Antipsychotics Flashcards
Second generation anitpsychotic examples
Clozapine
Amisulpride
Quetiapinne
Aripiprazole
Olanzapine
Risperidone
Examples of first generation antipsychotics
Haloperidol
Zuclopenthixol
Sulpiride
Chlorpromazine
Flupenthixol
How do first gen anitpsychotics work? e
Block dopamine 2 receptors
four dopamine pathways
Mesocortical
Mesolimbic
Nigrostriatal
Tuberoinfundibular
What dopamine pathway is ass with EPSE?
Nigrostriatal
Which dopamine pathway is ass with hyperprolactinaemia?
Tuberoinfundibular
Side effect profile of 1st generation antipsychotics
EPSE
Hyperprolactinaemia
Antimuscarininc side effects
Risks from antipsychotics
Sedations
EPSE - dystonia, arkathisia, parkinsonism, tardive dyskinesia
Neuroleptic malignant syndrome
Risks from antipsychotics
Sedations
EPSE - dystonia, arkathisia, parkinsonism, tardive dyskinesia
Neuroleptic malignant syndrome
How to manage dystonia
Anticholinergics eg procyclidine
How to manage akathisia?
Reduce the dose/change to an alternative antipsychotic drug
Reduction of symptoms - addition of low dose eg propanolol
Antipsychotics and physical health long term risks
Cardiovascular
Dyslipidemia
Weight gain
Diabetes
Hyperprolactinaemia
ESPSE
How can affect on cardiac conduction from antipscyhotics present?
Increased QT interval
Torsades de pointes
Ventricular fibrillation
Sudden death
What counts as a prolonged QTc intervl?
> 450ms is concerning
(women <470, men <440ms)
500ms - unquantifiable risk of leading to torsade de pointes - review and action
What antispychotics are ass with the highest risk of dyslipidemia?
Olanzapine and clozapine
What monitor with olanzapine and clozapine esp?
Lipid levels
How often monitor lipid levels on olanzapine and clozapine?
Full lipid profile at baseolinne
3 months
Then annually
When do you add atorvastatin 20mg daily on olanzapine or clozapine treatment>
CVD risk score >10% or >NICE guiidanve
What use to determine primary CV prevention if necessary (statins)>
QRISK3 tool
When is risk of weight gain on antipsychotics highest
first 6 months treatment
Why do antispychotics cause weight gain?
Unknown but related to sedative effect of H1 receptor binfing affinity/insulin resistance
What causes hyperprolactinaemia in antispychotics?
Dopamine inhibits prolactin release, so dopamine antagonsits increase plasma prolactin levels
What antipsyhcotics do not increase prolactin above normal range at standard dose?
Clozapine, olanzapine, quetiapine and aripiprazole
What determines if an antipsychotic causes hyperprolactinaemia?
Dose realted - all have potnetual
What are the symptoms of hyperprolactinaemia?
Galactorrhea, amernorrhea, gynaecomastia, hypogonadism, sexual dysfunction, reduction in BMD
What are the symptoms of hyperprolactinaemia?
Galactorrhea, amernorrhea, gynaecomastia, hypogonadism, sexual dysfunction, reduction in BMD
What does hyperprolactinaemia increase the risk of?
Osteoporosis and breast cancer
What are depot antipsychptics>
Long acting formulation of antipsychotics
How often are depot anitpsychotics used?
1-4 weekly, monthly and 3 monhtly deoending
only certain medciations availale as depot
Advantages of depot antipsychotics
Useful in non complicant patients
Convenient who struggle with oral formulations
Disadvantages of depot antipsychotic medications
Plasma lecels maintained for long time - ADRs, interactions
Unable to sitch antipsychotics quickly
How long does it take for a drug to be eliminated?
5 half lives
How long does it take for a drug to be eliminated?
5 half lives
How long is half life of haloperidol?
21-28 dyas
minimum of 105 days
What differentials would you have for:
* Patient has diaphoresis, tremor, rigidity, unsteady gait
* Tachycardia 125bpm
* Temp 38.3 C
* BP 120/84
* CK 6763 (25-200)
* CRP 54 (0-5)
* ESR 33
* AST 244 (0-40)
* ALT 102(0-40)
Neuroleptic Malignant Syndrome
* Malignant catatonia
* Serotonin syndrome
* Thyrotoxicosis
* Heatstroke
* CNS infection
Cuases of neuroleptic malignant syndrome
Dopaminergic antagonism + context of physiological stressors/genetic predisposition
first (more common) and second gen antipsyhcotics, antidepressatns (SSRIs, lithium)
Combo
Cuases of neuroleptic malignant syndrome
Dopaminergic antagonism + context of physiological stressors/genetic predisposition
first (more common) and second gen antipsyhcotics, antidepressatns (SSRIs, lithium)
Combo
What combination of psychiatric drugs increases risk of NMS>
Antipsychotics and SSRIs
Signs and symptoms of NMS?
Fever
Diaphoresis
Rigidity
Confusion
Fluctuating consciousness
Fluctuating BP
Tachycardia
Elevated creatinine kinase
Altered LFTs
Signs and symptoms of NMS?
Fever
Diaphoresis
Rigidity
Confusion
Fluctuating consciousness
Fluctuating BP
Tachycardia
Elevated creatinine kinase
Altered LFTs
How uquizkly can NMS be fatal?
1-3 dyas
Risk factors for NMS - drug realted
High potency typical drigs
Recent or rapid dose increase
Rapid dose reduction
Abrupt withdrawal of anticholinergics
Genetic vulnerability
Other risk factors for NMS (not drug related)
Catatonia - prodromal
Pscyhosis
Organic brain disease
Alcoholism
Parkinsons disease
agitated/overactive and/or in need of restraint or seclusion
Diagnostic tests for NMS?
Raised CK
CK - elevated > 1000
AST/ALT
Few signs /symptoms
How to treat NMS?
aNTIPSYCHOTICS, lithium, antidepressant withdrawal
Monitor temp, pulse, BP
Benzodiazapine - lorazepam
Correct any dehydration, hyperpyrexia
Med unit/A+E - rehydration, bromocriptine + dantrolene
When are bromocrpitine and dantrolene used in A+E?
Muscle relaxants - Neuroleptic malignant syndrome
How to restart antipsychtics after NMS?
STOP for at least 5 days
Reintroduce on v small dose, increase slowly, consider antipsychotic structurally undrealted or with low affinity for dopamine eg clozapine or quetiapine
