Anti-psychotics

Question 1

Which were developed first: typical or atypical anti-psychotics?

Answer 1

Typical anti-phsychotics

Question 2

Typical anti-psychotics - mechanism of action

Answer 2

Work primarily through inhibition of dopamine 2 receptor.

D2 Receptor blockade

Question 3

Typical anti-psychotics - examples (5)

Answer 3

Haloperidol
Chlorpromaxine
Thioridazine
Fluphenazine
Zuclopentixol

Question 4

Typical anti-psychotics - side effects (broad category)

Answer 4

Extrapyramidal side effects

Question 5

Typical anti-psychotics - extrapyramidal side effects

Answer 5

Parkinsonism
Acute dystonic reaction
Akathisia
Tardive dyskinesia

Question 6

What is parkinsonism?

Answer 6

Signs of parkinsons disease (tremor, rigidity, dyskinesia) but it is drug induced

Question 7

How do you manage parkinsonism?

Answer 7

Anti-cholinergics

Question 8

Typical anti-psychotics - extrapyramidal side effects - acute dystonic reaction

Answer 8

Sudden painful muscle spasms

Question 9

Typical anti-psychotics - extrapyramidal side effects - acute dystonic reaction is untreatable. True or false?

Answer 9

False

- completely treatable with IV anti-cholinergics

Question 10

Typical anti-psychotics - extrapyramidal side effects - akathisia

Answer 10

Restlessness

Question 11

Typical anti-psychotics - extrapyramidal side effects - akathisia responds well to anti-cholinergics. True or false?

Answer 11

False

Question 12

Typical anti-psychotics - extrapyramidal side effects - Tardive dyskinesia

Answer 12

Repetitive involuntary purposeless movements (eg sticking out tongue)

Due to long term anti-psychotic use

Question 13

Atypical anti-psychotics - mechanism of action

Answer 13

5-HT receptor blockade

Dopamine receptor blockade

Question 14

Atypical anti-psychoics - better at treating positive or negative symptoms?

Answer 14

Negative symptoms

Question 15

Atypical anti-psychotics - examples (6)

Answer 15

Olanzapine 
Risperidone
Quetiapine
Clozapine
Aripiprazole
Amisulphride

Question 16

Atypical anti-psychotics - side effects (broad category)

Answer 16

Metabolic syndrome

Question 17

Atypical anti-psychotics - side effects - metabolic syndrome

Answer 17

Increased abdominal girth 
Type 2 diabetes
Hypertension
High cholesterol
Weight gain

Question 18

Atypical anti-psychotics have more side effects than typical anti-psychotics. True or false?

Answer 18

False

Question 19

When is clozapine indicated?

Answer 19

If the patient has had 2 FAILED trials of anti-psychotics

Question 20

Clozapine is the most effective antipsychotic. True or false?

Answer 20

True

Question 21

Why is clozapine not used routinely?

Answer 21

Severe side effects

• Agranulocytosis
• myocarditis

also

• metabolic syndrome (weight gain, sedation)
• constipation
• hypersalivation

Question 22

Clozapine - investigations

Answer 22

Regular FBC monitoring
- weekly for first 6 weeks (looking for neutropenia - agranulocytosis)

ECG
- myocarditis

Question 23

Histamine H1 receptor blockade results in

Answer 23

Sedation

Increased appetite

Question 24

Alpha-adrenergic receptor blockade results in

Answer 24

Interruption of the baroreceptor reflex leading to

• dizziness
• light headedness
• fainting
• falls

Question 25

Muscarinic blockade results in

Answer 25

``` Blurred vision Dry mouth Constipation Urinary retetntion Sedation Confusion ```

Question 26

What was the first ever anti-psychotic discovered?

Answer 26

Chlorpromazine

Question 27

What is the most effective anti-psychotic drug?

Answer 27

Clozapine

Question 28

Main 2 side effects of atypical anti-psychotics

Answer 28

Weight gain | Sedation

Question 29

What is the treatment for someone who is taking typical antipsychotics and gets extra-pyramidal side effects...in particular, an acute dystonic reaction?

Answer 29

Procycladine (anti-cholinergic) | this reduces ACh to a new relative balance with the lower dopamine levels

Question 30

What are the features of NMS (neuroleptic malignant syndrome) ?

Answer 30

Increased muscle tone (over hours/days) Increase temperature ANS instability (swinging changes in BP and pulse rate) This can eventually lead to rhabdomyalisis -> AKI

Question 31

How do you manage NMS?

Answer 31

Refer to ICU urgently - rapid cooling - skeletal relaxants

Question 32

If you suspect NMS, which blood test should you do?

Answer 32

CK | - significant rise

Question 33

When starting people on an anti-psychotic medication, what is first line? typical antipsychotic or atypical antipsychotic?

Answer 33

``` Atypical (2nd generation) --> Atypical (2nd generation) / typical (1st generation) --> Clozapine (2nd generation) ```