Anti-Psychotic Medications

Question 1

What is the classification of anti-pyschotic drugs? What is the difference?

Answer 1

Typical vs Atypical

Typical are more prone to cause EPSEs

Question 2

Give some examples of typical anti-psychotics

Answer 2

Phenothiazines- Trifluoperazine (high potency), chlorpromazine (low potency)
Butyrophenones- Haloperidol (high potency)
Thioxanthenes- Flupentixol, Zuclopenthixol

Question 3

What are some advantages of typical APs?

Answer 3

Side effect profiles are known due to long duration of use
Cheap
Available as injections so can be given for aggression/agitation or as a long acting depot if compliance is an issue

Question 4

What side effects are due to APs action of dopamine receptors?

Answer 4

Movement disorder- Pseudo-parkinsonism, Acute dystonia, Tardive Dyskinesia, Akathisia
Sexual Dysfunction/ Impotence- Increased Prolactin
Galactorhoea- Increased Prolactin
Menstrual Disturbance- Increased prolactin

Question 5

What are being affected by APs causes the EPSEs?

Answer 5

Nigrostriatal Area

Question 6

What are the features of pseudo-parkinsonism?

Answer 6

Stooped posture
Shuffling gait
Pill rolling tremor
Rigidity
Bradykinesia
Pill Rolling Tremor

Question 7

What are the features of akathisia?

Answer 7

Restless legs
Pacing
Inability to keep still
Feet in constant motion

Question 8

What are the features of acute dystonia?

Answer 8

Facial grimacing
Involuntary upward eye movement
Muscle spasms of tongue, face, neck and back
Laryngeal Spasm- Risk of airway closure

Question 9

What are the features of tardive dyskinesia?

Answer 9

Lip smacking
Protrusion of tongue
Chewing motion
Facial dyskinesia

Question 10

How should you treat EPSEs?

Answer 10

Stop the AP/ Reduce the dose
Switch to an atypical AP

Anti-muscarinic- Procyclidine
Anti-cholinergic- Benztropine, trihexyphenidyl

Anti-cholinergics are due to excitatory action of ACh at the basal ganglia

Question 11

What anti-cholinergic side effects can be caused by APs?

Answer 11

Constipation
Blurred Vision
Dry mouth
Confusion

Question 12

How should you treat tardive dyskinesia?

Answer 12

Stop all APs

This is an irreversible side effect

Question 13

How should akathisia be treated?

Answer 13

Beta blockers

Benzodiazepine

Question 14

What side effect do APs cause at histamine receptors?

Answer 14

Sedation

Question 15

What side effects do AP casue due to their action at alpha 1 receptors?

Answer 15

Postural hypotension

Impotence

Question 16

What is neuroleptic malignant syndrome?

Answer 16

• Autonomic instability- fluctuating temperature, HR, BP
• Increased muscle tone and rigidity
• Prolonged contraction and little movement begins to cause muscle breakdown
• There is therefore CK and Myoglobin release which is detectable on a blood test
• Also changes on consciousness,

Question 17

What is the treatment for neuroleptic malignant syndrome?

Answer 17

Stop the AP
Supportive Treatment- Fluids, Temperature support (e.g. cooling blankets)
- Dopamine agonists (e.g. bromocriptine) to overcome dopamine blockade
- Muscle relaxants- dantrolene
- Benzodiazepines to control agitation

Question 18

Give some examples of atypical APs

Answer 18

Olanzapine
Risperidone
Aripiprazole
Quetiapine
Clozapine (Treatment resistant schizophrenia)

Less likely to cause EPSEs

Question 19

What are some advantages of atypical APs?

Answer 19

Less likely to cause EPSEs
Less risk of tardive dyskinesia
As effective as typicals
Some have an effect on negative symptoms of schizophrenia

Question 20

What are some disadvantages of atypical APs?

Answer 20

• Expensive
• Newer and so less experience of long term effects
• Many only available as oral (except Olanzapine (short acting IM), Risperidone (long acting IM), aripiprazole (short or long acting IM)

Question 21

What are some important side effects of atypical APs?

Answer 21

EPSE
Sedation
Weight Gain- METABOLIC SYNDROME
Decreased seizure threshold

Question 22

What are the components of metabolic syndrome?

Answer 22

Visceral obesity
Hyperglycaemia
High triglycerides
Low HDL
Insuline resistance

Question 23

What are patients on atypical APs prone to metabolic syndrome?

Answer 23

Increased appetite with cravings for sweet/carb heavy foods which leads to weight gain and then insulin resistance and other features

Question 24

What is a very important side effect of clozapine?

Answer 24

Marrow suppression or agranulocytosis

Question 25

What are some side effects of clozapine?

Answer 25

Sedation
Anticholinergic
Weight gain
Decreased seizure threshold
Hyper salivation
AGRANULOCYTOSIS

Question 26

Describe the FBC monitoring that is required for clozapine?

Answer 26

Blood Tests every week for 18 weeks
Every 2 weeks till 1 year
Then every month as long as taking drug

Blood counts are returned as red/amber/green results for interpretation. If amber repeat blood test in 3 days time.

Question 27

What kind of hallucinations are common in schizophrenia?

Answer 27

Auditory- third person voices that are often persecutory