Pimavanserin ($ Nuplazid)
Second generation antipsychotic (serotonin receptor antagonist (5-HT2A))
- Psychosis in Parkinsons
- Failed in trials of depression and schizophrenia (negative symptoms)
Features
Dosing
Start 10mg 1 qd x7days then 2 qd.
INTERACTIONS: Metabolized by 3A4. Raise 3-5x with carbamazepine. Lower 2x with nefazodone and grapefruit juice. May need to lower a little with non-pram SSRIs (fluoxetine, fluvoxamine, paroxetine, sertraline ≥ 150 mg/day).
Management
Lower risk of general antipsychotic side effects because dose not block D2 much.
Similar to lumateperone in its profile. Approved for parkinson’s psychosis. Low D2 effects mainly works through serotonin.
TOLERABILITY: Weight gain, sedation, edema.
RISKS: QTc prolongation (lacks other major risks of antipsychotics).
EMR Text
Parkinson’s psychosis
Pimavenserin use based on FDA approval in psychosis due to Parkinson’s disease.
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.
Psychosis (off-label)
Pimavenserin used off-label for psychosis based on uncontrolled trials.
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.