56 - Antipsychotics

Antipsychotics

Drug treatment of psychiatric symptoms in the context of other conditions CHAPTER 10 Antipsychotics Table 10.17 summarises the use of antipsychotics in bariatric surgery. Table 10.17  Antipsychotics in bariatric surgery. Medication Specific evidence and considerations Aripiprazole20 One case report of subtherapeutic levels post RYGB using aripiprazole tablets that became therapeutic on switching to suspension. Available as an LAI. Asenapine21 Primarily absorbed via oral mucosa. Problems after bariatric surgery are not expected One case report of successful use after RYGB. Brexpiprazole No data available on absorption after bariatric surgery Cariprazine No data available on absorption after bariatric surgery The absorption of oral contraceptives may be reduced after bariatric surgery.22 Therefore, to ensure highly effective contraception for women prescribed cariprazine, non-­oral methods are recommended. Clozapine23–­25 Two case reports of relapse after RYGB26 Take drug plasma levels before surgery and regularly monitor after. Constipation is common after surgery; the manufacturer recommends close monitoring and active treatment. Check smoking status (quitting before surgery is encouraged); adjust dose accordingly. Haloperidol27 Single case report suggests levels after RYGB are similar to those generally reported in the literature. Iloperidone No data available on absorption after bariatric surgery Lumateperone No data available on absorption after bariatric surgery Lurasidone Risk of reduced absorption with reduced or inconsistent calorific intake perioperatively. Must be taken with food for absorption (350kcal). One case report of relapse following GRDS. Significant reduction in bioavailability and peak serum concentration.28 One case report post-­RYGB showed significant reduction in plasma concentration with no worsening of psychotic symptoms.29 Consider switching to alternatives before surgery. Olanzapine One report of reduction in dose-­adjusted drug concentration following bariatric surgery30 One case report following RYGB of continued efficacy with no dose adjustment required31 In an in vitro model olanzapine was found to have a significantly lower dissolution after RYGB which may lead to decreased bioavailability.32 Follow general recommendations. Quetiapine7,30,33 Dose-­adjusted concentrations decreased following bariatric surgery. Switching to immediate-­release preparation and dividing doses above 300mg has been recommended. Risperidone34 Consider switching stable patients to an equivalent dose of paliperidone LAI. Risperidone LAI has been used successfully when oral treatment was not tolerated after bariatric surgery. Ziprasidone35 Must be taken with food for absorption (500kcal); risk of reduced absorption with reduced/inconsistent calorific intake perioperatively. Consider switching to alternatives before surgery. (Continued )