Users

Atypical Antipsychotic Monitoring

Affected Drug

• N05AX08 Risperidone
• N05AH03 Olanzapine
• N05AH04 Quetiapine
• N05AH02 Clozapine

Baseline

Baseline: ECG, wt, BP, BMI, FBG, HbA1c, AST, ALT, lipid profile

Follow-up

Follow-up: ** see clozapine monitoring on following page** Q1mo: prolactin, wt, BMI, waist circumference x 3 months Q3mo: HbA1c, FBG once at 3 months, wt, BMI, waist circumference Annually: HbA1c, FBG, prolactin Q2years: Lipid profile When clinical suspicion indicates: ALT/AST, TSH (quetiapine), ECG, electrolytes Serum Levels: Generally not indicated

Important Interactions

• Drugs: other CNS depressants
  Interaction addititive effects, consult with pharmacist for specific effects

Details

Conditions	System	Monitoring		ADE	Incidence	Recommendation
		Baseline	Follow-up
	CNS	None	Physical Exam, consider CBC/CK for NMS	drowsiness, insomnia, eps	common	Consider dose timing, reduction or switching to different drug
				nms (neuroleptic malignant syndrome)	Rare/random, not dose related	D/C drug, supportive care
	Cardiac	ECG, BP, family hx	ECG periodically (perhaps annual)	orthostatic hypotension, ↑ qtc		If QTc>450 do not use thioridazine, pimozide, ziprazidone
	Renal	none	Electrolytes prn for symptoms	adh disturbances→pip (polydipsia, intermittent hyponatremia, psychosis	5-20%	Fluid restriction, replace electrolytes, consider drug therapy (e.g. demeclocycline)
	Hepatic	AST/ALT	If clinically indicated	2-3x↑ast/alt, fatty liver	5-30%	Dose related, ↓dose or consider switching
	heme-Clozapine only	CBC	WBC/granulocyte weekly (after 6 mo = biweekly if normal)	falling wbc count;		GREEN: WBC>3.5 or ANC >2.0 YELLOW: WBC 2-3.5 or ANC 1.5-2.0 → repeat twice weekly until normal RED: WBC<2.0 or ANC<1.5 → D/C and monitor x 4 weeks → re-challenge not recommended
	endocrine	HbA1c, FBG, lipid profile	HbA1c, FBG at 3 months then annually; lipid profile q 2 years	dm, ↑ cholesterol		Dietary/lifestyle changes, consider switching drug
	endocrine	none	TSH prn for quetiapine	hypothyroidism (quetiapine)		Supplement thyroid or switch drug
	endocrine	none	Prolactin Q1month x 3 months then yearly	sexual side effects, ↓libido, ed, menstrual irregularities, galactorrhea		Dose related, consider ↓ dose, risperidone causes most hyperprolactinemia
	General	Weight, BMI, waist circumference	q1 month until 3 months on full dose then q3 months	wt gain	50% will gain 20% over base weight	Dietary changes, wt gain not dose related

References

• Bezchlibinyk-Butler, KZ, editor. Clinical Handbook of psychotropic drugs, 17th edition. Hogrefe and Huber Publishers
• 2007. Gray J, editor. Therapeutic Choices, 5th edition. Ottawa: The Canadian Pharmacists Association; 2007.
• Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. - Newcomer JW - CNS Drugs - 01-JAN-2005; 19 Suppl 1: 1-93