antipsychotics

Question 1

TEST: Recognize the positive and negative symptoms of schizophrenia and the relative effectiveness of typical and atypical antipsychotics to treat each

Answer 1

Positive (presence of what shouldn’t be)
Hallucinations
Delusions

Negative (lack of what should be)
Losing interest & motivation in life and activities (eg, food, relationships, sex)
Poor self care,

Question 2

TEST: Typical antipsychotics treat_____ and have a greater afinity for ______, and atypical antipsychotics treat _______ and have a greater affinity for ______

Answer 2

positive symptoms, D2 receptors (and 5-ht2A blockade); positive AND negative symptoms, 5-HT2A receptors (and some D2 blockade (only typical you’ll ever use is haloperidol bc of the se profile)

Question 3

TEST: MOA: psychosis works via , _____ which effects the ________, and results in ______; Another pathway that is inhibited by atypical drugs is the ______ which effects the ______

Answer 3

D2 receptor blockade, mesolimbic-mesocortical pathway, EPS via the nigrostriatal pathway; 5-HT2A receptor blockade, DA, NE glutamte GABA and ACh

Question 4

the low potency typical antipsychotics have____, while the high potency have ______

Answer 4

more sedation and anticholinergic effects; more EPS

Question 5

TEST: ______ is the old term for typical antipsychotics, and it includes 2 LP and 2 HP:

Answer 5

phenothiazine; CHLORPROMAZINE, thioridazine, fluphenazine, trifluoperazine

Question 6

TEST: the hp from the class of butyrophenones is:

Answer 6

haloperidol

Question 7

MAYbe TEST: the antipsychotic drugs all go through _____ and all ______

Answer 7

the liver, last a long time (long half-life), their dose for iv might be &laquo_space;PO

Question 8

additive effect for things like QTC prolongation or sedation

Answer 8

if you take a drug that increases sedation, and you take an atypical that increases sedation, you get combined effects

Question 9

orthostatic hypotension, impotence, failure to ejaculate

Answer 9

alpha adrenoceptor blockade

Question 10

CNS effects, like PD, akathisia, dystonias are all from:

Answer 10

d2 blockade form nigra striatal areas, and Tardive dyskinesia

Question 11

any time you have a muscarinic blockade, you can have ____

Answer 11

toxic-confusional state

Question 12

supersensitivity of dopamine receptors in the cns results in: :

Answer 12

tardive dyskinesia

Question 13

with the endocrine system, you can get ________ from _____

Answer 13

amenorrhea-galactorrhea, because you have high levels prolactin which is a side effecet of the dopamine blockade

Question 14

you can also get ______ or other ___ perhaps from blocking histamin and 5HT2 blockade

Answer 14

weight gain, metabolic disfunction

Question 15

you can also get ______ or other ___ perhaps from blocking histamin and 5HT2 blockade

Answer 15

weight gain, metabolic disfunction

Question 16

22 yr old present to ed with cc of “they are making me look toward heaven” Admits to a past diagnosis of schizophrenia, “but God cured me of it.” Review of the medical record reveals that he was discharged from the hospital the previous week on respiradone 4 mg at bedtime. His dose was increased to 6 mg by his outpatient psychiatrist 2 days prior to today’s visit. The patient believe that angels are forcing him to look up to heaven and he is unable to look “down to the devil in hell.” His mental status demonstrates a cooperative and appropriately dressed young man, alert, and oriented three times. Speech is not spontaneous, mood is worried, with flat afect. Thoughts are logical without looseness. He denies suicidal or homicidal ideation but has delusions. His insight is poor, but his judgement and impulse control are not currently impaired. Has upward gaze and his eyes are bilateral:

Answer 16

Medication induced dystonia (EPS); next step is benztropine
MOST COMMON IN YOUNG MEN!
antipsychotic medication can cause extrapyramidal symptoms (i.e. acute dystonia)
caused by dopamine antagonist needs to be treated with anticholinergic medication such as benztropin, or antihistamines such as diphenhydramine

Question 17

50 yo woman with schizoaffective disorder, bipolar type complains of nervous tics. Currently being treated with haloperidol 100 mg, denies significant affective symptoms but complains of chronic auditory hallucinations of whispers without commands. No suicidal or homicidal ideation, noted to be sticking tonuge in and out.

Answer 17

tardive dyskinesia, decrease dose, and switch to different atypical antipsychotic

Question 18

25 yo admitted with new onset of psychotic symptoms consisting of command hallucinations to harm others, paranoid delusions, and agitation. He begun olanzapine, After several days he is found lying in bed with eyes open but not responsive. Noted to be seating but is resistant to being moved. Vitals demonstrate 101.4F, bp 182/98, pulse 104, rep 22 breaths/min

Answer 18

NMS; acute mental status changes, diaporesis, rigidity, fluctuating vital signs

Question 19

43 yo with schizophrenia being followed in an outpatient community mental health clinic after being discharged from hospital. While hospitalized she was on risperidone. She has some paranoia, and ideas of reference, but denies auditory or visual hallucinations. Her mental status examination is significant for moderate psychomotor slowing, with little spontaneous speech, but coarse tremor of her hands. Her stated mood is “fine” and has blunted affect, with little expression, gait is wide based, and shuffling

Answer 19

Parkinsonism; bradykinesia, shuffling gait, masked faces, coarse tremor, increased risk factor is woman and older age

Question 20

32 yo admitted with the provisional diagnosis of psychotic disorder, rule-out dipolar. After 10 days, he is stabilized on valproate and aripiprazole. The nurses are concerned his medications need to be increased or switched as he has been recently sleeping less and is more agitated, often pacing the hallways. Upon examination, he admits to feeling “edgy,” but he denies racing thoughts increased energy, paranoia, delusions, stating “I just can’t stop walking; I feel like I’m going crazy!”

Answer 20

akathisia; treat with beta blocker or benzo

Question 21

EPS: highest incidence with ______ i.e. ______; Result from ______ and imbalance with _______; The ____ typically don’t exhibit as many EPS symptoms bc they already have ______, and ______

Answer 21

high potency typical agents. haloperidol, fluphenazine; the D2 blockade, the M1 receptors; LP typicals, anti-M1 action, atypicals don’t block D2 as much.

Question 22

TEST: if you encounter EPS from a typical HP drug, you treat by:

Answer 22

administering an anticholinergic drug: benzotropine, trihexyphenidyl, diphenhydramine (benedryl in an emergency), and you DONT GIVE LEVODOPA

Question 23

TEST: Someone who has been on a certain drug for 3-5 years, runs a great risk of having____ which has a relative cholinergic deficiency secondary to __________, and is worse with ______

Answer 23

Tardive Dyskinesia; SUPERSENSITIVITY OF DA RECEPTORS, high dose risperidone (low dose not so bad)

Question 24

_______ has a side effect issue with lowering the seizure thresholld; and some drugs cause sedation via:

Answer 24

clozapine, typical adgents; blocking the H1 receptor in the brain (histamine-1 blockade)

Question 25

All typical apsychotics and high dose risperidone can also cause:

Answer 25

hyperprolactinemia, as well as alpha-1 blockade (othostatic hypotension (reflex tachycardia) and impaired ejaculation. and patients that already have a cardiac conduction problem or are on three antipsychotics, may have heart QTc issues, and the worst of these is ziprasidone

Question 26

metabolic effects and anticholinergic effects:

Answer 26

worst is olanzapine, clozapine; worse with typical LP as well as clozapine, olanzapine

Question 27

TEST: Clozapine is unique in that it causes:

Answer 27

AGRANULOCYTOSIS, has to sign up for it, and they have to be monitored

Question 28

TEST: (chart) the two LP agents are really bad for____, the 3 HP are really bad for ______

Answer 28

sedation, anticholinergic effects, orthostasis; EPS

Question 29

Notes regarding side effects: clozapine has ______, and olanzapine______, ________ are the two drugs with the least amount of side effects, but _____ causes the ________

Answer 29

clozapine has a lot more side effects than typical drugs, and olanzapine has the worst metabolic effects, ziprasidone and aripirazole, ziprasidone causes the most QTc elongation

Question 30

Notes regarding side effects: clozapine has ______, and olanzapine______, ________ are the two drugs with the least amount of side effects, but _____ causes the ________

Answer 30

clozapine has a lot more side effects than typical drugs, and olanzapine has the worst metabolic effects, ziprasidone and aripirazole, ziprasidone causes the most QTc elongation

Question 31

TEST: anti-emetics to know: DA-receptor blockade

Answer 31

Prochlorperazine: high potency ADE (i.e. EPS) and Promethazine: Potent histamine-1 blocking effects, these are known as “phenothiazine” drugs

Question 32

TEST: anti-emetics to know: DA-receptor blockade

Answer 32

Prochlorperazine: high potency ADE (i.e. EPS, and sedation) and Promethazine: Potent histamine-1 blocking effects, these are known as “phenothiazine” drugs

Question 33

EPS is treated with:

Answer 33

anti-cholinergic i.e. benzotropine, trihexyphenidyl, diphehydramine (moa central muscarinic blockade)

Question 34

You are caring for 22 y/o male on the trauma unit who becomes acutely agitated. You order haloperidol 5mg IV push. The pt is still agitated 20 minutes later so you order the dose to be repeated. Suddenly the pt’s head turns to one side (he can’t move it back) and his eyes are involuntarily looking upward
What is going on?
What are you going to do about it?

Answer 34

having an acute dystonic reaction: treat with: anti-cholinergic i.e. benzotropine, trihexyphenidyl, dip gmmmmmmmmmehydramine

Question 35

During your first clinic, you are seeing a 37 y/o male with schizoaffective disorder who was stared on olanzapine at his last visit by the previous resident. He complains that he gets dizzy whenever he stands up from a chair. Although his HR was 73 in the waiting room, it is now 93 after standing and walking back to the exam room.
What is going on?
What are you going to do about it?

Answer 35

alpha-1 blockade (CNS effect along with impotence, failure to ejaculate, etc), switch to a different drug; if olanzapine is the only thing that works, maybe work around it;

Question 36

You have been caring for a pt who was admitted to the hospital for a COPD exacerbation. She received clozapine at home and this was continued while she was in the hospital. The pt is now going home, and you want to write her a prescription for clozapine to take upon hospital discharge. You are told that you can’t!
What’s up with that? what Side effect?

Answer 36

You can’t write a prescription for clozapine bc you have to be a registered physician; responsible for causing agraunlar cytosis

Question 37

56 yo with long history of paranoid schizophrenia has been taking chloropromazine regularly for 27 years. About 5 years ago, he developed writhing movements of his wrists and fingers that disappear when he goes to sleep.
Which extrapyramidal syndrome is this?
akathisia
dystonia
nms
parkinsonism
tardive dyskinesia

Answer 37

tardive dyskinesia
usually affects perioral or limb musculature and causes choreiform movements. Its onset is usually several years after being on the medication, and it is more likely to affect older patients

akathisia is best descrbied as psychomotor restlessness that may have an onset of hours to days after beinning the neuroleptic

dystonia is an acute reaction to neuroleptics in which particular muscle groups (neck or occular muscles) comonly contract involuntarily. It can be painful and should be treated immediately with anticholinergics. NMS is a potentially lethal medical emergency in which patients may have global rigidity, mental status changes, fever, cardiovascular instability, elevated creatine phosphokinases, adn risk of rhabdomyolysis

Parkinsonism looks identical to parkinsonism with tremor and bradykinesia, and may have onset within weeks to months of beginning medication

Question 38

56 yo with long history of paranoid schizophrenia has been taking chloropromazine regularly for 27 years. About 5 years ago, he developed writhing movements of his wrists and fingers that disappear when he goes to sleep.
Which anatomic structure in the brain is most likely implicated in the etiology of this movement disorder?
basal ganglia
cerebellum
frontal cortex
midbrain
motor cortex

Answer 38

the basal ganglia, implicated in the yoking of thought to motor action, and in controlling the initiation and quality of motor action, is theorized to be central to the pathophysiology of extrapyramidal syndromes, including dystonia, parkinsonism, akathisia, and tardive dyskinesia.

The cerebellum is important in controlling the coordination of motor movements and posture, as well as participating in procdural memory.

The frontal cortex is generally considered to be important in decision making, impulse control, short-term memory, and affect regulation. The midbrain contains nuclei that help to ensure the CNS homeostasis by regulating neurovegatative, autonomic, and arousal functions. The motor cortex servs as the last stage of cerebral processing of motor information before it descends into the spinal cord. An intact motor cortex is required for initiation of movement.