ANTIPSYCHOTIC DRUGS

Conventional Antipsychotics

I. CHLORPROMAZINE

A. BRAND NAME Thorazine

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Antipsychotic; 

Phenothiazine; Antiemetic

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Phenothiazine; antagonizes dopamine D2 receptors in brain; depresses release

of hypothalamic and hypophyseal hormones; may also depress reticular
activating system

E. INDICATIONS  psychosis (schizophrenia); typically reduces, but does not eliminate

the positive symptoms in schizophrenia
 intractable hiccups
 nausea/vomiting
 hyperactive children with excessive motor activity & accompanying
conduct disorders
 sedation

 Schizophrenia, Psychotic Disorders (Adult)

F. ROUTE AND DOSAGE
 PO: 30-75 mg/day divided q6-12hr initially; maintenance: usually 200
mg/day (up to 800 mg/day in some patients; some patients may
require 1-2 g/day)

 IV/IM: 25 mg initially, followed PRN with 25-50 mg after 1-4 hours,

then increased to maximum of 400 mg q4-6hr until patient is
controlled; usual dosage 300-800 mg/day

G. CONTRAINDICATIONS Hypersensitivity to phenothiazine derivatives; withdrawal states from alcohol;

comatose states, brain damage, bone marrow depression, Reye's syndrome;
children <6 mo; pregnancy (category C), lactation.

H. SIDE EFFECTS/ADVERSE  Drowsiness; dry mouth or stuffy nose; blurred vision; constipation; or
REACTIONS impotence, trouble having an orgasm

I. NURSING RESPONSIBILITIES/  Establish baseline BP (in standing and recumbent positions), and pulse,
CONSIDERATIONS before initiating treatment.
 Monitor BP frequently. Hypotensive reactions, dizziness, and sedation
are common during early therapy, particularly in patients on high
doses and in the older adult receiving parenteral doses. Patients
usually develop tolerance to these adverse effects; however, lower
doses or longer intervals between doses may be required.
 Monitor cardiac status with baseline ECG in patients with preexisting
cardiovascular disease.
 Monitor I&O ratio and pattern: Urinary retention due to mental
depression and compromised renal function may occur. If serum
creatinine becomes elevated, therapy should be discontinued.

II. PERPHENAZINE
A. BRAND NAME Trilafon

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Phenothiazine

Antipsychotic; Antiemetic

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Affects all parts of CNS similar to chlorpromazine, particularly the
hypothalamus. Antipsychotic effect: Antagonizes the neurotransmitter
dopamine by action on dopamine receptors in the brain. Antiemetic action
results from direct blockade of dopamine in the chemoreceptor trigger zone
(CTZ) in the medulla.

E. INDICATIONS  Psychotic disorders

 symptomatic control of severe nausea and vomiting
 acute conditions such as violent retching during surgery, and
 intractable hiccups

F. ROUTE AND DOSAGE

 Schizophrenia (Adult)

 Hospitalized patients: 8-16mg PO q6-12hr

 Hospitalized patients: Not to exceed 64 mg/day divided q6-12hr
 Outpatients: 4-8mg PO q8hr; reduce as soon as possible to
minimum effective dose

 Schizophrenia (Children)

 <12 years
Not recommended by manufacturer

 >12 years
Hospitalized patients: 8-16mg PO q6-12hr
Hospitalized patients: Not to exceed 64 mg/day divided q6-12hr
Outpatients: 4-8mg PO q8hr; reduce as soon as possible to minimum
effective dose

 Schizophrenia (Geriatric)

 Hospitalized patients: 8-16mg PO q6-12hr

 Hospitalized patients: Not to exceed 64 mg/day divided q6-12hr
 Outpatients: 4-8mg PO q8hr; reduce as soon as possible to
minimum effective dose

G. CONTRAINDICATIONS Hypersensitivity to perphenazine and other phenothiazines; preexisting liver

damage; suspected or established subcortical brain damage, comatose states;
bone marrow depression. Safety during pregnancy (category C), lactation, or in
children <12 y is not established.

H. SIDE EFFECTS/ADVERSE  Tardive dyskinesia, drowsiness, jaundice, blood dyscrasias,

REACTIONS hypotension, ECG changes, retinopathy, may mask emetic signs of
disease, lowered seizure threshold, rash, skin pigmentation,
anticholinergic effects, insomnia, adynamic ileus,
hyperprolactinemia, extrapyramidal reactions, neuroleptic malignant
syndrome.
 I. NURSING RESPONSIBILITIES/
CONSIDERATIONS  Establish baseline BP before initiation of drug therapy and check it at
regular intervals, especially during early therapy.
 Monitor BP and pulse continuously during IV administration. Keep
patient supine until assured that vital signs are stable. Observe older
adult patients carefully for hypotension and extrapyramidal reactions.
 Report restlessness, weakness of extremities, dystonic reactions
(spasms of neck and shoulder muscles, rigidity of back, difficulty
swallowing or talking); motor restlessness (akathisia: inability to be
still); and parkinsonian syndrome (tremors, shuffling gait, drooling,
slow speech). 
 Monitor I&O ratio and bowel elimination pattern.
 Suspect hypersensitivity, withhold drug, and report to physician if
jaundice appears between weeks 2 and 4.

III. FLUPHENAZINE

A. BRAND NAME Prolixin

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Antipsychotic;

Phenothiazine

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Potent phenothiazine, antipsychotic agent. Blocks postsynaptic dopamine

receptors in the brain. Similar to other phenothiazines with the following
exceptions: more potent per weight, higher incidence of extrapyramidal
complications, and lower frequency of sedative, hypotensive, and antiemetic
effects.

E. INDICATIONS Management of manifestations of psychotic disorders.

F. ROUTE AND DOSAGE

 Psychotic Disorders (Adult)

 Fluphenazine hydrochloride
2.5-10 mg/day PO divided q6-8hr initially; maintenance: 1-5 mg
PO/IM divided q6-8hr; not to exceed 40 mg/day

 Fluphenazine decanoate
16.25-25 mg (25 mg/mL) IM/SC q2weeks; after achieving steady
state, effects of a single injection may last 4-6 weeks; use caution
titrating dosages; if doses >50 mg needed; use increments of 12.5
mg; not to exceed 100 mg

 Psychotic Disorders (Pediatric)

Safety and efficacy not established

 Psychotic Disorders (Geriatric)

1-2.5 mg/day PO; dosage titrated according to response

G. CONTRAINDICATIONS Coma, CNS or bone marrow depression, Liver disease, Subcortical brain
damage, Blood dyscrasias.
 Drowsiness, anticholinergic and other autonomic effects, insomnia,
 H. SIDE EFFECTS/ADVERSE restlessness, rash, photosensitivity, tardive dyskinesia, blood
REACTIONS dyscrasias, jaundice, pneumonia, hypertension, retinopathy, lowered
seizure threshold, extrapyramidal reactions, neuroleptic malignant
syndrome, weight changes, endocrine effects.

 Report immediately onset of mental depression and extrapyramidal

I. NURSING RESPONSIBILITIES/ symptoms. Both occur frequently, particularly with long-acting forms
CONSIDERATIONS (decanoate and enanthate).
 Be alert for appearance of acute dystonia
 Be alert for red, dry, hot skin; full, bounding pulse, dilated pupils,
dyspnea, mental confusion, elevated BP, temperature over 40.6° C
(105° F). Inform physician and institute measures to reduce body
temperature rapidly.
 Monitor BP during early therapy. If systolic drop is more than 20 mm
Hg, inform physician.
 Monitor I&O ratio and bowel elimination pattern. Check for abdominal
distension and pain. Monitor for xerostomia and constipation.

IV. THIORIDAZINE

A. BRAND NAME Mellaril

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Phenothiazine

Antipsychotic

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Phenothiazine similar to chlorpromazine. Rarely produces extrapyramidal

effects. Has weak antiemetic but strong anticholinergic and alpha-adrenergic
agonist activity and potent sedative action.

E. INDICATIONS Management of nonpsychotic behavioral disturbances of senility,

manifestations of psychotic disorders, alcohol withdrawal; symptomatic
treatment of organic brain disease. Short-term treatment of moderate to
marked depression and for management of hyperkinetic behavior syndrome
(attention deficit disorder).

F. ROUTE AND DOSAGE  Psychotic Disorders

 Adult: PO 50–100 mg t.i.d., may increase up to 800 mg/d as needed
or tolerated

 Geriatric: PO 10 mg t.i.d., may increase up to 200 mg/d

 Child: PO >2 y, 0.5–3 mg/kg/d in divided doses; if hospitalized, may

start at 25 mg t.i.d.

G. CONTRAINDICATIONS Hypersensitivity to phenothiazines. Severe CNS depression; CV disease;

children <2 y. Safety during pregnancy (category C) or lactation is not
established.

H. SIDE EFFECTS/ADVERSE  Drowsiness, other CNS effects, anticholinergic effects, QT  prolongation,

REACTIONS arrhythmias, hyperprolactinemia, amenorrhea, ejaculation inhibition,
edema, tardive dyskinesia, neuroleptic malignant syndrome, blood
 dyscrasias, jaundice, gynecomastia, weight gain, pigmentary
retinopathy, orthostatic hypotension, hyperpyrexia, paradoxical
reaction.
I. NURSING RESPONSIBILITIES/
CONSIDERATIONS  Orthostatic hypotension may occur in early therapy. Female patients
appear to be more susceptible than males.

 Be aware that patients may be unable to adjust to extremes of

temperature because drug effects heat regulatory center in the
hypothalamus. Patient may complain of being cold even at average
room temperature; older adults are particularly susceptible.
 Monitor I&O ratio and bowel elimination pattern. Check for abdominal
distension and pain. Encourage adequate fluid intake as prophylaxis for
constipation and xerostomia. The depressed patient may not seek help
for either symptom or for urinary retention.

V. MESORIDAZINE

A. BRAND NAME Serentil

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Phenothiazine;

Antipsychotic

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Piperidine derivative of phenothiazine. Tranquilizer with stronger sedative

action than produced by chlorpromazine, but has more antiemetic action and
lower incidence of extrapyramidal adverse effects.

E. INDICATIONS Second-line therapy for schizophrenia, behavioral problems in mental

deficiency and chronic brain syndrome, acute and chronic alcoholism. Also to
reduce symptoms of anxiety and tension associated with many neurotic
disorders.

F. ROUTE AND DOSAGE  Psychotic Disorders

 Adult: PO 10–50 mg b.i.d. or t.i.d., may increase as needed up to 400
mg/d IM 25 mg, may repeat in 30–60 min if necessary

G. CONTRAINDICATIONS Known sensitivity to other phenothiazines; severely depressed (drug-induced)

patient; comatose state; children <12 y. Safety during pregnancy (category C)
or lactation is not established.

H. SIDE EFFECTS/ADVERSE  Dizziness, sedation, fainting, extrapyramidal effects, dystonic

REACTIONS reactions, akathisia, tardive dyskinesia, blurred vision, xerostomia,
nasal congestion,  urinary retention or incontinence, ejaculation
dysfunction, impotence, priapism, constipation, decreased sweating,
rash, exfoliative dermatitis photosensitivity, tachycardia, orthostatic
hypotension, arrhythmias (prolong qtc interval) heart block.

I. NURSING RESPONSIBILITIES/  Monitor I&O and bowel elimination patterns and check bladder for
CONSIDERATIONS distension. Depressed patients often fail to report urinary discomfort
or constipation.
 Report to physician if patient complains of blurred vision. Periodic
ophthalmic examinations are advisable with long-term therapy.
 Monitor BP with patient supine and standing.
  Avoid spilling drug on skin since it may cause contact dermatitis.
Thoroughly rinse off with water if spilling occurs.

VI. THIOTHIXENE

A. BRAND NAME Navane

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Phenothiazine

Antipsychotic

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Xanthene derivative chemically and pharmacologically similar to

chlorprothixene and the piperazine phenothiazines. Mechanism of
antipsychotic effects is unclear; thought to be related to blockade of
postsynaptic dopamine receptors in the brain.

E. INDICATIONS Manifestations of psychotic disorders.

 Schizophrenia (Adult)
F. ROUTE AND DOSAGE
 Mild-Moderate: initial: 2 mg PO q8hr; may increase to 15 mg/day
 Severe: initial 5 mg PO q12hr
 Maintenance: 20-30 mg/day; no more than 60 mg/day PO divided
q8-12hr

 Schizophrenia (Pediatrics)

 <12 years
Not recommended
 >12 years
Mild-Moderate: initial: 2 mg PO q8hr; may increase to 15 mg/day
Severe: initial 5 mg PO q12hr
Maintenance: 20-30 mg/day; no more than 60 mg/day PO divided q8-
12hr

G. CONTRAINDICATIONS Hypersensitivity to thioxanthenes and phenothiazines; children <12 y;

comatose states; CNS depression; circulatory collapse; blood dyscrasias. Safety
during pregnancy (category C) or lactation is not established.

H. SIDE EFFECTS/ADVERSE  Tardive dyskinesia, hypotension, drowsiness, insomnia, jaundice,

REACTIONS blood dyscrasias, may mask emetic signs of overdosage or disease,
lowered seizure threshold, rash, photosensitivity,
hyperprolactinemia, anticholinergic effects, pigmentary retinopathy,
lenticular pigmentation, extrapyramidal reactions, neuroleptic
malignant syndrome (monitor).

I. NURSING RESPONSIBILITIES/  Keep patient recumbent for at least 1 h following IM because of

CONSIDERATIONS possibility of orthostatic hypotension. Check BP periodically.

 Monitor BP for excessive hypotensive response when thiothixene is

added to drug regimen of patient on hypertensive treatment until
therapy is stabilized.
 Monitor response when patient is changed from IM to PO forms
(capsules, concentrate). Dosage adjustment may be necessary.
  Report extrapyramidal effects (pseudoparkinsonism, akathisia,
dystonia) to physician; dose adjustment or short-term therapy with
an antiparkinsonism agent may provide relief.
 Be alert to first symptoms of tardive dyskinesia. Discontinue drug
immediately and inform physician.

VII. HALOPERIDOL

A. BRAND NAME Haldol

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Antipsychotic;

Butyrophenone

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Phenylbutylpiperadine; antagonizes dopamine D1 and D2 receptors in brain;

depresses reticular activating system and inhibits release of hypothalamic and
hypophyseal hormones

E. INDICATIONS Management of manifestations of psychotic disorders and for control of tics

and vocal utterances of Gilles de la Tourette's syndrome; for treatment of
agitated states in acute and chronic psychoses. Used for short-term treatment
of hyperactive children and for severe behavior problems in children of
combative, explosive hyperexcitability.

F. ROUTE AND DOSAGE  Psychosis

 Adult: PO 0.2–5 mg b.i.d. or t.i.d. IM 2–5 mg repeated q4h prn;
Decanoate: 50–100 mg q4wk
 Child: PO 0.5 mg/d in 2–3 divided doses, may be increased by 0.5 mg
q5–7d to 0.05–0.15 mg/kg/d

 Severe Psychosis
 Adult: PO 3–5 mg b.i.d. or t.i.d., may need up to 100 mg/d IM 2–5
mg, may repeat q.h. prn; Decanoate: 50–100 mg q4wk
 Child: PO 0.05–0.15 mg/kg/d in 2–3 divided doses

G. CONTRAINDICATIONS Parkinson's disease, parkinsonism, seizure disorders, coma; alcoholism; severe

mental depression, CNS depression; thyrotoxicosis. Safe use during pregnancy
(category C), lactation, or in children <3 y is not established.

Extrapyramidal effects (sudden, often jerky, involuntary motions of the head,

H. SIDE EFFECTS/ADVERSE neck, arms, body, or eyes, muscle stiffness, akathisia, Parkinsonism), dizziness,
REACTIONS hyperactivity, tiredness, and nausea, sedation, weight gain, erectile
dysfunction, menstrual irregularities, insomnia, gynecomastia, dry mouth,
vomiting, and constipation.

I. NURSING RESPONSIBILITIES/  Target symptoms expected to decrease with successful haloperidol

CONSIDERATIONS treatment include hallucinations, insomnia, hostility, agitation, and
delusions.
 Monitor patient's mental status daily.
 Monitor for extrapyramidal (neuromuscular) reactions that occur
frequently during first few days of treatment. Symptoms are usually
dose related and are controlled by dosage reduction or concomitant
administration of antiparkinson drugs.
  Be alert for behavioral changes in patients who are concurrently
receiving antiparkinson drugs.
 Observe patients closely for rapid mood shift to depression when
haloperidol is used to control mania or cyclic disorders. Depression
may represent a drug adverse effect or reversion from a manic state.

VIII. LOXAPINE

A. BRAND NAME Loxitane

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Antipsychotic

C. PREGNANCY CATEGORY C

D. MODE OF ACTION This dibenzoxazepine antipsychotic is chemically distinct from other

antipsychotics. Its exact mode of action is not established. Sedative action is
less than that produced by chlorpromazine, but anticholinergic effects are
comparable and extrapyramidal effects may be more intense. Also has
antiemetic activity; lowers seizure threshold in patients with history of
convulsive disorders.

E. INDICATIONS Manifestations of psychotic disorders.

F. ROUTE AND DOSAGE  Schizophrenia (Adult)

 Initial: 10-25 mg PO q12hr

 Maintenance: 60-100 mg/day divided q6-12hr; not to exceed 250
mg/day

Severe drug-induced CNS depression; comatose states, children <16 y. Safe use
G. CONTRAINDICATIONS
during pregnancy (category C) or lactation is not established.

 Dizziness, problems with balance or walking; swelling in your face;

H. SIDE EFFECTS/ADVERSE
itching or rash; tremors, muscle twitching or stiffness; numbness,
REACTIONS
weakness; blurred vision; feeling restless or agitated; nausea,
vomiting, constipation; dry mouth, stuffy nose; or sleep problems
(insomnia).

I. NURSING RESPONSIBILITIES/
 Monitor baseline BP pattern prior and during therapy; both
CONSIDERATIONS
hypotension and hypertension have been reported as adverse
reactions.
 Observe carefully for extrapyramidal effects such as acute dystonia
during early therapy. Most symptoms disappear with dose adjustment
or with antiparkinsonism drug therapy.
 Discontinue therapy and report promptly to physician the first signs of
impending tardive dyskinesia (fine vermicular movements of the
tongue) when patient is on long-term treatment.
 Monitor I&O and bowel elimination patterns and check for bladder
distention. Depressed patients often fails to report urinary retention or
constipation.
 Risk of seizures is increased in those with history of convulsive
disorders.

IX. MOLINDONE
 A. BRAND NAME Moban

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Antipsychotic

Phenothiazine

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Tranquilizer structurally unrelated but pharmacologically similar to the

piperazine phenothiazines; thought to block postsynaptic dopamine receptors
in the brain. Has less sedative but comparable anticholinergic activity and
greater incidence of extrapyramidal adverse effects than chlorpromazine. EEG
studies suggest ascending reticular system is chief site of action.

E. INDICATIONS Management of manifestations of psychotic disorders.

F. ROUTE AND DOSAGE  Psychotic Disorders

 Adult: PO 50–75 mg/d in 3–4 divided doses, may be increased to 100
mg/d in 3–4 d or may be able to decrease to 15–60 mg/d in divided
doses (max: 225 mg/d)

G. CONTRAINDICATIONS Known hypersensitivity to molindone or to phenothiazines; severe CNS

depression; comatose states; children <12 y. Safety during pregnancy (category
C) or lactation is not established.

H. SIDE EFFECTS/ADVERSE  Drowsiness, dizziness, lightheadedness, constipation, dry mouth, or

REACTIONS blurred vision may occur.

I. NURSING RESPONSIBILITIES/  Withhold dose and consult with physician if the following symptoms
CONSIDERATIONS occur: Tremor, involuntary twitching, exaggerated restlessness,
changes in vision, light-colored stools, sore throat, fever, rash.
 Monitor bowel pattern and urinary output. The depressed patient may
not report constipation or urinary retention, both adverse effects of
this medicine.
 Be alert early during treatment to onset of parkinsonism
(extrapyramidal) symptoms: Rigidity, immobility, reduction of
voluntary movements, tremors, fine vermicular tongue movements.
Withhold dose and report promptly to physician.
 Supervise ambulation and other ADL in the older adult or debilitated or
patient with impaired vision to prevent injury or falling because drug
increases motor activity.

X. TRIFLUOPERAZINE

A. BRAND NAME Stelazine

B. CLASSIFICATIONS Central Nervous System Agent; Psychotherapeutic; Antipsychotic

Phenothiazine

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Phenothiazine similar to chlorpromazine. Produces less sedative,

cardiovascular, and anticholinergic effects and more prominent antiemetic and
 extrapyramidal effects than other phenothiazines. Antipsychotic effects
thought related to blockade of postsynaptic dopamine receptors in the brain.

E. INDICATIONS Management of manifestations of psychotic disorders; "possibly effective"

control of excessive anxiety and tension associated with neuroses or somatic
conditions.

 Psychotic Disorders
F. ROUTE AND DOSAGE  Adult: PO 1–2 mg b.i.d., may increase up to 20 mg/d in hospitalized
patients IM 1–2 mg q4–6h (max: 10 mg/d)

 Child: PO 6–12 y, 1 mg 1–2 times/d, may increase up to 15 mg/d in

hospitalized patients IM 6–12 y, 1 mg 1–2 times/d, may increase up
to 15 mg/d

G. CONTRAINDICATIONS Hypersensitivity to phenothiazines; comatose states; CNS depression; blood

dyscrasias; children <6 y; bone marrow depression; preexisting liver disease;
pregnancy (category C), lactation.

H. SIDE EFFECTS/ADVERSE  Drowsiness, insomnia, dizziness, agitation, extrapyramidal

REACTIONS effects, neuroleptic malignant syndrome, nasal congestion, dry
mouth, blurred vision, pigmentary retinopathy, agranulocytosis,
photosensitivity, skin rash, sweating, constipation,
tachycardia, hypotension, depressed cough reflex, gynecomastia,
galactorrhea.

I. NURSING RESPONSIBILITIES/  Monitor HR and BP. Hypotension is a common adverse effect.

CONSIDERATIONS  Hypotension and extrapyramidal effects (especially akathisia and
dystonia) are most likely to occur in patients receiving high doses or
parenteral administration and in older adults. Withhold drug and notify
physician if patient has dysphagia, neck muscle spasm, or if tongue
protrusion occurs.
 Monitor I&O ratio and bowel elimination pattern. Check for abdominal
distention and pain. Encourage adequate fluid intake as prophylaxis for
constipation and xerostomia. The depressed patient may not seek help
for either symptom or for urinary retention.
 Agitation, jitteriness, and sometimes insomnia may simulate original
neurotic or psychotic symptoms. These adverse effects may disappear
spontaneously.
 Expect maximum therapeutic response within 2–3 wk after initiation of
therapy.

Atypical Antipsychotics

I. CLOZAPINE

A. BRAND NAME Clozaril

B. CLASSIFICATIONS Central Nervous System (Cns) Agent; Psychotherapeutic Agent; Antipsychotic;

Atypical

C. PREGNANCY CATEGORY B

D. MODE OF ACTION Mechanism is not defined. Interferes with binding of dopamine to D 1 and
 D2 receptors in the limbic region of brain. It binds primarily to
nondopaminergic sites (e.g., alpha-adrenergic, serotonergic, and cholinergic
receptors).

E. INDICATIONS Indicated only in the management of severely ill schizophrenic patients who
have failed to respond to other neuroleptic agents.

F. ROUTE AND DOSAGE  Schizophrenia

 Adult: PO >16 y: Initiate at 25–50 mg/d and titrate to a target dose of
350–450 mg/d in 3 divided doses at 2 wk intervals, further increases
can be made if necessary, max of 900 mg/d

G. CONTRAINDICATIONS
Severe CNS depression, blood dyscrasia, history of bone marrow depression;
patients with myeloproliferative disorders, uncontrolled epilepsy; clozapine-
induced agranulocytosis, severe granulocytosis, chemotherapy, coma,
leukemia, leukopenia, neutropenia, myocarditis, concurrent administration of
benzodiazepines or other psychotropic drugs; renal failure, dialysis, hepatitis,
jaundice; infants, lactation.

H. SIDE EFFECTS/ADVERSE  Hypotension, fever, tachycardia, constipation, dizziness, headache,

REACTIONS nausea, sedated state, vomiting, and weight gain, syncope, and
diaphoresis. See below for a comprehensive list of adverse effects.

I. NURSING RESPONSIBILITIES/  Monitor diabetics for loss of glycemic control.

CONSIDERATIONS  Monitor for seizure activity; seizure potential increases at the higher
dose level.
 Closely monitor for recurrence of psychotic symptoms if the drug is
being discontinued.
 Monitor cardiovascular and respiratory status, especially during the
first month of therapy. Report promptly S&S of CHF and other
potential cardiac problems.
 Monitor for development of tachycardia or hypotension, which may
pose a serious risk for patients with compromised cardiovascular
function.
 Monitor daily temperature and report fever. Transient elevation above
38° C (100.4° F), with peak incidence during first 3 wk of drug therapy,
may occur.

II. RISPERIDONE

A. BRAND NAME Risperdal

B. CLASSIFICATIONS Central Nervous System (Cns) Agent; Antipsychotic; Atypical

C. PREGNANCY CATEGORY C

D. MODE OF ACTION
Mechanism is not well understood. Interferes with binding of dopamine to D 2-
interlimbic region of the brain, serotonin (5-HT 2) receptors, and alpha-
adrenergic receptors in the occipital cortex. It has low to moderate affinity for
the other serotonin (5-HT) receptors and no affinity to nondopaminergic sites
(e.g., cholinergic, muscarinic, or beta-adrenergic receptors).

E. INDICATIONS Reduction or elimination of psychotic symptoms in schizophrenia and related

psychoses; treatment of bipolar disorder. Seems to improve negative
 symptoms such as apathy, blunted affect, and emotional withdrawal.

F. ROUTE AND DOSAGE  Psychosis

 Adult: PO 1–6 mg b.i.d., start with 1 mg b.i.d., increase by 1 mg b.i.d.
daily to an initial target dose of 3 mg b.i.d. (max: 8 mg/d) IM 25 mg
once q2wk (max: 50 mg)
 Geriatric: PO Start with 0.5 mg b.i.d. and increase by 0.5 mg b.i.d. daily
to an initial target of 1.5 mg b.i.d. (max: 4 mg/d) IM 25 mg once
q2wk (max: 25 mg)

 Bipolar Disorder
 Adult: PO 2–3 mg once daily for up to 3 wk
 Geriatric: PO Start with 0.5 mg b.i.d. and increase by 0.5 mg b.i.d. daily
to an initial target of 1.5 mg b.i.d. (max: 4 mg/d). May convert to
once daily dosing after stabilized in b.i.d. 2–3 d

G. CONTRAINDICATIONS Hypersensitivity to risperidone; elderly with dementia-related psychosis; QT

prolongation, Reye's syndrome, brain tumor, severe CNS depression, head
trauma; suicidal ideation, tardive dyskinesia; sunlight (UV) exposure, tanning
beds; pregnancy (category C), lactation, children <15 y.

H. SIDE EFFECTS/ADVERSE Extrapyramidal effects (sudden, often jerky, involuntary motions of the head,
REACTIONS neck, arms, body, or eyes), dizziness, tiredness, drowsiness, fatigue, fever,
weight gain, feeling hot or cold, headache, dry mouth, increased appetite,
restlessness, anxiety, sleep problems (insomnia), nausea, vomiting, stomach
pain, constipation, cough, sore throat, runny or stuffy nose, or skin rash.

I. NURSING RESPONSIBILITIES/  Monitor diabetics for loss of glycemic control.

CONSIDERATIONS  Reassess patients periodically and maintain on the lowest effective
drug dose.
 Monitor closely neurologic status of older adults.
 Monitor cardiovascular status closely; assess for orthostatic
hypotension, especially during initial dosage titration.
 Monitor closely those at risk for seizures.
 Assess degree of cognitive and motor impairment, and assess for
environmental hazards.

III. OLANZAPINE

A. BRAND NAME Zyprexa

B. CLASSIFICATIONS Central Nervous System (Cns) Agent; Psychotherapeutic Agent; Antipsychotic

Agent; Atypical; Selective Serotonin Reuptake Inhibitor; Dopamine-Reuptake
Inhibitor

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Antipsychotic activity is thought to be due to antagonism for both serotonin
5HT2A/2C and dopamine D1–4 receptors. May inhibit the CNS presynaptic
neuronal reuptake of serotonin and dopamine. Antagonism of alfa-adrenergic
receptors results in the adverse effect of orthostatic hypotension.

E. INDICATIONS Management of psychotic disorders, treatment of bipolar disorder, acute

agitation (IM).
 F. ROUTE AND DOSAGE  Psychotic Disorder
 Adult: PO Start with 5–10 mg once/d, may increase by 2.5–5 mg q wk
until desired response (usual range 10–15 mg/d, max: 20 mg/d)
 Geriatric: PO Start with 5 mg once/d

 Bipolar Mania
 Adult: PO Start with 10–15 mg once/d, may increase by 5 mg q24h if
needed

 Acute Agitation
 Adult: IM 10 mg, do not repeat more frequently than q2h (max: 30
mg/24h)
 Geriatric: IM 2.5–5 mg once

Hypersensitivity to olanzapine; abrupt discontinuation, coma, severe CNS

G. CONTRAINDICATIONS
depression, subcutaneous or intramuscular injection of olanzapine; tardive
dyskinesia; infants, pregnancy (category C), lactation.
 dizziness/low blood pressure upon standing, weight gain, dose
dependent, high levels of triglycerides in the blood, high cholesterol,
H. SIDE EFFECTS/ADVERSE
drowsiness, dose dependent, extrapyramidal symptoms (eps), dose
REACTIONS
dependent (muscle spasms, jerky movements, slow movements), dry
mouth, weakness, dizziness, accidental injury, insomnia,
elevated alanine aminotransferase (alt) level, constipation,
indigestion, elevated levels of prolactin in the blood, high blood
sugar, low blood pressure, tremor, weakness, restlessness,
parkinsonism reactions.

 Monitor diabetics for loss of glycemic control.

I. NURSING RESPONSIBILITIES/
 Withhold drug and immediately report S&S of neuroleptic malignant
CONSIDERATIONS
syndrome; assess for and report S&S of tardive.
 Monitor BP and HR periodically. Monitor temperature, especially
under conditions such as strenuous exercise, extreme heat, or
treatment with other anticholinergic drugs.
 Monitor for seizures, especially in older adults and cognitively impaired
persons.

IV. QUETIAPINE

A. BRAND NAME Seroquel

B. CLASSIFICATIONS Central Nervous System (Cns) Agent; Psychotherapeutic Agent; Antipsychotic,

Atypical

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Antagonizes multiple neurotransmitter receptors in the brain including

serotonin (5-HT1A and 5-HT2) as well as dopamine D1 and D2 receptors.
Mechanism of action is unknown, however, antipsychotic properties thought
to be related to antagonized responses. Antagonizes histamine H 1 receptors
resulting in possible somnolence, and adrenergic alpha 1 and alpha2 receptors
which may lead to orthostatic hypotension.
 E. INDICATIONS Management of psychotic disorders, management of bipolar disorder.

F. ROUTE AND DOSAGE  Psychosis, Acute Mania

 Adult: PO Initiate with 25 mg b.i.d., may increase by 25–50 mg b.i.d.
to t.i.d. on the second or third day as tolerated to a target dose of
300–400 mg/d divided b.i.d. to t.i.d., may adjust dose by 25–50 mg
b.i.d. q.d. as needed (max: 800 mg/d)
 Geriatric: PO Initiate with 25 mg b.i.d., titrate more slowly than adult
patients, target range 150–200 mg/day in divided doses

 Agitation, Dementia
 Geriatric: PO Initiate with 25 mg b.i.d., may increase by 25–50 mg
b.i.d. q 2–7 d if needed (max: 200 mg/d)

G. CONTRAINDICATIONS Hypersensitivity to quetiapine; pregnancy (category C), lactation; alcohol use.

Safety and efficacy in children have not been established.

 Mood or behavior changes, constipation, stomach pain, upset

H. SIDE EFFECTS/ADVERSE
stomach, nausea, vomiting, drowsiness, dizziness, lightheadedness,
REACTIONS
tiredness, headache, trouble sleeping, dry mouth, sore throat, breast
swelling or discharge, missed menstrual periods, increased appetite,
or weight gain.

 Monitor diabetics for loss of glycemic control.

I. NURSING RESPONSIBILITIES/
 Reassess need for continued treatment periodically.
CONSIDERATIONS
 Withhold the drug and immediately report S&S of tardive dyskinesia or
neuroleptic malignant syndrome.
 Perform baseline cataract exam when therapy is started and at 6 mo
intervals thereafter.
 Monitor patients with a history of seizures for lowering of the seizure
threshold.

V. ZIPRASIDONE

A. BRAND NAME Geodon

B. CLASSIFICATIONS Central Nervous System (Cns) Agent; Psychotherapeutic Agent; Antipsychotic;

Atypical

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Acts as antagonist at dopamine D2 and serotonin type 1 and 2 (5HT1D, 5HT2A)
receptors; acts as agonist at serotonin 5HT1A receptor; moderately inhibits
reuptake of norepinephrine and serotonin; has alpha-blocking and
antihistaminic activity.

E. INDICATIONS Treatment of schizophrenia, acute bipolar mania.

F. ROUTE AND DOSAGE  Schizophrenia

 Adult: PO Start with 20 mg b.i.d. with food, may increase q2d up to
80 mg b.i.d. if needed IM 10 mg q2h or 20 mg q4h up to max of 40
mg/d

 Acute Mania
 Adult: PO Start with 40 mg b.i.d. with food; may increase q2d up to
 80 mg b.i.d. if needed

G. CONTRAINDICATIONS Hypersensitivity to ziprasidone; history of QT prolongation including congenital

long QT syndrome or with other drugs known to prolong the QT interval; AV
block, bundle branch block, cardiac arrhythmias, congenital heart disease,
recent MI or uncompensated heart failure; bradycardia, hypokalemia or
hypomagnesemia; intravenous administration; neuroleptic malignant
syndrome and tardive dyskinesia; dehydration or hypovolemia; UV exposure
and tanning beds; pregnancy (category C), lactation. Safety and efficacy in
children are not established.

H. SIDE EFFECTS/ADVERSE  Feeling unusually tired or sleepy; nausea, vomiting, upset stomach,
REACTIONS loss of appetite; constipation; dizziness, drowsiness; restlessness;
anxiety, headache, depression; abnormal muscle movements such
as tremor, shuffling, and uncontrolled involuntary movements,
muscle pain or twitching; diarrhea; skin rash; weight gain, and
increased cough or runny or stuffy nose. Serious side effects of
Geodon include fainting or loss of consciousness or
heart palpitations.

I. NURSING RESPONSIBILITIES/
CONSIDERATIONS  Monitor diabetics for loss of glycemic control.
 Monitor for S&S of torsade de pointes (e.g., dizziness, palpitations,
syncope), tardive dyskinesia (see Appendix F) especially in older adult
women and with prolonged therapy, and the appearance of an
unexplained rash. Withhold drug and report to physician immediately
if any of these develop.
 Monitor I&O ratio and pattern: Notify physician if diarrhea, vomiting or
any other conditions develops which may cause electrolyte imbalance.
 Monitor BP lying, sitting, and standing. Report orthostatic hypotension
to physician.
 Monitor cognitive status and take appropriate precautions.
 Monitor for loss of seizure control, especially with a history of seizures
or dementia.

VI. ARIPIPRAZOLE

A. BRAND NAME Abilify

B. CLASSIFICATIONS Central Nervous System (Cns) Agent; Psychotherapeutic; Antipsychotic;

Atypical

C. PREGNANCY CATEGORY C

D. MODE OF ACTION Atypical antipsychotic; partial agonist at dopamine D2 and serotonin type 1 (5-
HT1A) receptors; antagonist at serotonin type 2 (5-HT2A) receptor; also has
alpha-blocking activity.

E. INDICATIONS Treatment of schizophrenia, bipolar mania, maintenance in bipolar 1 disorder;

depression with psychotic features.

F. ROUTE AND DOSAGE  Schizophrenia

 Adult: PO 10–15 mg once daily, may increase at 2-wk intervals to
max of 30 mg/d if needed
  Bipolar Mania
 Adult: PO 30 mg once daily, may reduce to 15 mg/d

G. CONTRAINDICATIONS Hypersensitivity to aripiprazole; lactation; pregnancy (category C).

H. SIDE EFFECTS/ADVERSE  Dizziness, lightheadedness, drowsiness, weakness, lightheadedness,

REACTIONS nausea, vomiting, stomach upset, tiredness,
excess saliva or drooling, choking or trouble swallowing, blurred
vision, headache, anxiety, weight gain, drowsiness, sleep problems
(insomnia), constipation.
 Other serious side effects include tardive dyskinesia (involuntary,
repetitive movements), neuroleptic malignant syndrome, shaking
(tremors), muscle spasms, fainting, mental/mood changes (such as
increased anxiety, depression, suicidal thoughts), trouble
swallowing, restlessness (especially in the legs), mask-like expression
of the face, seizures, signs of infection (such as fever, persistent sore
throat).

I. NURSING RESPONSIBILITIES/  Monitor diabetics for loss of glycemic control.

CONSIDERATIONS  Monitor cardiovascular status. Assess for and report orthostatic
hypotension. Take BP supine then in sitting position. Report systolic
drop of >15–20 mm Hg. Patients at increased risk are those who are
dehydrated, hypovolemic, or receiving concurrent antihypertensive
therapy.
 Monitor body temperature in situations likely to elevate core
temperature (e.g., exercising strenuously, exposure to extreme heat,
receiving drugs with anticholinergic activity, or being subject to
dehydration).
 Monitor for and report signs of tardive dyskinesia.
 Monitor for and immediately report S&S of neuroleptic malignant
syndrome (NMS) that include: hyperpyrexia, muscle rigidity, altered
mental status, irregular pulse or blood pressure, tachycardia,
diaphoresis, and cardiac dysrhythmia. Withhold drug if NMS is
suspected.