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Y5 Psych > Antipsychotics > Flashcards

Antipsychotics Flashcards

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1
Q

What are the domains of psychosis

A
  1. Positive symptoms: hallucinations, delusions, thought disorder
  2. Negative symptoms: alogia, apathy, avolition, associalty, affective blunting
  3. Disorganisation symptoms: bizarre, chaotic and agitated behaviours
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2
Q

What is the dopamine theory

A

Dopamine release from the mesolimbic pathway into the nucleus accumbens regulates motivation and facilitates reinforcement and reward

Excessive dopamine → positive symptoms of psychosis

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3
Q

What are the four dopamine pathways in the brain

A

Mesolimbic
Mesocortical
Nigrostriatal
Tuberoinfundibular

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4
Q

What is the role of the mesolimbic dopamine pathway in psychosis

A

Ventral tegmental area → dopaminergic neurons → ventral striatum of basal ganglia
Responsible for positive symptoms

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5
Q

What is the role of the mesocortical dopamine pathway in psychosis

A

Ventral tegmental area → dopaminergic neurons → prefrontal cortex
Cognitive control, motivation, emotional response
Negative symptoms

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6
Q

What is the role of the nigrostriatal dopamine pathway in psychosis

A

Substantia nigra → dopaminergic neurons → striatum/basal ganglia
Extrapyramidal nervous system, controls motor movement
EPSE

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7
Q

What is the role of the tuberoinfundibular dopamine pathway in psychosis

A

Hypothalamus → dopaminergic neurons → anterior pituitary gland
Normally active and inhibits the release of prolactin
Hyperprolactinaemia

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8
Q

Which area of the brain is associated with aggressive and impulsive symptoms

A

Orbitofrontal cortex and connections to the amgydala

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9
Q

What receptors do typical antipsychotics act on and give examples

A

Widely acts on D2 dopamine receptors

Chlorpromazine (first)
Haloperidol
Zuclopenthixol
Flupentixol

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10
Q

What receptors do atypical antipsychotics act on and give examples

A

Selectively acting for dopamine, serotonin and 5-HT2A

Clozapine
Olanzapine
Quetiapine
Risperidone
Aripiprazole

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11
Q

Why are atypical antipsychotics preferred to typical antipsychotics

A

Antagonist of the 5HT-2A receptor
Reduces antipsychotic receptor occupancy from 80-60% in the nigrostriatal pathway → reduces risk of EPSEs

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12
Q

Which antipsychotics have partial agonist activity

A

aripiprazole
cariprazine
furasidone

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13
Q

What are the side effects of antipsychotics

A

Hyperprolactinaemia
QTc prolongation
Extra-pyramidal side effects:
- Parkinsonism
- Dystonia
- Tardive dyskinesia
- Akathisia
Metabolic syndromes
Neuroleptic malignant syndrome

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14
Q

What are the differentials for hyperprolactinaemia

A

Physiological: pregnancy, lactation, stress
Antipsychotics - amisulpride, risperidone
Antidepressants
Organic: prolactinoma

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15
Q

What are the symptoms of hyperprolactinaemia

A

Often asymptomatic, clinically significant >1000
Women: reduced libido, amenorrhoea, galactorrhoea, osteoporosis, increase breast Ca risk
Men: reduced libido, erectile dysfunction, gynaecomastia, galactorrhoea

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16
Q

What is the management for hyperprolactinaemia caused by antipsychotics

A

Switch to a prolactin sparing agent e.g. quetiapine, aripiprazole (dopamine agonist)
Add in aripiprazole
Avoid dopamine agonists e.g. cabergoline, bromocriptine

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17
Q

What does the QT segment represent, what is classified as prolongation, and why is prolongation a risk

A

Ventricular depolarisation and repolarisation
Corrected fro heart rate (QTc)
>500ms - risk increases significantly
Increases risk of cardiac arrhythmias e.g. polymorphic ventricular tachycardia (Torsade de Pointes) → loss of cardiac output → unconsciousness → death

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18
Q

What is the management for QTc prolongation caused by antipsychotics

A

Switch to a more QTc sparing agent e.g. aripiprazole

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19
Q

Describe parkinsonism EPSEs from antipsychotics

A

Occurs when 80-90% of the neurons are lost

Classic symptoms: bradykinesia, rigidity, pill rolling tremor, postural instability
Stooped posture
Shuffling gate, reduced arm swing
Hypomimia
Generally bilateral

20
Q

What investigations and management should be done for parkinsonism EPSEs from antispychotics

A

dopamine transporter (DAT) scan

Management: switch medication, add procyclidine (anti-muscarinic)

21
Q

What is tardive dyskinesia as an EPSE of antipsychotics

A

Involuntary orofacial dyskinesia associated with long term antipsychotic use
Develops after months/years of treatment
Typically seen as continuous mouth and tongue movements e.g. lip smacking, eye closing, jaw clenching, trunk/extremity movement

22
Q

What are the the risk factors for developing tardive dyskinesia from antipsychotics

A

Typical antipsychotics
High dose
Elderly

23
Q

What is the management for tardive dyskinesia caused by antipsychotics

A

May be permanent, even when the medication is stopped
Stop the causative agent
Consider tetrabenazine

24
Q

What is dystonia as an EPSE of antipsychotics

A

Involuntary muscle spasm/contractions
Develops within hours of starting antipsychotics

Specific types:
- Oculogyric crisis (eyes rolling upward)
- Torticollis (head and neck twisted to one side)
- Laryngeal dystonia (can compromise airway and be life threatening)

25
Q

What are the risk factors for developing dystonia from antipsychotic use

A

Antipsychotics naive
young males
High dose typical antipsychotics

26
Q

What is the management for dystonia caused by antipsychotics

A

Anticholinergics e.g. procyclidine

27
Q

What is akathisia as an EPSE of antipsychotics

A

A sense of internal restlessness.
Occurs within days to weeks of starting/increasing an antipsychotic
The patient feels compelled to constantly move, rock, fidget or pace around.
Associated with an increased risk of suicide

28
Q

What is the management for akathisia caused by antipsychotics

A

Change medication
Diphenhydramine
Propranolol
Low dose benzodiazepines

29
Q

Describe metabolic syndrome

A

Schizophrenia reduces life expectancy by 15-20 years, partly mediated by the metabolic side effects:
Weight gain
Dyslipidaemia
Insulin insensitivity

Leads to heart disease, lipid problems, HTN, T2DM, dementia, PCOS, cancer, NAFLD

30
Q

What is the management for metabolic syndrome caused by antipsychotics

A

Monitor weight, BP, lipid profile, and HbA1c
Treat any complications on their merits e.g. statins, anti-glycaemics, anti-hypertensives
Promote health eating and exercise

30
Q

How long does it take for antipsychotic effects to be apparent

A

Sedation: minutes-hours
Antipsychotic effect: 1-2 weeks, max benefit within 6 weeks

31
Q

What is high dose antipsychotic treatment (HDAT)

A

total antipsychotic dose >100% BNF maximum dose

32
Q

What antipsychotics can be used for rapid tranquilisation

A

IM olanzapine
IM haloperidol

33
Q

What cautions should be taken for antipsychotic use as tranquilisation

A

Pre-treatment ECG needed with haloperidol due to risk of QTc prolongation
IM olanzapine not to be given within 1 hr of IM lorazepam due to risk of respiratory depression
No more than 3 days of IM olanzapine to be given in a row due to risk of post-injection syndrome

34
Q

What is treatment resistance and what can be used

A

Treatment resistance = If two antipsychotics have been given an adequate trial (6 weeks at a therapeutic dose including one atypical)
→ consider clozapine (i.e. treatment resistance pathway)

35
Q

Which medication has evidence towards negative symptoms

A

Clozapine

36
Q

What needs to be done before clozapine is started in a patient

A

FBC and ECG prior
Register with national clozapine monitoring service

37
Q

How often does a patient need to be monitored while on clozapine

A

Weekly → fortnightly → monthly (after 1 year of treatment)

38
Q

What is the traffic light system for clozapine monitoring

A

Green: continue
Amber: continue but FBC monitoring increased to twice weekly
Red: stop immediately

39
Q

What are the side effects of clozapine

A

Lowering of seizure threshold
Constipation
Agranulocytosis/Neutropenia/leucopenia → regular FBC test monitoring
Myocarditis, cardiomyopathy, tachycardia, hypotension
Hypersalivation
Prothrombotic → DVT/PE
Sedation, increased appetite → weight gain (Blocks histamine-H1 receptors)

40
Q

What are the symptoms of agranulocytosis caused by clozapine

A

Ulcer development in mucous membranes that line the mouth and GI tract
Susceptible to bacterial infections
Sepsis occurs to bacterial contamination

41
Q

How should clozapine be started and stopped

A

Start at a low dose and titrate slowly
Re-titrate if stopped >48 hours
Stop slowly - if abruptly stopped there is a high risk of rebound psychosis

42
Q

What monitoring is done for patients on antipsychotics

A

6 weeks: weight
12 weeks: weight, pulse, BP, HbA1c//glucose, lipids
1 year: weight, pulse, BP, HbA1c//glucose
Annually:
- Weight, pulse, BP, waist circumference
- HbA1c, U&Es, FBC, lipids, prolactin, LFTs, CK

43
Q

Describe neuroleptic malignant syndrome

A

Acute potentially life threatening complication of antipsychotic treatment, seen in <1% of patients
A disorder of thermoregulation and neuromotor control

Within hours to days of starting an antipsychotic:
agitated delirium with confusion
pyrexia
muscle rigidity
Hyporeflexia
autonomic lability: hypertension, tachycardia and tachypnoea
Diaphoresis

Raised CK, AKI, leukocytosis

Mortality 10%

44
Q

What is the management for neuroleptic malignant syndrome

A
  1. stop antipsychotic
  2. Admit/transfer to MEDICAL ward
  3. IV fluids (prevent renal failure) ± dantrolene ± bromocriptine

Y5 Psych (46 decks)

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