Risperidone Quetiapine

First, initiate and/or optimize mood-stabilizing medication lithium3 or valproate3 or atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone)... 

Conventional antipsychotic drugs such as chlorpromazine and haloperidol have long been used in the treatment of acute mania. More recently, atypical antipsychotic drugs including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasi-done have been approved for the treatment of bipolar mania or mixed mood episodes as monotherapy or in combination with mood-stabilizing drugs.25 Aripiprazole and olanzapine are also approved for maintenance therapy. The combination of olanzapine and fluoxetine is approved for treatment of bipolar depression. Quetiapine is approved for treatment of... 

Stroup, T. S., Lieberman, J. A., McEvoy, J. P. et al. (2006). Effectiveness of olanzapine, quetiapine, risperidone, and ziprasidone in patients with chronic schizophrenia following discontinuation of a previous atypical antipsychotic. Am. J. Psychiatry, 163, 611-22. 

Current antipsychotics used to treat patients are divided into two classes the first generation antipsychotics (FGA) or typicals (e.g., chlorproma-zine, haloperidol, thioridazine, and loxapine) and the second generation antipsychotics (SGA) or atypicals (i.e., clozapine, olanzapine, quetiapine, risperidone, aripiprazole, ziprasidone, and asenapine). 

First, optimize current mood stabilizer or initiate mood-stabilizing medication lithium,0 valproate,0 or carba-mazepine0 Consider adding a benzodiazepine (lorazepam or clonazepam) for short-term adjunctive treatment of agitation or insomnia if needed Alternative medication treatment options carbam-azepine0 if patient does not respond or tolerate, consider atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone) or oxcarbazepine. 

Ari pi prazole, olanzapine, quetiapine, risperidone, and ziprasidone are effective as monotherapy or as add-on therapy to lithium or valproate for acute mania. Prophylactic use of antipsychotics can be needed for some patients with recurrent mania or mixed states, but the risks versus benefits must be weighed in view of long-term side effects (e.g., obesity, type 2 diabetes, hyperlipidemia, hyperprolactinemia, cardiac disease, and tardive dyskinesia). 

Aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone are FDA approved for the treatment of acute manic episodes in bipolar I disorder. 

The Clinical Antipsychotic Trials of Intervention Effectiveness study showed that olanzapine, compared with quetiapine, risperidone, ziprasi-... 

CNS drugs Quetiapine Risperidone Olanzapine Chlorpromazine Eluphenazine Clozapine... 

Choice of a Mood Stabilizer. With the advance of atypical antipsychotics and an ever-expanding list of anticonvulsants, the number of medications reported to treat acute mania and hypomania continues to grow. In fact, all of the atypical antipsychotics, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole have FDA approval for the treatment of acute mania. Long-term protection against future episodes of illness has also been demonstrated with several of these agents, which can influence the choice of initial therapy. 

CypP450 3A3 /4 Antidepressants tricyclics, nefazodone, fluoxetine, fluvoxamine, citalopram, mirtazepine, venlafaxine Antipsychotics chlorpromazine, clozapine, pimozide, quetiapine, risperidone... 

Clozapine, quetiapine, risperidone, sertindole, ziprasidone Antidepressants... 

The availability of the more recent, so-called atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone see Table 1.2) makes it prudent... 

Another group of mood-stabilizing drugs that are also anticonvulsant agents have become more widely used than lithium. These include carbamazepine and valproic acid for the treatment of acute mania and for prevention of its recurrence. Lamotrigine is approved for prevention of recurrence. Gabapentin, oxcarbazepine, and topiramate are sometimes used to treat bipolar disorder but are not approved by FDA for this indication. Aripiprazole, chlorpromazine, olanzapine, quetiapine, risperidone, and ziprasidone are approved by FDA for the treatment of manic phase of bipolar disorder. Olanzapine plus fluoxetine in combination and quetiapine are approved for the treatment of bipolar depression. 

Until recently, lithium carbonate was the universally preferred treatment for bipolar disorder, especially in the manic phase. With the approval of valproate, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone for this indication, a smaller percentage of bipolar patients now receive lithium. This trend is reinforced by the slow onset of action of lithium, which has often been supplemented with concurrent use of antipsychotic drugs or potent benzodiazepines in severely manic patients. The overall success rate for achieving remission from the manic phase of bipolar disorder can be as high as 80% but lower among patients who require hospitalization. A similar situation applies to maintenance treatment, which is about 60% effective overall but less in severely ill patients. These considerations have led to increased use of combined treatment in severe cases. After mania is controlled, the antipsychotic drug may be stopped and benzodiazepines and lithium continued as maintenance therapy. 

Risperidone (1) has high affinity for D2, 5-HT2c and tti receptors and a very high affinity for the 5-HT2a receptor. Risperidone is the most likely of the atypical antipsychotics to cause prolactin increases, but has a lower weight gain liability than olanzapine or quetiapine. Risperidone has a relatively narrow therapeutic window since doses above 6 mg/day cause EPS in a dose-dependent manner. 

Several studies have shown a relation between neuroleptic drug dosages, extrapyramidal adverse effects, and the degree of dopamine D2 receptor occupancy (SEDA-18, 48) (181,182). Atypical neuroleptic drugs, such as olanzapine, quetiapine, risperidone, and sertindole, which have lower affinities for D2 receptors, cause fewer extrapyramidal effects than typical neuroleptic drugs (183,185,186). However, there are reports of extrapyramidal effects associated with these atypical neuroleptic drugs (187-189). 

Leucht S, Pitschel-Walz G, Abraham D, Kissling W. Efficacy and extrapyramidal side-effects of the new anti-psychotics olanzapine, quetiapine, risperidone, and sertin-dole compared to conventional antipsychotics and placebo. A meta-analysis of randomized controlled trials. Schizophr Res 1999 35(1) 51—68. 

Antidepressants mirtazapine, nefazodone, sertraline Neuroleptics thioridazine, haloperidol, clozapine, quetiapine, risperidone, sertindole, ziprasidone Mood stabilizers carbamazepine, gabapentin, lamotrigine... 

Higher affinity for limbic D2 and D2-like receptors than for striatal D2 receptors clozapine, sertindole, amisulpiride, quetiapine risperidone (limbic selectivity is lost at higher doses for all, except possibly clozapine). 

Loose binding to striatal D2-like receptors clozapine, quetiapine, risperidone, sertindole, olanzapine (but may be a pharmacokinetic rather than pharmacodynamic effect). 

Currently, amisulpiride, aripiprazole, olanzapine, quetiapine, risperidone, sertindole (with restrictions) and zotepine are licensed in the UK. 

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