pharmacologic considerations in the treatment of schizophrenia and psychosis presented by: ann m....

Pharmacologic Considerations in the Treatment of Schizophrenia and Psychosis

Presented by: Ann M. Hamer, PharmD, BCPPDate: 3/12/2015

Disclosures and Learning Objectives

• Learning Objectives– Be able to discuss first-line treatment

recommendations for schizophrenia– Be able to discuss benefits and risks of

typical and atypical antipsychotics– Be able to identify differences between

available atypical antipsychotics

Disclosures: Dr. Ann Hamer has nothing to disclose.

Use of Antipsychotics in Primary Care

Results from a UK study:• 47,724 individuals prescribed an AP

• 13,941 received traditional AP

• 27,966 received atypical AP

Rates of prescribing were higher among:• Females

• Older people (80+)

• Those from the most deprived areas

BMJ Open 2014;4:e006135. doi:10.1136/bmjopen-2014-006135

Use of Antipsychotics in Primary Care

Diagnoses:• Less than 50% of traditional AP users had a diagnosis of

psychosis/bipolar disorder

• For AAP users, the numbers ranged from 4824 (36%) for quetiapine to 7094 (62%) for olanzapine had a diagnosis of psychosis/bipolar disorder.

In patients without psychosis/bipolar disorder, common diagnoses included anxiety, depression, dementia, sleep and personality disorders.

BMJ Open 2014;4:e006135. doi:10.1136/bmjopen-2014-006135

Schizophrenia: 6 Diagnostic Clusters

http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providers-am-j-m-2012.pdf

Role of Antipsychotic Medications

Choosing an Antipsychotic

The choice of antipsychotic medication should be made by the patient and provider together. Provide information and discuss the likely benefits and possible side effects of each drug, including:

• metabolic (including weight gain and diabetes)

• extrapyramidal (including akathisia, dyskinesia and dystonia)

• cardiovascular (including prolonging the QT interval)

• hormonal (including increasing plasma prolactin)

• other (including unpleasant subjective experiences)

www.nice.org.uk

Traditional Antipsychotics

Generic Brand

Chlorpromazine Thorazine

Thioridazine Mellaril

Mesoridazine Serentil

Loxapine Loxitane

Molindone Moban

Perphenazine Trilafon

Thiothixene Navane

Trifluoperazine Stelazine

Haloperidol Haldol

Fluphenazine Prolixin

Droperidol Inapsine

Prochlorperazine Compazine

Atypical Antipsychotics

Generic Brand

Aripiprazole Abilify

Asenapine Saphris

Clozapine Clozaril

Iloperidone Fanapt

Lurasidone Latuda

Olanzapine Zyprexa

Paliperidone Invega

Quetiapine Seroquel

Risperidone Risperdal

Ziprasidone Geodon

Receptor Binding Profiles of Antipsychotics

Traditional Atypical

Effects from Receptor Blockade

Treatment Selection

CATIE

• Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)

• Compared rates of all-cause discontinuation in 1432 patients treated with either an SGA (olanzapine, quetiapine, risperidone, or ziprasidone) or the FGA perphenazine.

• Olanzapine showed a longer time to discontinuation for any reason compared with the other antipsychotics (9.2 months for olanzapine vs 3.5-5.6 months for the others).

• This difference was not significant when compared with perphenazine alone.

• Perphenazine showed effectiveness comparable to that of the other SGAs used in the study.

Treatment Selection

CATIE

• Patients with schizophrenia treated with olanzapine experienced higher rates of clinically significant weight gain (≥7% of body weight) compared with the other antipsychotics (30% with olanzapine vs 7% with ziprasidone, 12% with perphenazine, 14% with risperidone, and 16% with quetiapine; P <.001) and had greater increases in HbA1C, total cholesterol, and triglycerides.

• Other adverse effects seen were generally consistent with those observed in clinical practice. Risperidone was associated with the greatest increase in prolactin (P <.001) and perphenazine had the highest rate of discontinuation due to EPS, although there were no significant differences in the rates of EPS between the different treatment groups.

Treatment Selection

CUtLASS

• European Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1).

• Examined improvement in quality of life as measured by the Quality of Life Scale (QLS) in 185 patients who were treated over a period of 1 year with either an FGA or an SGA.

• No significant difference was observed in the primary outcome (QLS) in either treatment arm, nor in any of the secondary outcomes, including symptom improvement, treatment adherence, attitudes toward medication, or extrapyramidal side effects.

Treatment Selection

EUFEST

• European First Episode Schizophrenia Trial (EUFEST)

• Examined 498 first episode patients over 1 year of randomized treatment with haloperidol, amisulpride, olanzapine, quetiapine, or ziprasidone.

• More patients discontinued haloperidol for any reason than the other antipsychotics (72% vs 40% for amisulpride, 33% for olanzapine, 53% for quetiapine, and 45% for ziprasidone; P <.001).

• There were no differences in symptom improvement or rates of hospital admission between the treatment groups.

• Patients treated with haloperidol experienced the most EPSs, and patients treated with olanzapine experienced the most weight gain.

Treatment Selection

CAFE

• Comparison of Atypicals for First Episode Schizophrenia (CAFE)

• Patients treated with either olanzapine, quetiapine, or risperidone had similar all-cause discontinuation rates at 1 year, no differences in overall symptom severity measures, and side effects similar to those seen in other trials.

Treatment Selection

Treatment Selection

Considerations:

• patient preference

• prior treatment response (or first degree relative)

• side effect profile

• medical history and risk factors

• adherence history

Treatment Selection

• In patients with schizophrenia experiencing their FEP, the SGAs are generally preferred for initial treatment.

• These patients are also particularly vulnerable to the adverse effects of antipsychotic medications, such as weight gain and EPS, and are generally more responsive to lower doses than patients who have experienced multiple episodes.

• Therefore, the lowest possible dose, typically about half the dose used in patients with chronic schizophrenia, should generally be used in these patients

Risperidone (Risperdal)

• The pharmacokinetics of the oral formulations are all equivalent, with rapid absorption and 20-hour elimination half life.

• Risperidone has little activity at muscarinic receptors and no anticholinergic effects.

• Drug-drug interactions are infrequent, but its serum levels are modestly decreased by inducers of the cytochrome P450 system, such as carbamazepine, and are increased by inhibitors such as fluoxetine and ketoconazole.

• Although it is not necessary to adjust the dose of risperidone whenever such a medication is added or withdrawn, clinicians should be aware of the potential for a change in serum level with the simultaneous use of these medications.


• The drug is typically dosed once daily.

• Starting doses for adults are 1 to 2 mg/day, and maintenance doses are typically in the 2 to 6 mg/day range, with 4 mg/day the average dose in the community. Doses above 6 to 8 mg/day are associated with higher rates of extrapyramidal symptoms.

• Titration should be done over the course of several days in order to minimize the emergence of extrapyramidal symptoms or akathisia.

• For the elderly population, doses typically start at 0.25 to 0.5 mg/day, average about 1 mg/day, and do not usually exceed 2 mg/day.


• Hepatic impairment results in increased serum levels and activity due to a 35 percent greater free fraction of the drug. Renal dysfunction reduces elimination of risperidone by 60%. Both conditions may require dose reductions.

• The usual dose of the oral solution and rapid-disintegrating formulation of risperidone for acute agitation is 1 to 2 mg every 30 minutes to two hours, to a maximum of 4 mg/day. The primary side effects of risperidone are mild sedation, hypotension, akathisia, prolactin elevation, and weight gain.

• Preliminary data suggest that risperidone may be associated with an increased incidence of pituitary adenomas compared to other antipsychotic agents. At higher doses, the drug is associated with a somewhat greater risk of extrapyramidal symptoms than other atypicals.

Olanzapine (Zyprexa)

• Generic olanzapine is available in standard tablets and orally disintegrating tablets

• Proprietary olanzapine is available in coated tablets, rapid-disintegrating tablets, short-acting injectable solution, and a long-acting injectable (depot) formulation, olanzapine pamoate.

• The oral formulations have gradual absorption and 30-hour elimination half life. The drug is usually given once a day.

• Olanzapine has significant activity at histaminic and muscarinic receptors.

• Drug-drug interactions are not prominent with olanzapine, but olanzapine is dependent upon CYP 1A2 for clearance.


• Coadministration of medications that strongly inhibit or induce CYP 1A2 can alter olanzapine levels. Olanzapine levels are decreased somewhat by cigarette smoking. This may be an issue when patients are stabilized on a specific dose of olanzapine while on a nonsmoking hospital unit and then resume smoking upon discharge, reducing serum levels of the drug.

• For adults, the starting dose of olanzapine is usually 5 to 10 mg/day.

• Maintenance doses of 15 to 30 mg/day are common and doses up to 40 mg/day can be useful in selected cases, though exceeding the manufacturer's recommended maximum of 20 mg/day.


• Doses for most non-treatment-refractory patients should not exceed 20 mg/day, as data have suggested equivalent efficacy of 10, 20 and 40 mg/day, but worsened tolerability at doses of 40 mg compared to 10 mg/day.

• The average dose for stable schizophrenia patients participating in an 18-month effectiveness study was about 20 mg daily [12]. For the elderly population, doses begin at 1.25 to 2.5 mg/day, average 5 mg/day, and may go up to 10 mg/day [13].

• The usual dose of oral olanzapine for acute agitation is 5 to 10 mg, repeated every 30 minutes to two hours to a maximum of 20 mg/day. There is no significant absorption of the rapid-disintegrating formulation of olanzapine across the oral mucosa.


• An intramuscular injectable form of the medication is available for the treatment of acute agitation. The recommended dose is 10 mg, repeated at intervals of two to four hours, up to a total of 30 mg/day.

• The most common side effects of olanzapine are weight gain, sedation, akathisia, hypotension, dry mouth, and constipation. Weight gain, hyperglycemia, and hyperlipidemia are greater with olanzapine than with other SGAs, and are particularly prominent in adolescents. The FDA has recommended that olanzapine be used with caution when treating this age group.

• No specific recommendations have been made regarding dosing changes for patients with renal or hepatic impairment.

Quetiapine (Seroquel)

• Quetiapine is available as immediate or extended release tablets.

• The immediate release formulation is available as a generic

• It is rapidly absorbed and cleared with a six to seven hour elimination half life.

• The extended release tablets give a peak concentration at six hours, followed by a seven-hour clearance half life.

• For both formulations, an active metabolite, norquetiapine, represents about half of the active drug in circulation and has a 12 hour elimination half time.


• Although the manufacturer recommends twice daily dosing for the immediate release tablets, both formulations are commonly used in the community on a once daily schedule without substantial problems.

• The drug has strong histaminic, cholinergic, and alpha-1-adrenergic binding, responsible for relatively high levels of sedation, anticholinergic effects, and orthostatic hypotension.

• Drug-drug interactions are not common with quetiapine, but serum levels are affected by induction or inhibition of the cytochrome P450 system by drugs including carbamazepine, fluoxetine, and ketoconazole. In practice, dose adjustments with these medications are not commonly required.


• The usual adult starting dose of immediate release quetiapine is 25 mg twice daily, followed by a relatively slow titration at the rate of 25 to 50 mg/day to a total dose of 300 to 600 mg/day.

• The titration of the drug may be even slower if the patient develops hypotension or excessive sedation.

• The manufacturer suggests a starting dose of quetiapine extended release to be up to 300 mg/day, with titration to 600 mg/day by Day 2, and 800 mg/day by Day 3.

• Final doses of the two formulations are equivalent. The manufacturer recommends a maximum dose of 800 mg/day, but doses as high as 1200 mg/day have been used and appear to be well tolerated.


• For the elderly population, doses usually start at 12.5 to 25 mg twice daily and are titrated to doses substantially lower than for younger adults.

• The drug does not require renal function for clearance, but patients with hepatic impairment may experience an increase in serum levels necessitating dose adjustment.

• The main side effects of quetiapine are sedation, orthostatic hypotension, akathisia, dry mouth, and weight gain.

• Sedation is most often noted early in treatment and seems more closely related to treatment duration than to dose, so patients may find their sedation improving after several days, even if the medication dose is still being titrated.


• Quetiapine causes QT prolongation in combination with other factors prolonging the QT interval; use of the drug should be avoided in conjunction with other medications that prolong the QT interval or patient risk factors for QT prolongation.

• Quetiapine appears to cause less extrapyramidal symptoms than other antipsychotics, with the exception of clozapine or iloperidone, and is less likely to increase prolactin levels.

Ziprasidone (Geodon)

• Ziprasidone is available in capsules and as a sterile solution for intramuscular injection.

• A generic preparation of the oral medication is also available.

• The oral formulation is absorbed slowly and cleared with an elimination half life of seven hours.

• The drug is approved for twice daily dosing, but once daily administration is commonly used in the community without apparent problem.

• Bioavailability in the absence of food is inconsistent. It has been estimated to be 50 percent lower than when ziprasidone is taken with the recommended ≥500 calorie meal.


• The drug has low histaminic and no appreciable muscarinic activity.

• Drug-drug interactions are of two types. • First, serum levels respond modestly to concurrent treatment with inhibitors and

inducers of the cytochrome P450 system, such as carbamazepine, fluoxetine, and ketoconazole .

• Second, the drug causes mild QT prolongation, not usually clinically significant in isolation, but use of the drug with other medications that prolong the QT interval is contraindicated.

• The recommended adult starting dose of oral ziprasidone is 20 to 40 mg twice daily, followed by titration over two to five days to the manufacturer's highest recommended dose of 80 mg twice daily.


• In practice, doses up to 240 mg/day are common and well tolerated. A dose of at least 120 mg/day is believed to be necessary to achieve sufficient dopamine D2 blockade for therapeutic efficacy.

• The oral drug is not affected by renal impairment, but a component of the intramuscular preparation is cleared through the kidney, leading to the manufacturer’s recommendation that it be used with caution in that population.

• Hepatic impairment causes mild increases in serum levels and clearance time that may require dose adjustment.

• Injectable ziprasidone has been FDA-approved for acute agitation. It is recommended in 20 mg doses every four hours or 10 mg doses every two hours to a maximum of 40 mg/day.


• Side effects include mild sedation early in treatment, nausea, weakness, nasal congestion, and mild QT prolongation.

• Ziprasidone appears to cause less weight gain, hyperglycemia, and hyperlipidemia than other second-generation antipsychotics.

• There are rare reports of severe hypersensitivity, including drug reaction with eosinophilia and systemic symptoms (DRESS), a potentially life-threatening reaction that begins as a rash.

• Despite the report of QT prolongation in clinical trials, this has not emerged as a clinically significant problem in post-marketing surveillance.

Aripiprazole (Abilify)

• Aripiprazole is unique among the SGA in its pharmacology and pharmacokinetics, but is similar in clinical efficacy.

• Aripiprazole acts as a partial agonist at dopamine D2 receptors, activating the receptor but eliciting a reduced response compared to the natural neurotransmitter. The drug is also a partial agonist at serotonin 5HT1a receptors, but an antagonist at 5HT2a, H1, and alpha-1-adrenergic receptors.

• Aripiprazole is available as a standard and orally disintegrating tablet, as a sterile solution for intramuscular injection, and as a long-acting intramuscular formulation for monthly administration.


• Oral aripiprazole is absorbed slowly and cleared with a 75-hour elimination half life.

• The injectable preparation shows significant clinical efficacy within 45 minutes, and reaches peak serum levels in one to three hours. Its long elimination half life has the advantage of creating relatively steady serum levels throughout the day, even with an occasional missed dose, but may slow the impact of a dose adjustment or transition to a different medication.

• Drug-drug interactions have not commonly been reported with aripiprazole, but it is metabolized via the cytochrome P450 system. A two-fold increase in dosing in the presence of metabolic inducers, and a 50%reduction in dose with cytochrome P450 inhibitors, such as fluoxetine, quinidine, or ketoconazole.


• Clinical trials of adults with schizophrenia started the drug at 10 to 15 mg daily, administered in a single dose. This dose proved to be adequate for many patients, but doses up to 30 mg daily have been approved. The manufacturer's clinical trials for bipolar disorder started patients at 30 mg daily and lowered the dose only for side effects.

• The manufacturer does not recommend dose adjustment for patients with hepatic or renal insufficiency .

• The most common side effects of aripiprazole are headache, nausea, vomiting, insomnia, tremor, and constipation. Weight gain has been minimal in short and long-term trials. The drug has a lower risk of extrapyramidal symptoms, increases in lipid or prolactin levels, and sedation, compared to other atypicals in a small number of comparative trials.


• Aripiprazole may be a cause of QT prolongation, based on a case report. Avoidance of aripiprazole is suggested in patients with congenital prolonged QT syndrome.

• Rates of akathisia are substantially higher for patients receiving aripiprazole for major depressive disorder and bipolar disorder compared to patients receiving aripiprazole for schizophrenia.

• The use of aripiprazole in conjunction with other antipsychotic medications is not generally recommended, because the combination of a partial agonist with an antagonist leads to unpredictable levels of receptor activity.

• Switching patients to aripiprazole should be done slowly because of aripiprazole’s exceptionally high affinity for dopamine D2 receptors in the face of its partial agonism at this receptor.

Paliperidone (Invega)

• Paliperidone is available in an osmotic delivery capsule to be swallowed whole, not crushed or chewed, and requires several days to achieve steady-state kinetics. It is also available as a LAI.

• The bioavailability of paliperidone is increased by about 50% when taken with a high calorie meal.

• Once absorbed, paliperidone has a 23-hour elimination half time.

• About 60% is excreted unchanged in the urine, with the remainder metabolized by cytochrome P450 isoenzymes. The high level of urinary excretion of unmetabolized paliperidone makes it unique among antipsychotics in not requiring intact hepatic function for clearance.

• Thus, in contrast to other antipsychotics, paliperidone requires no dose adjustment with hepatic impairment. Significant drug-drug interactions have not been identified.

Paliperidone (Invega)

• For non-elderly adults, paliperidone is typically started at 6 mg once daily and, if needed, can be increased in 3 mg/day increments at five day intervals. For elderly patients, or those with renal impairment, 3 mg per day may be used.

• The most common side effects are extrapyramidal symptoms, including parkinsonism, dystonia, dyskinesia, and akathisia. Other side effects include prolactin elevation and tachycardia.

• Paliperidone has a mild to moderate risk of weight gain; comparative trials found that the increase in weight was less than that caused by olanzapine.

• Paliperidone can prolong the QT interval, and should not be used with other drugs with similar effects.

• These side effects are dose-dependent, more prominent at doses above 6 mg per day.

Iloperidone (Fanapt)

• Iloperidone has antagonist activity at dopamine D2 and serotonin 5HT2a receptors, similar to other SGAs.

• Short-term studies of varying doses found optimal efficacy at 12 to 24 mg daily.

• Because of the propensity for orthostatic hypotension, dosing should be initiated at 1 mg BID with gradual titration, reaching 6 mg BID by Day 4.

• The elimination half life is 18 to 33 hours.

• Plasma levels increase with CYP 2D6 and CYP3A4 inhibitors, leading to the recommendation that dose be reduced by 50% in the presence of medications such as fluoxetine.

Iloperidone (Fanapt)

• Side effects include dizziness, orthostatic hypotension, tachycardia, weight gain, dry mouth, and sedation.

• Compared to other antipsychotics, iloperidone caused relatively few extrapyramidal symptoms, an intermediate degree of weight gain, and above average QT prolongation, though not to a degree that cardiac monitoring or avoidance of other drugs that prolong the QT interval has been recommended.

• The drug is not affected by renal insufficiency or mild hepatic impairment. Moderate hepatic impairment is associated with increased levels of drug metabolites, suggesting a lower dose may be needed. The manufacturer recommends against its use in patients with severe hepatic impairment, which has not been studied.

Asenapine (Saphris)

• Asenapine has a broad range of receptor activities, including antagonism of dopamine, serotonin, adrenergic, and histaminic receptors, but minimal muscarinic activity.

• It is rapidly absorbed and has a 24-hour elimination clearance half-time.

• Its major route of metabolism is through CYP 1A2 and glucuronidation, with no major active metabolites.

• Drug interactions tend to be mild and generally do not require an adjustment in dose.

• Asenapine is unique among antipsychotics in its sublingual administration, necessitated by its poor GI absorption.

Asenapine (Saphris)

• Both the starting and maintenance doses of the medication are 5 to 10 mg BID. The maximum recommended dose is 10 mg BID.

• The drug dissolves and is absorbed quickly, but the patient should not eat or drink within 10 minutes of administration.

• The most common side effects are sedation, weight gain, dizziness, EPS (especially akathisia), and oral hypoesthesia. Weight gain is intermediate among the SGAs.

• QT prolongation was limited to 2 to 5 milliseconds at doses as high as 20 mg BID, a level not expected to be of clinical significance.

• Prolactin levels do not differ from those seen with placebo.

Asenapine (Saphris)

• Rare reports of serious hypersensitivity reactions, including anaphylaxis, caused the issuance of a safety communication and product warnings by the FDA. Eight of 52 cases described in the communication occurred after only one dose of asenapine and 19 prompted emergency intervention or hospitalization.

• Systematic studies of asenapine in geriatric patients have not been reported, but caution is recommended early in treatment because of a mildly elevated risk of orthostatic hypotension and syncope.

• No data on use in children or adolescents have been reported.

• Severe hepatic dysfunction caused a 7-fold increase in serum levels of asenapine, leading the manufacturer to recommend against its use in that population.

• Renal impairment has no impact on drug levels or clearance.

Lurasidone (Latuda)

• Lurasidone shows high affinity for dopamine D2 and serotonin 5-HT2A receptors, as is characteristic of other second-generation antipsychotics.

• It also has potent antagonism at 5-HT7 receptors of unclear significance.

• It has moderate affinity for 5-HT1A and alpha2 adrenergic receptors, and minimal binding at alpha1 adrenergic, histamine H1, and muscarinic M1 receptors.

• Absorption of the drug occurs over one to three hours, followed by a serum half-life of 18 to 37 hours.

Lurasidone (Latuda)

• Bioavailability increases two to three-fold when the drug is taken with a 350 calorie meal, but is not dependent on the fat content of the meal.

• Its major route of metabolism is via CYP3A4, which produces both active and inactive metabolites. Medications that are strong inhibitors or inducers of CYP3A4 substantially alter serum levels of lurasidone and their coadministration is contraindicated.

• Dose reduction is recommended in the presence of moderate CYP3A4 inhibitors, such as diltiazem.

• The drug is supplied as 20, 40, 80 and 120 mg tablets intended for once daily dosing with a meal.

Lurasidone (Latuda)

• The suggested initial dose is 40 mg daily for most patients; dose titration was not employed in the efficacy studies. The maximum daily dose of 160 mg received approval based upon results of a 6 week efficacy trial. However, results of an unpublished trial that included 120 mg daily showed no benefit over and more adverse effects than 80 mg per day.

• Dose reduction is needed in the setting of moderate or severe renal or hepatic insufficiency.

• Common side effects include somnolence, akathisia, nausea, and parkinsonism. Less commonly reported adverse effects include acute dystonia, agitation, anxiety, and dizziness.

Lurasidone (Latuda)

• Weight gain was mild in short-term studies and was not observed in open-label extension studies of 24 to 52 weeks. Fasting glucose is more likely to be elevated with lurasidone (10 to 14% of patients compared to 8.6% on placebo), but lipid levels show little difference compared to placebo treatment.

• Prolactin elevation occurs in 8.3% of women and 1.9% of men on the drug, compared to 0.6 to 1% of those on placebo.

• The mean change in QT interval was -1.2 milliseconds in the initial clinical trial and no other ECG abnormalities were reported subsequently

• The drug has not been tested in children or adolescents.

• Its pharmacokinetics appear unchanged in the elderly population, but no studies of its efficacy or safety in that group are available

Role of Clozapine

• For patients who have failed treatment with adequately dosed trials (generally 4-6 weeks) of more than 1 antipsychotic medication, the most evidence-based treatment strategy is to initiate clozapine.

• Clozapine may be instituted earlier in the treatment of patients with schizophrenia who have persistent suicidality, aggression, or hostility, as these patient populations in particular seem to benefit from clozapine (as in 1 meta-analysis which demonstrated a 3-fold reduction in suicidal behaviors compared with other antipsychotics).

• The high risk of weight gain and other metabolic effects, and the risk for agranulocytosis, myocarditis, orthostatic hypotension, seizures, and other adverse effects limit the use of clozapine, but many experts agree that the agent is likely underutilized.

Schizophr Res. 2005;73(2-3): 139-145.

Antipsychotic Comparison

Adobe Acrobat Document

Antipsychotic Comparison

Drug Usual Dosage Cost of 30 day supply

First Generation Antipsychotics

Chlorpromazine 200mg BID $140

Fluphenazine 10mg QD $11

Haloperidol 5mg BID $14

Loxapine 60 – 100mg in 2-4 divided doses

$129

Perphenazine 24mg/day in 2-3 divided doses

$139

Thioridazine 100-200mg BID $24

Thiothixene 10mg BID $26

Trifluoperazine 10mg BID $57

Cost Comparison


Second Generation Antipsychotics

Abilify 10-30mgQD $669

Abilify Discmelt 10mg QD $797

Saphris (sl tab) 5mg BID $690

Clozapine 100-300mg TID $218

Clozapine ODT 100-300mg TID $589

Fazaclo 100-300mg TID $783

Fanapt 6-12mg BID $697

Latuda 40-160mg QD $553

Olanzapine 10-20mg QD $23

Olanzapine ODT 10-20mg QD $340

Cost Comparison


Second Generation Antipsychotics

Invega 6-12mg QD $604

Quetiapine 300-800mg in 2-3 divided doses

$72

Seroquel XR 400-800mg QD $585

Risperidone 4-8mg QD $42

Risperidone ODT 4-8mg QD $362

Ziprasidone 60-80mg BID $292

Cost Comparison

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pharmacologic considerations in the treatment of schizophrenia and psychosis presented by: ann m....

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