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reduced The dose can be repeated every 3 4 hours; when the patient is less symptomatic, oral doses can replace parenteral administration in most cases In the elderly, both atypical (eg, risperidone 025 mg 05 mg daily or olanzapine 125 mg daily) and conventional (eg haloperidol 0,5 mg daily or perphenazine 2 mg daily) antipsychotics, often used effectively in small doses for behavioral control, have been linked to premature death in some cases Various factors play a role in the absorption of oral medications Of particular importance are previous gastrointestinal surgery and concomitant administration of other drugs There are racial differences in metabolizing the neuroleptic drugs eg, many Asians require only about half the usual dosage Bioavailability is influenced by other factors such as smoking or hepatic microsomal enzyme stimulation with alcohol or barbiturates and enzyme-altering drugs such as carbamazepine or methylphenidate Neuroleptic plasma drug level determinations are not currently of major clinical assistance Divided daily doses are not necessary after a maintenance dose has been established, and most patients can then be maintained on a single daily dose, usually taken at bedtime This is particularly appropriate in a case where the sedative effect of the drug is desired for nighttime sleep, and undesirable sedative effects can be avoided during the day Risperidone is an exception, being given twice daily First-episode patients especially should be tapered off medications after about 6 months of stability and carefully monitored; their rate of relapse is lower than that of multiple-episode patients Psychiatric patients particularly paranoid individuals often neglect to take their medication In these cases and in nonresponders to oral medication, the enanthate and decanoate (the latter is slightly longer-lasting and has fewer extrapyramidal side effects) forms of fluphenazine or the decanoate form of haloperidol may be given by deep subcutaneous injection or intramuscularly to achieve an effect that will usually last 7 28 days A patient who cannot be depended on to take oral medication (or who overdoses on minimal provocation) will generally agree to come to the clinician s office for a shot The usual dose of the fluphenazine longacting preparations is 25 mg every 2 weeks Dosage and frequency of administration vary from about 100 mg weekly to 125 mg monthly Use the smallest effective amount as infrequently as possible A monthly injection of 25 mg of fluphenazine decanoate is equivalent to about 15 20 mg of oral fluphenazine daily Risperidone is the first atypical neuroleptic now available in a long-acting injectable form (25 50 mg intramuscularly every 2 weeks) Concomitant use of a benzodiazepine (eg, lorazepam, 2 mg orally twice daily) may permit reduction of the required dosage of oral or parenteral antipsychotic drug Intravenous haloperidol, the neuroleptic most commonly used by this route, is often used in critical care units in the management of agitated, delirious patients Intravenous haloperidol should be given no faster than 1 mg/min to reduce cardiovascular side effects, such as torsades de pointes
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may help decrease side effects More activating than sedating, aripiprazole is thought to impose a low risk of extrapyramidal symptoms, weight gain, hyperprolactinemia, and delayed QT interval None of the antipsychotics produce true physical dependency All decrease adrenergic responses Despite higher costs, atypical neuroleptics are often considered preferable to traditional antipsychotics because they are thought to be associated with reduced extrapyramidal symptoms and a lesser risk of tardive dyskinesia
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The antipsychotics are used to treat all forms of the schizophrenias as well as psychotic ideation in organic brain psychoses, delirium and dementia, drug-induced psychoses, psychotic depression, and mania They are also effective in Tourette s disorder They quickly lower the arousal (activity) level and, perhaps indirectly, gradually improve socialization and thinking The improvement rate is about 80% Patients whose behavioral symptoms worsen with use of antipsychotic drugs may have an undiagnosed organic condition such as anticholinergic toxicity Symptoms that are ameliorated by these drugs include hyperactivity, hostility, aggression, delusions, hallucinations, irritability, and poor sleep Individuals with acute psychosis and good premorbid function respond quite well The most common cause of failure in the treatment of acute psychosis is inadequate dosage, and the most common cause of relapse is noncompliance Although typical antipsychotics are efficacious in the treatment of so-called positive symptoms of schizophrenia such as hallucinations and delusions, atypical antipsychotics are thought to have efficacy in reducing both positive symptoms and negative symptoms such as withdrawal, psychomotor retardation, and poor interpersonal relationships Antidepressant drugs may be used in conjunction with neuroleptics if significant depression is present Resistant cases may require concomitant use of lithium, carbamazepine, or valproic acid The addition of a benzodiazepine drug to the neuroleptic regimen may prove helpful in treating the agitated or catatonic psychotic patient who has not responded to neuroleptics alone lorazepam, 1 2 mg orally, can produce a rapid resolution of catatonic symptoms and may allow maintenance with a lower neuroleptic dose Electroconvulsive therapy (ECT) has also been effective in treating catatonia
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