Anti-psychotics

Question 1

Typical anti-psychotic mechanism?

Answer 1

block dopamine D2 receptors

Question 2

Atypical anti-psychotic mechanism?

Answer 2

block both dopamine D2 and serotonin 2A receptors

Question 3

What are the benefits of atypical vs typical?

Answer 3

atypicals may be more effective at treating neg symptoms

atypicals have favorable side effect profile (less EPS, tar dive dyskinesia or neuroleptic malignant syndrome), but greater metabolic syndrome/weight gain

atypicals often more expensive

Question 4

What is the difference in side effects between low and high potency typicals?

Answer 4

Low potency requires higher dose–>higher incidence of anticholinergic and antihistaminic side effects (sedation, orthostatic); also more likely to cause seizures (lower seizure thresholds)

Low potency have more lethality in overdose due to QT prolongation

High potency have higher risk for extrapyramidal and tardive dyskinesia

Question 5

Chlorpromazine (Thorazine) and Thioridazine (Mellaril) are low/mid/high potency typicals?

Answer 5

low

Question 6

Chlorpromazine (Thorazine) specific side effects?

Answer 6

orthostatic hypotension, blueish skin discoloration, photosensitivity

Question 7

Chlorpromazine (Thorazine) can also be used to treat…

Answer 7

nausea and vomiting, intractable hiccups

Question 8

Thioridazine (Mellaril) specific side effects?

Answer 8

retinitis pigmentosa

Question 9

Loxapine (Loxitane), thiothixene (Navane), Trifluoperazine (Stelazine) and Perphenazine (Trilafon) are low/mid/high potency typicals?

Answer 9

mid

Question 10

Loxapine (Loxitane) specific side effects?

Answer 10

higher risk of seizure

*metabolite is an antidepressant amoxapine

Question 11

Thiothixene (Navane) specific side effects?

Answer 11

ocular pigment changes

Question 12

Trifluoperazine (Stelazine) can also help to…

Answer 12

reduce anxiety

Question 13

Haloperidol (Haldol), Fluphenazine (Prolixin), Pimozide (Orap) are low/mid/high potency typicals?

Answer 13

high

Question 14

What are the high-potency neuroleptics best used for?

Answer 14

as IM injections to treat acute agitation or psychosis

Question 15

Haloperidol and fluphenazine are available as long acting IM forms known as:

Answer 15

deconate

Question 16

What 4 dopamine pathways are affected by antipsychotics?

Answer 16

mesolimbic, mesocortical, nigrostriatum, tuberoinfundicular

Question 17

Effect on the mesolimbic pathway by antipsychotics?

Answer 17

• positive symp of SCZ treated

Question 18

Effect on the mesocortical pathway by antipsychotics?

Answer 18

• negative symp of SCZ treated

Question 19

Effect on the nigrostriatal pathway by antipsychotics?

Answer 19

• EPS: parkinsonism, akathisia, dystonia (torticollis, tongue, oculogyric crisis, life-threatening if involves airway or diaphragm)

Question 20

Effect on the tuberoinfundibular pathway by antipsychotics?

Answer 20

• hyperprolactinemia (dec libido, galactorrhea, gynecomastia, impotence, amenorrhea, osteoporosis)

Question 21

When is the risk of tardive dyskinesia the greatest for a patient on neuroleptics?

Answer 21

> 6 months

• often older women
• 50% will spontaneously remit, but some cases are permanent

Question 22

What medical emergency does one worry about with antipsychotics?

Answer 22

Neuroleptic malignant syndrome (especially young males early in treatment)

• FALTERED: Fever, Autonomic instability (tachy, labile HTN, diaphoresis), Leukocytosis, Tremor, Elevated creatine phosphokinase, Rigidity (lead-pipe), Excessive sweating (diaphoresis), Delirium
• 20% mortality rate

Question 23

How does one treat EPS?

Answer 23

• anticholinergic: benztropine (Cogentin)
• antihistaminergic: diphenhydramine (Benadryl)
• antiparkinsonian: amantadine (Symmetrel)

Question 24

Atypical antipsychotics are used to treat SCZ as well as…

Answer 24

acute mania, bipolar disorder, adjunctive to unipolar depression

sometimes for personality disorders and certain psychiatric disorders in childhood

Question 25

Which atypical is least likely to cause tardive dyskinesia?

Answer 25

Clozapine (Clozaril)

Question 26

Which atypical is the only one shown to be more efficacious?

Answer 26

Clozapine (Clozaril)

Question 27

Which atypical has more anticholinergic side effects than other atypicals or high-potency typicals?

Answer 27

Clozapine (Clozaril)

Question 28

Clozapine (Clozaril) specific side effects?

Answer 28

• associated with tachycardia and hypersalivation
• myocarditis
• 1-2% incidence of agranulocytosis (must have routine WBC counts weekly for first 6 mon must stop if absolute neutrophil count drops before 1500/uL)
• 2-5% incidence of seizures

Question 29

Which atypical is the only antipsychotics shown to dec risk of suicide?

Answer 29

Clonzapine (Clozaril)

Question 30

Which atypical has a long-acting injectable known as Consta?

Answer 30

Risperidone (Riserdal)

Question 31

Risperidone (Risperdal) specific side effects?

Answer 31

• Hyperprolactinemia
• Orthostatic hypotension
• Reflex tachycardia

Question 32

Quetiapine (Seroquel) specific side effects?

Answer 32

sedation and orthostatic hypotension

Question 33

Olanzapine (Zyprexa) specific side effects?

Answer 33

Weight gain

Question 34

Which two atypicals are less likely to cause weight gain?

Answer 34

Ziprasidone (Geodon) and Aripiprazole (Abilify)

Question 35

Aripiprazole (Abilify) has what unique mechanism?

Answer 35

partial D2 agonism

Question 36

Aripiprazole (Abilify) specific side effects?

Answer 36

can be more activating (akathisia) and less sedating

Question 37

What atypicals have approval for treatment of mania?

Answer 37

Quetiapine (Seroquel), olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), ziprasidone (Geodon)

Question 38

What atypical has a long acting injectable form known as Sustenna?

Answer 38

Paliperidone (Invega)

• metabolite of risperidone

Question 39

List the side effects of atypical antipsychotics

Answer 39

• Metabolic syndrome!
• weight gain!
• hyperlipidemia
• hyperglycemia
• some anti-HAM effects
• liver dysfunction
• QT prolongation

Question 40

List atypicals

Answer 40

Clozapine (Clozaril), Risperidone (Risperdal), Quetiapine (Seroquel), Olanzapine (Zyprexa), Ziprasidone (Geodon), Aripiprazole (Abilify), Paliperidone (Invega), Asenapine (Saphris), Iloperidone (Fanapt)