Antipsychotic Meds

Question 1

Too much dopamine can cause ____

Answer 1

Schizophrenic symptoms

Question 2

Too little dopamine can cause ___

Answer 2

Parkinsonian symptoms
■ Parkinson’s is a degeneration of dopamine-secreting neurons. One med we treat it
with is Levodopa (L-DOPA), which is a precursor to dopamine

Question 3

_____ is the source of dopamine in the brains

Answer 3

Basal ganglia

Question 4

Two areas of the BG produce dopamine:

Answer 4

■ Substantia nigra (SN)
■ Ventral tegmental area (VTA)

Question 5

Dopaminergic Pathways

Answer 5

1. Mesolimbic pathway “reward pathway” (site of positive symptoms)
2. Mesocortical pathway (site of negative symptoms)
   These two pathways are where psychosis disease processes occur
3. Nigrostriatal Pathway (site of extrapyramidal symptoms and tardive dyskinesia)
4. Tuberoinfundibular pathway (site of hyperprolactinemia)
   These two pathways are where medication side effects occur

Question 6

Mesolimbic pathway (behavior & pleasure)

Answer 6

• Location where positive symptoms originate
• Changes occur here within the Gray matter in Schizophrenia

Question 7

Mesocortical pathway (emotions & cognition)

Answer 7

• Location where negative symptoms originate

Question 8

Nigrostriatal Pathway (Movement - Think of parkinson’s disease)

Answer 8

This is part of the extrapyramidal system (part of the motor system responsible for
involuntary actions, influences the function of the skeletal muscles).
- Where extrapyramidal symptoms and tardive dyskinesia originate

Question 9

Tuberoinfundibular pathway (prolactin release)

Answer 9

• Where hyperprolactinemia originates

Question 10

Extrapyramidal symptoms (EPS):

Answer 10

● Dopamine blockade or depletion in the basal ganglia
● A lack of dopamine (like in parkinson’s) causes similar symptoms to
EPS
● Every antipsychotic has a risk for EPS
● Drug induced movement disorders include:
○ Dystonia (continuous spasms and muscle contractions)
○ Akathisia (motor restlessness)
○ Tardive dyskinesia (TD)

Question 11

Dystonia

Answer 11

Dystonia is a movement disorder in which your muscles contract
involuntarily, causing repetitive or twisting movements or posture.

Question 12

Akathisia:

Answer 12

A state of agitation, distress, and restlessness that is an occasional
side-effect of antipsychotic and antidepressant drugs

Question 13

Tardive dyskinesia

Answer 13

● Involuntary, repetitive body movements that usually have a slow or belated
onset
● Often reversible, but can be permanent.
● Cause: Most often from long-term or high-dose use of antipsychotic drugs

Question 14

Tardive dyskinesia risk factors

Answer 14

Women, elderly, higher doses, long term use

Question 15

Tardive dyskinesia Treatment

Answer 15

Stop the offending medication.
○ Remission can occur within a few month, but can continue to improve over
1-3 years.
○ Early identification of TD can lead to 50-90% remission rates (meaning,
screen for this in patients!)
○ Newer FDA-approved therapies (VMAT2 inhibitors) Ingrezza and
Austedo, can help treat this

Question 16

AIMS

Answer 16

Abnormal Involuntary Movement Scale (AIMS):

Question 17

Neuroleptic malignant syndrome (NMS):

Answer 17

● Life-threatening neurologic disorder most often caused by adverse
reaction to antipsychotic drugs.
● Caused by a sudden, marked reduction in dopamine activity
○ Muscle rigidity, fever, autonomic instability, and cognitive changes
THIS IS AN EMERGENCY

Question 18

First-generation antipsychotic medications (FGAs)

Answer 18

“Neuroleptics”, “Conventional” or “Typical” Antipsychotics
Dopamine receptor (D2) antagonists.
1. haloperidol (Haldol)
2. chlorpromazine (Thorazine)
3. prochlorperazine (Compazine)

Question 19

FGAs MOA

Answer 19

• Selectively antagonizes dopamine D2
  receptors
  The blockade of D2 receptors in the mesolimbic pathway tends to alleviate positive symptoms. The same D2 blockade in other pathways can lead to adverse effects.

Question 20

FGAs Contrainidications

Answer 20

Severe CNS depression. Don’t use in patients with decreased levels of consciousness. Use caution if history of NMS

Question 21

FGAs side effects

Answer 21

Anticholinergic effects, sedation, weight gain, ED, amenorrhea,
gynecomastia, lactation, decreased sex drive

Question 22

FGAs adverse reactions

Answer 22

Extrapyramidal symptoms, NMS, agranulocytosis

Question 23

Second-Generation (atypical) Antipsychotic
medications (SGAs)

Answer 23

Serotonin-Dopamine Antagonists
● clozapine (Clozaril)
● risperidone (Risperdal)
● olanzapine (Zyprexa)
● quetiapine (Seroquel)
● ziprasidone (Geodon)
● aripiprazole (Abilify)

Question 24

SGAs MOA

Answer 24

● Blocks D2 and has serotonin receptor antagonist action
● Targets positive, negative, cognitive, and affective symptoms

Question 25

SGAs Contraindications

Answer 25

Use caution if history of NMS for all atypicals.
Clozapine - agranulocytosis, liver disease, renal and cardiac disease, paralytic ileus,
seizure disorders
Ziprasidone - QT prolongation

Question 26

SGAs side effects

Answer 26

varies widely between drugs, use drug reference.
Common: Orthostatic hypotension, EPS, sedation, anticholinergic effects

Question 27

SGAs adverse effects

Answer 27

• All: increased mortality in elderly, weight gain, NMS
  Clozapine - agranulocytosis, seizures
  Quetiapine - cataracts
  Ziprasidone - QT prolongation

Question 28

SGAs follow up/monitoring

Answer 28

All drugs have different monitoring parameters such as initial
labs and rechecking them, ophthalmologic exams, lipids, weight/girth monitoring, etc.
Monitor for EPS at least quarterly.

Question 29

Use for Non-Psychotic Disorders for quetiapine (Seroquel)

Answer 29

One of first line for Bipolar depression.

Question 30

Use for Non-Psychotic Disorders for aripiprazole (Abilify)

Answer 30

• BP, adjunct for severe depression, Autism related
  irritability in children, Tourette’s disorder

Question 31

Use for Non-Psychotic Disorders for lurasidone (Latuda)

Answer 31

One of first line for Bipolar depression