Antipsychotics

Question 1

What are antipsychotics primarily used for and what else can they be used for?

Answer 1

Schizophrenia, but they are also effective against other psychotic and manic disorders, and recurrent suicidal thoughts and behavior

Question 2

What is the main difference between first and second generation antipsychotics as far as side effects?

Answer 2

First generation agents are more likely to be associated with movement disorders known as EPS because they bind so tightly to dopamine receptors

Second generation do not have the movement disorder side effects but they have more metabolic side effects

Question 3

What is the primary MOA for first generation antipsychotics?

Answer 3

Block D2 post synaptic receptors with a tiny bit of 5ht2

Question 4

First generations agents can also block which receptors?

Answer 4

Muscarinic, alpha adrenergic and histamine

Question 5

Besides the side effects that come from blocking the other 3 receptors, what 2 other side effects can occur when taking a first generation agent?

Answer 5

QTc prolongation and seizure activity

Question 6

2 dopamine associated side effects with First generation agents?

Answer 6

Too much prolactin

EPS, specifically acute akathisia/Parkinson like issues and tardive dyskinesia

Question 7

How do we further break down the first generation agents and what does this classification mean?

Answer 7

Either high potency or low potency for the D2 receptor. This doesn’t mean efficacy, but has more to do with the adverse effect profile.

Low potency leads to more sedation, hypotension and seizures
High potency leads to more EPS and endocrine issues through too much prolactin

Question 8

2 types of drugs we can use to treat EPS?

1 family of drugs we can use to treat Tardive Dyskinesia and give two examples?

Answer 8

Anticholinergic agents and Benadryl

VMAT2 blockers, valbenazine and Deutetrabenazine

Question 9

What is the primary MOA of second generation antipsychotics?

Answer 9

Block D2 receptors and 5HT2a, and they block the serotonin ones way more.

Question 10

3 metabolic side effects for the second generation antipsychotics?
What is a class warning for SGA?

Answer 10

Diabetes, high cholesterol and weight gain

Stroke, especially in the elderly with dementia

Question 11

What is 1 rare but severe side effect for Clozapine?

What is 1 rare but severe side effect for Olanzapine?

Answer 11

Agranulocytosis

DRESS, drug reaction with eosinophilia and systemic symptoms

Question 12

What is 1 rare but severe side effect he mentioned with all antipsychotics, what is the name and presentation?
What are the 4 clinical signs/symptoms of it?
What is the MOA of the side effect?
What 2 drugs do we use to treat it?

Answer 12

NMS, neuroleptic malignant Syndrome. Parkinson like movement disorder with wide spread muscle contraction.
Altered mental status, muscle rigidity and rhabdomyolysis, hyperthermia, and dehydration
Ryanodine receptor remains open so calcium is out and causing contraction
Dantrolene to close the ryanodine receptor or bromocriptine

Question 13

What are 4 baseline values we want for patients who will be prescribed antipsychotics?
2 medical history items we want as well?

Answer 13

Glucose, lipids, weight, BP

Personal and family history of metabolic and CV disease

Question 14

4 scales we can use for antipsychotic monitoring?

Answer 14

GASS, AIMS, BARS and SAS

Question 15

2 clinical indications for clozapine?

Answer 15

Multi drug resistance

Psychotic with anti suicidal thoughts and behaviors

Question 16

How can we best treat those patients who are not very good with compliance/adherence to the treatment protocol because adherence is key?
What are the 4 specific drugs?

Answer 16

Long acting injectable agents
R - risperiodone
O - olanzapine
A - Aripiprazole
P - Paliperidone

Question 17

What is generally first line therapy for schizophrenia?

What is the clinical use for the second generation Agents?

Answer 17

First generations

Use second generations for people who experience EPS with first generations

Question 18

All antipsychotics lower the threshold for what?

Answer 18

Seizure activity