpotentially suffering from medicshould be considered for a wash-reassessment.
If possible, the medication regimendropping psychiatric medications patient close to baseline. This does n
ing all of the medications.
Continued on next page
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D. The following inappropriate use of polypharmacyshould be avoided:
Generally, same-class polypharmacy should not be used totreat the same symptoms in a patient.
More than one medication from any of the following med-ication classes should not be used in a single patient:
O Typical antipsychotics(haloperidol, fluphenazine, etc.),
O Selective serotonin reuptake inhibitors(paroxetine, fluoxetine, etc.),
O Tricyclic antidepressants(amitriptyline, imipramine, etc.),
O Monoamine oxidase inhibitors(phenelzine, tranylcypromine, etc.),
O Stimulants(methylphenidate, amphetamine),
O Benzodiazepines(diazepam, alprazolam, etc.).
More than two antipsychotic medical, should not be used simultaneou
The dose of medication should notlevels have reached steady state
achieve therapeutic effect has passe Patients should not be discharged fwithout allowing adequate time forication to be assessed. Patients on podischarge from a facility are at a higheication problems.
An increased level of monitoring &sidered when the patient is dischar
medication regimen.
* NASMHPD Technical Report on Psychiatric Polyp
Technical report originates from the National As
Program Directors.
26 Continued below
ANTIPSYCHOTIC SWITCH METHODS *NOTES *In most instances the rebound of
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ANTIPSYCHOTIC SWITCH METHODS NOTES
*No single crossover technique has been recognized as theaccepted protocol. Abrupt crossovers to early atypical antipsy-chotics have been unsuccessful; current accepted practicesinclude cross-titration (gradually reducing the dose of the firstantipsychotic while gradually increasing the dose of the new
antipsychotic) and slowly overlapping and tapering antipsy-chotics (maintaining the dose of the old antipsychotic untilthe new antipsychotic is at full therapeutic dose).
*The switch should be undertaken over a period of 4 to 5weeks if the switch does not involve clozapine and 7 to 8weeks if the switch involves clozapine.
*Withdrawal Symptoms. The signs and symptoms associated
with antipsychotic medication withdrawal are varied. Areemergence or worsening of psychosis, rebound or unmaskeddyskinesia, and cholinergic rebound can occur.
Reminder:
*Psychotic symptoms may be exacerbated by withdrawalsymptoms and by the patient's anxiety over switchingmedication.
In most instances, the rebound of al can be prevented by cautiously the existing antipsychotic agenantiparkinsonian drug or sedative h
*If the patient is taking an anticholnation with a conventional agent ued, the anticholinergic agent sho
over 1 to 2 weeks following discconventional antipsychotic (longertion was a depot formulation).rebound is greatest with low potewhich have stronger anticholinergic agents. It is recommended that all discontinued, if possible.
*Olanzapine and clozapine have co
gic, antiadrenergic, and antiserodrawal symptoms may be expectedrugs are discontinued.
*Medication dosage errors are commby the dosage regimens used durin
Bezchlibnyk-Butler & Jeffries, Clinical Handbook PsychotroGuidelines, J Clin Psych. 1999; 60 (suppl.11); Weiden. J Clin al., J Clin Psych 1998; 59 (suppl.19).
ANTIPSYCHOTIC [AP] SWITCH METHODS
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Abrupt discontinuation of first APand starting a new AP (e.g., stop
previous agent immediately & rapidlyincrease new agent)
Straightforward
Best for inpatient setting or wherepatients are supervised and fastcrossovers are needed
Medication errors less likely
Appropriate for patients on depotmeds secondary to long half-life
Increased chations associate
Not recommereceiving cloz
High risk of r
28
ANTIPSYCHOTIC [AP] SWITCH METHODS
1. ABRUPT DISCONTINUATION ADVANTAGES DISADVANTAG
Continued on next page
Antipsychotic [AP] Switch Methods, continued
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2. CROSS TITRATION OR ADVANTAGES DISADVANTAGCROSS TAPERS
Overlap and tapering strategies(Note: slower titrations [e.g., 6 weeks ormore], result in improved effect).
A. Gradual Cross Taper (Begin todecrease dose of AP #1; at the sametime, initiate AP #2; increase dose tomaintenance over 2 to 6 weeks)
B. Full Dose CrossTitration (MaintainAP #1 dose; initiate AP #2 & increaseto maintenance; overlap & maintainstable doses for two weeks; decrease to
cessation AP #1)C. 50% Reduction Taper (Immediate50% dose decrease AP #1; simultaneousinitiation AP #2 to 50% maintenancedose; follow with gradual dose adjustmente.g., decrease AP #1 to cessation;increase AP #2 to maintenance)
Appropriate when relief from adverseeffects such as EPS is needed
Perhaps the safest method when
consequences of crossover relapse(s)are greatest concern
May be appropriate to use thecrossover time as a test period toascertain oral compliance for patientson depot antipsychotics
May be appropriate when switchingpatients who have been recentlystabilized (
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Haloperidol Perphenazine Chlorpromaz
Fluphenazine Loxapine Thioridazine
Trifluoperazine Molindone Mesoridazine
Thiothixene
30
CONVENTIONAL ANTIPSYCHOTICS: POTENCY TABLE
High Mid Low
REVIEW:
All First Generation Antipsychotics (FGA; conventionalantipsychotics) have equal efficacy; the selection of drug isbased on adverse effect profile and patient comorbidity.Conventional agents increase density of post-synaptic D2receptors (supersensitivity).A9 Tract / Nigrostriatal path
(midbrain to neostriatum),responsible for Extrapyramidal adverse effects
A 10 / Mesolimbic (midbrain to limbic structures) possiblyassociated with relief of positive symptoms / psychosis
A 10/ Mesocortical (midbrain to frontal and temporalcerebral cortex) possibly associated with relief of negativesymptoms
Adverse effects with convention
High-potency conventional agents:Dystonia
Akathisia
Parkinsonism
Low potency agentsSedationHypotension
Weight gain (molindone may producAnticholinergic symptoms (dry mou
constipation, blurred vision)
Continued below
S C O C OS G G
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Adverse effects unrelated to potency--(can occur with all D2 antagonists)Hyperprolactinemia (amenorrhea, galactorrhea, sexual
dysfunction)Tardive dyskinesiaNeuroleptic malignant syndrome
Other: Impaired heat regulation (hyper or hypothermia);pigmentary retinopathy (thioridazine >800mg/d); ECG
changes (pimozide, chlorpromazine, thioridazine)
Extrapyramidal Side Effects (EPS)
Dystonia
Involuntary muscle contraction--may involve tongue, neck,
back, eyesExtremely uncomfortable, jeopardizes future compliance
Usually occurs within first four days of neuroleptic treatment
Risk factors: young males and high-potency neuroleptics
All patients under age 30 started on high potency neurolep-tics should receive prophylaxis: benztropine 2 mg bid x 10days-then taper
ANTIPSYCHOTIC DOSING: GE
Treating first-break patients:
Avoid side effects (drug selection a Prophylax for dystonia if using con Develop alliance Educate patient and family about i
Best to use low to moderate fixed d15mg/d, risperidone 2-4 mg/d, quetiapine 300-600mg/d, zipraaripiprazole 10-15 mg/d)
An adequate trial should last 4-6 w Data suggests a rapid & early resp
of treatment
Gradual improvement seen over 4
Response of first-break patients:
Respond better than chronic patie 74% full remission; 12% partial re Respond to lower doses Early treatment associated with be
31 Continued on next page
Blood levels Maintenance Treatment
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Blood levels Should not substitute for clinical titration Inconsistent evidence for haloperidol therapeutic window
(5-15 ng/mL) Approx 7% of patients (Caucasian, Asian), are slow metab-
olizers (low P450 2D6)-may develop toxic levels Blood levels useful in cases of nonresponse, noncompliance,
or drug interactionsTherapeutic Ranges
Haloperidol 5-15 ng/mL Chlorpromazine 30-100 ng/mL Fluphenazine 0.2-2.0 ng/mL Perphenazine 0.8-2.4 ng/mL Clozapine >350 ng/ml
Estimated Relapse Rates
Relapse rates in schizophrenia
Medication (N) Placebo (N)Relapse in first year 41% (814) 68% (189)Second year post discharge 15% (500) 65% (448)
C. Jackson, Pharm.D., BCPP, with permission.
Maintenance Treatment
Haloperidol conversion:10 mg/d ORAL x10-20mg = InHaloperidol time to steady stat3 months
Fluphenazine decanoate:
Conventional dose Fluphenazine dq 2wks
Low dose Fluphenazine decanoate cq 2 wks
Low dose and conventional doses odecanoate: approximately equal in in first year
Low dose produces significantly les
Conventional dose may be superiorpreventing relapse
Requires approx 4 dosing intervals Always establish tolerability with ora
Fluphenazine conversion: 10mg/d ORAL = 12.5 mg IM/SC Fluphenazine time to steady state a
32
SGAs or Atypical Antipsychotics
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Second Generation Antipsychotics (SGA)
SGAs share D2 & 5HT antagonismCause minimal EPSCause minimal elevation of prolactionGenerally, more effective for negative symptoms
Clozapine is the only agent clearly more effective forpsychotic symptoms
Risperidone may produce EPS and elevate prolactin athigh doses (partially atypical)
Clozapine (Clozaril) Atypical properties Minimal EPS More effective than conventional agents for Does not elevate prolactin
Pharmacology: Weak D2 antagonist Relatively greater D1 and D4 antagonism
Strongly anticholinergic Alpha adrenergic antagonist Histaminergic (H1) antagonist Serotonin (5HT2) antagonist Blocks ketamine behavioral effects (NMDA
Clinical Pharmacology Usual daily dose 300-600 mg/d (900 mg/d m Half life: 16 hrs Metabolized by cytochromes 1A2 and 3A4
Efficacy Effective in 30% of treatment-resistant patie
50% at 6 months) Prevents relapse Stabilizes mood; excellent anti-manic agent Improves negative symptoms Improves polydipsia & hyponatremia Reduces hostility, aggression, suicide Reduces cigarette smoking and substance ab
SGAs or Atypical Antipsychotics, continued
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SGAs or Atypical Antipsychotics, continued
Adverse Effects Sedation 39% (tolerance); Dizziness 19% Hypersalivation 31% (may impair swallowing) Constipation 14%; Nausea 11% Headache 11% Tachycardia 25%; Hypotension 9% (tolerance) Fever 5% (usually within first 3 wks, lasting few days)
Seizures 1-6% (related to absolute dose and rate of increase) Weight gain 30% Hypertriglyceridemia common Agranulocytosis (Granulocytes 3500 Repeat CBC if:
WBC=3000-3500 WBC drops by 3000 from previ 3 consecutive weekly drops
If WBC=3000-3500 & granuloctwice-weekly WBCs
Hold drug if WBC
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ADULT: SUGGESTED SECOND GENERATION ANTIPSYCHOTIC TITRATI(Dosing & titration schedule based on Monograph information for psychosis and not to be interpreted as specific to one pguidelines only. Medically comprised / elderly require lower doses; the chronic, treatment resistant population may require higher do
SGA First Dose Titration Range Schedule / Brief N
Clozapine 12.5mg Day 2: 25mg hs 200 900 Eventual maintenance dosemg/day (1/3 in am, 2/3 in p.m.)
Day 3: 25mg bid Day 3, dose is increased evDay 6: 25mg am
& 50mg hs
Day 9: 50mg bid
Day 12: 75mg bid Monitor weight, lipids, CV
Day 15: 100mg bid
Day 18: 125mg bid May cause agranulocytosis;
performed before initiating (initially weekly then biweefor 4 weeks after DC therap
Day 21: 150mg bid Should be used cautiously idiabetes; regular periodic mand fasting glucose is sugge
Day 24: 100mg am Blood levels for CLZ sugge& 200mg hs mg/day
Potential life threatening adMonitor weight, lipids, CV
Continued on next page
SGA First Dose Titration Range Schedule / Brief N
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g
Olanzapine 5-10 mg 5 mg/week 10 20 Should be used cautiously mg/day diabetes; regular periodic m
and fasting glucose is sugge
Risperidone 1 mg 1 mg / 3-5 days 2 6 HS or AM; Monitor weighmg/day mg/day associated with inc
Quetiapine 25 mg bid 50 mg/day 150 800 BID; Monitor weight, lipidmg/day
Ziprasidone 20 mg bid Day 2: 20 mg bid 80 - 160 BID: Give with food; Quicw/food [OR 40 mg qod] mg/day monitor CV status
Day 3: 40 mg bid
Day 4: 40 mg bid
Day 5: 60 mg bid
Day 6: 60 mg bidDay 7: 80 mg bid
Day 8: 80 mg bid
Aripiprazole 15 mg qd 15 mg qd 10 - 15 QD; Quicker titrations nomg /day monitor weight; long half-
reccmd. dose not be increaseof 2 weeks therapy. Dosageday have not been shown t
Risperidone (Risperdal) Olanzapine (Zyprexa)
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Clinical Pharmacology 5HT2 and D2 antagonist and D4, noradrenergic and
histaminergic receptors Half life: 24 hours (can be given once daily) Metabolized by P450 2D6 Mean optimal dose:
4-6 mg/d in chronic patients 2-4 mg/d in treatment naive patients 0.5-2 mg/d in elderly/ compromised
Dose must be titrated up (start at 1-2 mg/d in non-elderly)
Efficacy Fewer EPS (EPS adverse effects increase with doses above 6 mg/d) More effective for negative symptoms (partly result of less EPS) More effective for psychotic symptoms (in some treatment-resistant
patients)
Adverse effects Dizziness/ hypotension (particularly after first dose) Headache Nausea/vomiting Anxiety Rhinitis; Coughing Hyperprolactinemia Weight gain QT delay (usually clinically insignificant)
Clinical Pharmacology High 5HT2/D2 ratio Histaminergic & alpha adrenergic antagonis Metabolized by CYP 1A2 & 3A4 Half life approx. 20 hrs Can start with 10 mg/d at hs in non-compr Optimal dose 10-20 mg/d (2.5-5 mg/d in el
Efficacy Antipsychotic efficacy comparable to halope May be more effective for negative symptom May have substantial antidepressant effect Anti-manic efficacy
Adverse effects Low incidence of EPS Somnolence; dizziness (without hypotension
Dry mouth Constipation Elevation of SGPT (no evidence of hepatoto Hypertriglyceridemia Weight gain common
37
Continued on next page
Quetiapine (Seroquel) Ziprasidone (Geodon)
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Pharmacology High D2/5HT2 ratio (may be effective with
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Pharmacology High affinity for dopamine D2, D3, 5HT1A & 5HT2A receptors;
moderate for alpha 1-adrenergic and histaminic receptors. Alpha1-adrenergic receptors: decreased propensity for
orthostatic hypotension? H1 histamine receptors: decreased liability for weight
gain and somnolence?
No appreciable affinity for cholinergic muscarinic receptors: decreased potential for cognitive impairment?
Partial agonist at dopamine D2 & 5HT1A receptors, antagonist at5HT2A receptor
Most activity primarily due to the parent drug aripiprazole, and to a lesserextent, to an active, but major metabolite (dehydro-aripiprazole)
Half life: Approx. 75-hours for parent drug (aripiprazole) Approx. 94 hours for active metabolite (dehydro-aripiprazole)
Steady state attained within 14 days
Eliminated mainly through hepatic metabolism involving two P450isozymes:
CYP2D6 & CYP3A4 Agents that induce CYP3A4 (carbamazepine) could cause
an increase in clearance and lower blood levels Agents that inhibit CYP3A4 (ketoconazole) or CYP2D6
(floxetine, paroxetine) can inhibit elimination and causeincreased blood levels
Four pivotal, but separate trials indicating efplacebo, haloperidol, risperidone.
Dosing Recommended starting and target dose of 1 Peak plasma concentrations within 3 to 5 ho Administer once a day without regard to me Doses higher than 10 or 15 mg per day not
more effective
Adverse effects Orthostatic Hypotension Headache Anxiety Insomnia Nausea / vomiting Use with caution in patients with:
Cardiovascular disease (history m
ischemic heart disease, heart failuabnormalities),
Hypotension (or conditions thatdehydration, hypovolemia, antih
History of seizures or with condithreshold
39 Continued on next page
TREATMENT RESISTANCE 4. Adjunctive agentsAdd i id l i i id
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1. Reassess diagnosis, consider: Substance abuse (alcohol, PCP, stimulants) Neurological disorders (partial complex seizures) Psychotic depression Drug toxicity/ delirium (steroid psychosis, anticholinergic delirium) Personality disorder PTSD
Identify psychosocial stressors
2. Adjust antipsychotic dose Assess compliance Time-limited trial of higher dose, particularly if:
No or mild EPS On drugs which induce hepatic enzymes (carbamazepine) Clozapine as high as tolerated (up to 900 mg/d)
Reduce dose, particularly if moderate or severe EPS or based on resultsof blood levels if applicable
3. Switch antipsychotics If failure on adequate dose of conventional agent, switch to atypicals Atypicals differ in patterns of efficacy; therefore, each one is worth
consideration Clozapine remains most effective agent
Add risperidone, or olanzapine, or ziprasido Add lithium (particularly if affective sympto
of 0.9-1.2 for 3-5 wk trial) ECT (catatonia, affective symptoms), most eff Antidepressants (SSRIs for negative sympto
response of psychosis) Buspirone (15-30 mg/d for agitation, anxiet
5. Psychosocial Interventions Family interventions: education, realistic exp Dual diagnosis treatment Assertive community treatment (ACT)
outreach compliance monitoring
Social skills training Supported employment Cognitive behavioral therapy
6. Question: is relapse due to: Medication noncompliance? Side effects (EPS, sexual side effects, weight) Lack of insight? Complexity of dosing:
Consider single dosing where ava Depot injections Minimize titrations
40 Continued below
7. Stressors Weight gain
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7. Stressors Expressed emotion in family memberscritical, affective arousal,
enmeshed Stressful life events
8. Substance abuse Alcohol Marijuana
Stimulants PCP & ketamine
Comparisons of SGAs (Atypical Antipsychotics)
Efficacy for Positive Symptoms
Clozapine is effective in treatment-resistant patients Risperidone more effective than haloperidol in some patients Olanzapine, quetiapine & ziprasidone comparable to haloperidol Olanzapine may not be effective in strictly treatment-resistant patients
Risperidone & olanzapine comparable to clozapine Clozapine is the Gold Standard
Efficacy for Negative symptoms
Conventional agents mayimprove some portion of negative symptomatol-ogy; watch out for EPS resulting in secondary negative symptoms
Clozapine more effective than chlorpromazine Risperidone & olanzapine more effective than Haloperidol Quetiapine & ziprasidone comparable to haloperidol
e g t gaClozapine> olanzapine> quetiapine> risperidoaripiprazole> or 10 kg/yr 20%
Not dose related; tends to plateau at six mon
Predictors: Increased appetite Good clinical response Low baseline weight Youth Male gender
Start nutritional education& counseling early
Approx. weight loss withbehavioral interventions:
Olanzapine 4kg Risperidone 2.5kg Haloperidol 2kg
Wirshing et al., 1999
Monitor serum glucose
C. Jackson, Pharm. D., BCPP, with permission
41
Me
Risk Fact
Abdominal OMen
WomenTriglycerideHDL Choles
MenWomen
Blood Press
Fasting Glu
Relative Receptor Interactions & Generalized Effects of SGAs (may be
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Clozapine Risperidone Olanzapine Quetiapine Ziprasid
D2(Extrapyramidal
Side Effects) + (++) (+++) ++ + ++
5HT2(Antidepressant) (+) (++) ++++ +++ + ++++
ALPHA 1&2(Orthostatic Hypotension;
Sedation) +++ (++) (+++) +++ +++ (+) (+
H1(Sedation; Antihistaminic) +++ ++ (++) (+++) +++ (+) (+
M1(Antimuscurinic;Anticholinergic) +++ - +++ +/- -
Adapted from Matyunas, 2003; Davis 2003; PI's AZ, BMS, Janssen, Lilly, Pfizer
42
Clinical Signs / Symptoms: SGA Excessive Blood Levels
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+++ High ++ Moderate + Mid / Low +/- Possible - Not Noted
CNS Clozapine Risperidone Olanzapine Quetiapine Zipra
Lethargy ++ ++ +++ ++ +Somnolence NR NR NR NR NConfusion / Agitation + +/- ++ +/- NComa ++ +/- + +/- N
*Central Anticholinergic Syndrome +/- +/- + - ++ - N
Seizures + - - +/- NMyoclonus +/- +/- + - N
Cardiovascular
Tachycardia ++ + ++ + +
Hypotension/orthostasis + + + + +
ECG changes/dysrhythmias + ++ + +/- N
Respiratory Depression +/- - +/- +/-Other
EPS +/- +/- +/- - N
Pupil Contraction +/- +/- ++ +/- N
Pupil Dilation +/- +/- - - N
Vomiting NR NR NR NR N
*Central Anticholinergic Syndrome: altered mental status, disorientation, incoherent speech, delirium, hallucinations, agitation, violent behavior, somnolence, coma, centra
Matyunas 2003; Watanabe 2001; Bezchlibnyk-Butler & Jeffries, Clinical Handbook of Psychotropic Drugs, 10th ed.; PI's AstraZeneca, BMS, Janssen, Lilly, Pfizer43
Mood Stabilizer / Anticonvulsant Overview
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44
Clinical Use Drug Name
Lithium Divalproex Carbamazepine **Lamotrigine Clonazepam Olanzapine
Treatment of acute mania *+ *+ + - + *+
Treatment of rapid cycling - + + ? + +
Treatment of mixed mania - + + - - +
Treatment of recurrent mania + ? ? - - -
Prevention of recurrentdepression + ? ? + - -
Augmentation of other moodstabilizers / anticonvulsants + + + + + +
Rapid onset - + - - + +Treatment with comorbidsubstance / alcohol abuse - + + ? - ?
FDA approved + + - + - +
Green "+" signifies FDA indication Yes = + No = - More data needed = ?
* FDA Approved for Monotherapy & Use In Combination with Lithium or Valproate to Treat Acute Manic Episodes of Bipolar I Disorder.
** Serious rash associated with lamotrigine; please review current dosing guidelines. Best to avoid coadministration with enzyme inhibitors (e.g., valproic acid) due to incre
Web Links:
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Web Links:
American Psychiatric Associationhttp://www.psych.org/
NASMHPD:National Assoc. of State Mental Health ProgramDirectors Technical Report on PsychiatricPolypharmacyhttp://www.nasmhpd.org/Polypharmacy.pdf
National Library of Medicinehttp://www.nlm.nih.gov/
OMAP:
Ohio Medication Algorithm Project.http://www.psychiatry.uc.edu/cqir/omap.asp
Pharmacy Benefits ManagementStrategic Healthcare Group Department of Veterans
Affairs http://www.vapbm.org/PBM/treatment.htm
The Psychiatric Society of Virginiahttp://www.psva.org/
Psychopharmacology Algorithms Directoryhttp://www.ipap.org/algorithms.php
TMAP/TIMA:Texas Medication Algorithm Projecthttp://www.mhmr.state.tx.us/centraloffice/medicator/TIMA.html
Virginia Association of Community Psychiatristshttp://www.vacp.net
Virginia Department of Medical Assistant Servichttp://www.dmas.state.va.us/pharm-home.htm
45
alpra
ama
Amb
amit
Amo
amp
salts
Amy
Ana
Anta
Arip
Arta
Atar
aten
Ativa
atom
Ave
Ben
benz
beth
bipe
bupr
Bus
busp
buta
Butis
carb
Cata
Cele
chlo
chlo
chlo
Ciba
cital
clom
clon
clon
clora
cloz
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azolam
Xanax
Antianxiety
antadine
Sym
metrel
Side-effectcontrol
*
bien
zolpidem
Hypnotic
triptyline
Elav
il
Antidepressan
t
*
obarbital
Amy
tal
Hypnotic
phetamine
s
Adderall
Psychostimula
nt/ADD
ytal
amo
barbital
Hypnotic
franil
clom
ipramine
Antidepressan
t
*
abuse
disulfiram
Rxofalcoholism
*
iprazole
Abilify
Antipsychotic
*
ane
trihexyphenidylSide-effectcontrol
*
rax
hydroxyzineHClHypnotic,Antianxiety
nolol
Teno
rmin
Sideeffectcontrol
an
Lora
zepam
Antianxiety
*
moxetine
Strattera
Anti-ADD
ntyl
nortriptyline
Antidepressan
t
*
adryl
diphe
nhydramineHypnotic,
Side-effectcontrol
*
ztropine
Cogentin
Side-effectcontrol
*
hanechol
Urec
holine
Side-effectcontrol
eriden
Akin
eton
Sideeffectcontrol
ropion
Wellbutrin
Antidepressan
t
*
par
busp
irone
Antianxiety
*
pirone
Buspar
Antianxiety
*
abarbital
Butisol
Hypnotic
sol
buta
barbital
Hypnotic
bamazepine
Tegr
etol
Moodstabilize
r
*
apres
clonidine
Anti-ADD,Antianxiety
exa
citalopram
Antidepressan
t
*
oralhydrate
Som
note
Hypnotic
rdiazepoxideLibrium
Antianxiety
*
orpromazine
Thorazine
Antipsychotic
*
alith-S
lithiu
mcitrate
Moodstabilize
r
*
opram
Cele
xa
Antidepressan
t,
Anti-OCD,Antipanic
mipramine
Anafranil
Antidepressant/Anti-OCD
*
nazepam
Klon
opin
Antianxiety
*
nidine
Cata
pres
Anti-ADD,Antianxiety
azepate
Tran
xene
Antianxiety
*
apine
Cloz
aril
Antipsychotic
*
46
cypr
Cyto
Dalm
Dep
Dep
depr
desi
Deso
dexa
Dexe
dext
amp
diaz
diphe
disu
diva
Dora
doxe
Effex
Elav
Equi
Eska
esta
felba
Felb
fluox
fluph
flura
fluvo
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47
roheptadine
Periactin
Side-effectcontrol
omel
liothyronine
Potentiatesantid
epressants
mane
flura
zepam
Hypnotic
akene
valproicacid/
valproate
Moodstabilize
r
*
akote
divalproex,
valproate
MoodStabilizer
*
renyl
see
selegiline
Antidepressan
t
pramine
Norp
ramin
Antidepressan
t
*
oxyn
methamphet-
amin
e
Psychostimula
nt/ADD
*
amethasoneDecadron
Diagnostictes
tfor
depression.
edrine
dextro-
Psychostimulant/ADD,
amp
hetamine
PotentiatesAntid
epressants
tro-
Psychostimulant/ADD,
phetamine
Dexedrine
PotentiatesAntid
epressants
epam
Valiu
m
Antianxiety
*
enhydramineBenadryl
Hypnotic,
Side-effectcontrol
*
lfiram
Anta
buse
Rxofalcoholism
*
lproex
Depakote
Moodstabilize
r
*
al
quazepam
Hypnotic
epin
Sine
quan,
Adapin
Antidepressant,Antipanic
*
xor
venlafaxine
Antidepressant,Anti-OCD
Antipanic
*
vil
amitriptyline
Antidepressan
t,
Antipanic
*
inil
mep
robamate
Antianxiety
alith
lithiumcarbonateMoodstabilize
r
*
azolam
Pros
om
Hypnotic
amate
Felb
atol
Anticonvulsant,
Moodstabilize
r
batol
felba
mate
Moodstabilize
r
xetine
Proz
ac
Antidepressan
t,
Anti-OCD,Anti-panic
*
henazine
Prolixin
Antipsychotic
*
azepam
Dalm
ane
Hypnotic
oxamine
Luvo
x
Antidepressan
t,
Anti-OCD,Antipanic
*
Halc
Hald
halop
hydr
pam
imipr
Inde
isoca
Kem
Kepp
Klon
Lam
lamo
levet
levot
Libri
liothy
lithiu
lithiu
Litho
Litho
loraz
loxap
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cion
triazolam
Hypnotic
dol
haloperidol
Antipsychotic
*
peridol
Hald
ol
Antipsychotic
*
oxyzine
oate
Vista
ril
Hypnotic,Antianxiety
*
ramine
Tofra
nil
Antidepressant,Antipanic
*
ral
prop
ranolol
Side-effectcontrol,
Angercontrol
*
arboxazid
Marplan
Antidepressan
t
madrin
proc
yclidine
Side-effectcontrol
pra
levetiracetam
Anticonvulsant,
Moodstabilize
r
opin
clonazepam
Antianxiety,
Moodstabilize
r
*
ictal
lamo
trigine
Anticonvulsant,
Moodstabilize
r
*
otrigine
Lam
ictal
Anticonvulsant,
Moodstabilize
r
*
tiracetam
Keppra
Anticonvulsant,
Moodstabilize
r
thyroxine
Synthroid
Potentiates
antidepressan
ts,
Moodstabilize
r
um
chlordiazepoxideAntianxiety
*
yronine
Cyto
mel
Potentiates
antidepressan
ts,
Moodstabilize
r
mcarbonateEska
lith,
Moodstabilize
r,
Litho
tab
Potentiates
antidepressan
ts
*
umcitrate
Ciba
lith-S
Moodstabilize
r,
Potentiates
antidepressan
ts
*
onate
lithiu
m
Moodstabilize
r,
carb
onate
Potentiates
antidepressan
ts
*
otabs
lithiu
m
Moodstabilize
r,
carb
onate
Potentiates
antidepressan
ts
*
zepam
Ativa
n
Antianxiety
pine
Loxitane
Antipsychotic
*
48
p
Marp
mepr
meso
metha
meth
meth
Ext.R
Milto
Mirap
mirta
Moba
moda
molin
naltre
Nard
nefaz
Nem
Neur
Norp
nortr
olanz
Orap
oxaz
oxca
Pam
Parn
parox
Paxil
pemo
Peria
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49
p
plan
isocarboxazid
Antidepressant,Antipanic
robamate
Milto
wn,EquinilAntianxiety
oridazine
Sere
ntil
Antipsychotic
*
amphetamineDesoxyn
Psychostimula
nt/ADD
ylphenidate
Ritalin
Psychostimula
nt/ADD
ylphenidate
Release
Concerta
Psychostimula
nt/ADD
own
meprobamate
Antianxiety
pex
pram
ipexol
Potentiates
antidepressants
azepine
Rem
eron
Antidepressan
t,
Antipanic
an
molindone
Antipsychotic
*
afanil
Prov
igil
Narcolepsy,Po
tentiates
antidepressants
ndone
Moban
Antipsychotic
*
exone
ReVia
Rxofalcoholism,
Potentiates
antidepressants
dil
phen
elzine
Antidepressan
t,
Antipanic
*
zodone
Serz
one
Antidepressan
t
*
mbutal
Pentobarbital
Hypnotic
rontin
gaba
pentin
Moodstabilize
r
*
pramin
desipramine
Antidepressan
t
*
riptyline
Aven
tyl,PamelorAntidepressant,Antipanic
zapine
Zypr
exa
Antipsychotic
*
p
pimo
zide
Antipsychotic
zepam
Sera
x
Antianxiety
*
arbazepine
Trileptal
Anticonvulsant,
Moodstabilize
r
elor
nortriptyline
Antidepressant,Antipanic
*
nate
trany
lcypromineAntidepressant,Antipanic
*
xetine
Paxil
Antidepressant
,
Anti-OCD,Antipanic
*
l
paro
xetine
Antidepressan
t,
Anti-OCD,Antipanic
*
oline
Cyle
rt
Psychostimula
nt/ADD,
Potentiates
antidepressants
actin
cyproheptadineSide-effectcontrol
Placi
pram
praze
procy
Prolix
propr
Proso
protri
Provi
Proza
Quaz
queti
Rem
ReVi
Rispe
Rispe
rispe
rispe
acting
Ritali
seco
Seco
seleg
Serax
Sero
sertra
Serzo
Somn
Sona
Stela
Stratt
Surm
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50
p
dyl
ethchlorvynol
Hypnotic
mipexole
Mirapex
Potentiates
antidepressants
epam
Centrax
Antianxiety
yclidine
Kem
adrin
Side-effectcontrol
*
xin
fluph
enazine
Antipsychotic
*
ranolol
Inderal
Side-effectcontrol
*
om
estazolam
Hypnotic
iptyline
Vivactil
Antidepressant,Antipanic
*
igil
modafinil
Psychostimula
nt/ADD,
potentiates
ac
fluox
etine
Antidepressant,Anti-OCD,
Antipanic
*
zepam
Dora
l
Hypnotic
apine
Sero
quel
Antipsychotic
*
eron
mirta
zepine
Antidepressant,Antipanic
*
a
naltrexone
Rxofalcoholis
m,
Potentiates
antidepressants
erdal
rispe
ridone
Antipsychotic
*
erdalConstarispe
ridonelongAntipsychotic
*
actin
ginjection
ridone
Risp
erdal
Antipsychotic
*
ridonelongRispe
rdalConstaAntipsychotic
*
ginjection
in
meth
ylphenidatePsychostimula
nt/ADD,
Potentiates
barbital
Seco
nal
Hypnotic
onal
seco
barbital
Hypnotic
giline
Elde
pryl
Antidepressan
t
x
oxaz
epam
Antianxiety
*
quel
quetiapine
Antipsychotic
*
aline
Zoloft
Antidepressan
t,
Anti-OCD,Antipanic
*
one
nefazodone
Antidepressan
t
*
note
chloralhydrateHypnotic
ata
zaleplon
Hypnotic
azine
trifluoperazine
Antipsychotic
*
tera
atom
oxetine
Anti-ADD
montil
trimipramine
Antidepressan
t,
Antipanic
g
tema
tenor
thiorid
Thora
tiaga
Tofra
Topa
topira
Tranx
trany
trazo
triazo
trihex
Trilafo
Trilep
trimip
Urech
Valium
Valpr
valpro
venla
Vista
Wellb
Xana
zalep
zipras
Zolof
zolpid
Zypre
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51
p
zepam
Restoril
Hypnotic
*
rmin
atenolol
Side-effectcontrol
dazine
Mellaril
Antipsychotic
*
azine
chlorpromazineAntipsychotic
*
bine
Gabitril
Anticonvulsant,
Moodstabilize
r
nil
imipramine
Antidepressan
t,
Antipanic
*
max
topiramate
Anticonvulsant,
Moodstabilize
r
*
amate
Topa
max
Anticonvulsant,
Moodstabilize
r
*
xene
clora
zepate
Antianxiety
*
lcypromineParn
ate
Antidepressan
t,
Antipanic
*
done
Desyrel
Antidepressant,Hypnotic
*
olam
Halcion
Hypnotic
xyphenidylArtane
Side-effectcontrol
*
on
perphenazine
Antipsychotic
*
ptal
oxca
rbazepineAnticonvulsant,
Moodstabilize
r
pramine
Surm
ontil
Antidepressant,Antipanic
holine
bethanechol
Side-effectcontrol
m
diazepam
Antianxiety
*
roate
Depakote/
Depakene
Moodstabilize
r
oicacid
Depakene
Moodstabilize
r
*
Antid
epressant,Anti-OCD,
afaxine
Effex
or
Antipanic
hydroxyzine
*
ril
pamoate
Hypnotic,Antianxiety
*
butrin
bupropion
Antidepressan
t
*
ax
alpra
zolam
Antianxiety
*
plon
Sonata
Hypnotic
sidone
Geodon
Antipsychotic,
Moodstabilize
r
*
t
sertraline
Antidepressan
t,
Anti-OCD,Antipanic
*
dem
Amb
ien
Hypnotic
exa
olanzapine
Antipsychotic
*
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52
We have made every effort to ensure the accuracy of the data listed and that they are
within current practice recommendations at the time of publication. However, due to
changing regulations and drug information, the readers are strongly urged to checkthe package insert for drug data as well as updated versions of the State AfterCare
Formulary for current prices.
The authors and Virginia DMHMRSAS disclaim any responsibilities for consequences
secondary to the utilization of this Guide.
Notes
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Notes
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54
Notes
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55
Notes
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56
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Produced in part under unrestricted educational grants fromAstraZeneca, Janssen and Pfizer Pharmaceuticals.