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Mental health > Antipsychotics > Flashcards

Antipsychotics Flashcards

1
Q

What are the different types of antipsychotics?

A
  • First generation (typical) antipsychotics
  • Second generation (atypical) antipsychotics
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2
Q

Which receptor is involved in the mechanism of action of antipsychotics?

A

D2 receptors

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3
Q

Name 2 first generation antipsychotics

A
  • Haloperidol
  • Chlorpromazine
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4
Q

What is the mechanisms of action of FGAs?

A

D2-antagonism in the CNS

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5
Q

List 2 indications for Haloperidol

A
  • Acute emergency rapid tranquillisation and sedation in:
    • Acute delirium
    • Agression/psychosis in Alzheimers
    • Schizophrenia and psychosis
    • Mania and hypomania
    • Severe tic disorders
  • NaV in palliative care
  • Restlessness/confusion in palliative care
  • Consider for post-op NaV
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6
Q

Name 2 side effects of Haloperidol

A
  • EPSP
  • Neuroleptic Malignant Syndrome
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7
Q

How is choice of antipsychotic decided?

A

Side effect profile (patient preference)

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8
Q

What is Neuroleptic Malignant Syndrome?

A

Life-threatening reaction in response to neuroleptic medication - due to dopamine blackage.

  • Fever
  • Autonomic instability
    • Tachycardia
    • Hypertension
  • Delirium/mental state changes
  • Muscular rigitiy
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9
Q

Outline the extrapyramidal symptoms which may be seen with antipsychotic use

A

Oculogyric crisis can be seen with arirpiprazole

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10
Q

How does efficacy vary between antipsychotics?

A

All antipsychotics have similar efficacy (60-70%). Therefore, choice is decided on side effect profile.

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11
Q

Name 4 second generation antipsychotics

A
  • Aripiprazole
  • Clozapine
  • Olanzapine
  • Quetiapine
  • Risperidone
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12
Q

Name 3 side effects of SGAs

A
  • Anti-histaminic: Weight gain, sedation
  • Anti-adrenergic: Tachycardia, sexual dysfunction, postural hypotension
  • Anti-cholinergic: dry mouth, blurred vision, urinary retention, constipation, cutaneous flushing
  • HTN
  • Hyperprolactinaemia
  • Impaired glucose tolerence: hyperglycaemia/diabetes
  • EPSE
  • Prolonged QTc
  • Neuroleptic malignant syndrome
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13
Q

Name two common side effects of Olanzapine and Clozapine?

A
  • Weight gain
  • Sedation
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14
Q

What 2 SGAs have the greatest risk of weight gain and sedation?

A
  • Olanzapine
  • Clozapine
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15
Q

What is the benefit of SGAs over FGAs?

A

SGAs have a lower risk of EPSEs. However, they still have potentially significant side effects that shouldn’t be ignored.

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16
Q

Outline the NICE guidance on first line choice of antipsychotic medication

A

SGAs and FGAs can be prescribed as first line medication, and this should be determined by side effect profile and patient preference.

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17
Q

Which side effects are Risperidone associated with?

A

Increased prolactin secretion Erectile dysfunction Feminisation (rare cause of SIADH)

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18
Q

Which side effect does not appear whilst on Quetiapine?

A

Quetiapine does not increase prolactin secretion

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19
Q

How does Aripiprazole differ from other SGAs? What is the effect of this?

A

Aripiprazole is a partial D2 agonist rather than a D2 antagonist. It has less metabolic side effects, but is also less effective.

20
Q

Besides D2 receptors, SGAs interact with which receptors?

A

Alpha 1 and 2 receptors Histamine receptors

21
Q

What syndrome is associated with SGAs?

A

Metabolic syndrome:

  • Waist circumference
  • HTN
  • Diabetes
  • Hyperlipidaemia
22
Q

How does Risperidone cause hyper-prolactinaemia?

A

Dopamine blockade removes the inhibition on prolactin secretion

23
Q

What is the effect of hyper-prolactinaemia?

A

*Think pregnancy state* Amenorrhoea Galactorrhea Gynaecomastia Sexual dysfunction - vaginal dryness or erectile dysfunction Feminisation - loss of body hair and muscle mass (osteoporosis)

24
Q

Outline the anti-muscarinic/cholinergic side effects

A

Blurred vision Urinary retention Dry mouth Constipation (Can’t see, can’t pee, can’t spit, can’t shit)

25
Q

Describe general antipsychotic monitoring needs

A

Metabolic: Weight, BMI, waist, BP, glucose, lipids at baseline, 3 months, and every 12 months ECG: assess QTc - beware that dual antipsychotics exponentially lengths QTc rather than additively. before starting antipsychotics

26
Q

What monitoring is required when taking clozapine?

A

FBC weekly (18wk), fortnightly (until 1yr) then monthly (indefinite). Clozapine levels if concerns over compliance.

27
Q

What is the indication for Clozapine?

A

Treatment-resistant schizophrenia: reduces overall mortality Not responding to at least two different antipsychotics, one of which is a non-clozapine SGA.

28
Q

What is the mechanism of action of Clozapine?

A

Blocks D1 and D4 receptors Low affinity to D2 - lack of EPSEs and hyperPRL

29
Q

Name 2 potentially fatal side effects of Clozapine

A

Agranulocytosis - acute severe dangerous leukopenia Myocarditis Cardiomyopathy

30
Q

What is the dosing regime of Clozapine?

A

Start at 12.5mg Second day: 25-50mg Gradually increase by 25-50mg up to 300mg May be increased by 50-100mg weekly *Seizure frequency increases above 600mg/d

31
Q

What is the traffic light reporting symptoms for Clozapine?

A

A written report system for blood results that advises the use of Clozapine and the risk of agranulocytosis. Green - Clozapine may be administered Amber - Caution, further blood samples advised Red - STOP Clozapine immediately

32
Q

Outline important DDIs of Clozapine

A

Clozapine undergoes extensive first pass metabolism via CYP enzymes. CYP1A2 inducers: Carbamazepine, phenobarbital, phenytoin, rifabutin, rifampicin. CYP1A2 inhibitors: Cimetidine, clarithryomycin, erythromycin, ciprofloxacin. CYP2D6 inhibitors: Amiodarone, cimetidine, clomipramine, haloperidol, fluoxetine, paroxetine, sertraline

33
Q

Name 3 highly protein-bound drugs, and state the effect this has on serum Clozapine

A

Digoxin Heparin Phenytoin Warfarin May increase serum concentration as it displaces protein-bound Clozapine.

34
Q

Name 3 CYP enzyme inducers

A

Carbamazepine Phenytoin Rifampicin Phenobarbital Rifabutin

35
Q

Name 3 CYP enzyme inhibitors

A

Clarithryomycin and erythromycin Ciprofloxacin Amiodarone Clomipramine Haloperidol Fluoxetine, paroxetine, sertraline

36
Q

What is the effect of smoking cigarettes whilst taking Clozapine?

A

Clozapine dosage becomes less effective as smoking increases its clearance, and may substantially reduce serum levels.

37
Q

What is an effect of Clozapine that is highly desirable for Schizophrenia?

A

Reduces mortality by lowering risk of suicide.

38
Q

Despite its potency, why is Clozapine not first line treatment for Schizophrenia?

A

Risk of fatal Agranulocytosis (1:4250) Risk of fatal myocarditis or cardiomyopathy (up to 1:1300)

39
Q

Why does Clozapine have such a strict dosing regime?

A

It is cardiotoxic to Clozapine naive patients Narrow therapeutic window

40
Q

Besides oral medication, what is the other route for antipsychotics?

A

Depot injections

41
Q

What is the benefit of depot injections over oral antipsychotics?

A

Depot injections are long-acting and provide a sustained release over 1-4 weeks. This increases compliance as the patient does not need to take as many tablets on a daily basis.

42
Q

What are the indications for depot injections?

A

Poor compliance with oral treatment Failure to respond to oral medication Memory problems Community Treatment Order

43
Q

Where are depot antipsychotics injected?

A

Large muscles - most commonly gluteus maximus

44
Q

Name 2 complications of depot injections

A

Pain/swelling at injection site Abscess Nerve Palsy

45
Q

What antipsychotic medications can be given as a depot?

A

Olanzapine Haloperidole Risperidone Aripiprazole

46
Q

Which specific side effects may occur when antipsychotics are used in elderly patients?

A

Increased risk of stroke Increased risk of VTE

Mental health (27 decks)

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