Antipsychotics Flashcards
Give examples of first generation/typical antipsychotics
Chlorpromazine Haloperidol Prochlorpromazine Fluphenazine Zuclopenthixol
What is the mechanism of action for typical antipsychotics?
Dopamine D2 receptor blockers
Give examples of second generation/atypical antipsychotics
Aripiprazole Clozapine Olanzapine Rispiridone Quetiapine
What is the mechanism of action for atypical antipsychotics?
More selective blockade of certain D2 receptors
Also block 5-HT receptors
Which type of antipsychotics are more likely to cause extra-pyramidal side effects?
Typical/first generation
What are the extra-pyramidal side effects?
Parkinsonism
Tardive dyskinesia
Akathisia
Acute dystonia
What is tardive dyskinesia?
Lip smacking Rocking Rotating ankles Marching in place Repetitive sounds --> happens with chronic use
How is tardive dyskinesia treated?
Tetrabenazine (monoamine uptake inhibitor)
What is akathisia?
Inner state of restlessness
- carries an increased risk of suicide
What is acute dystonia?
Painful, sustained muscle spasm
- especially of neck (torticollis), jaw or eyes
How can acute dystonia be treated?
Procyclidine, Benztropine or Prochlorperazine
Which type of antipsychotic is thought to have the greatest risk of metabolic syndrome?
Atypical (second generation)
- especially clozapine and olanzapine
What other side effects are seen with antipsychotic drugs?
Raised prolactin Sedation + apathy Metabolic syndrome - weight gain and T2DM Stroke and VTE risk in elderly Sexual dysfunction Long QT Neuroleptic malignant syndrome Postural hypotension Photosensitivity (chlorpromazine)
Why do antipsychotics increase prolactin?
Dopamine usually inhibits it’s release
Which atypical antipsychotic has a potentially better side effect profile?
Aripiprazole
- lower risk of sedation and metabolic syndrome
- LOWERS prolactin
Which antipsychotic can be considered most effective, but the ‘dirtiest’?
Clozapine –> lots of side effects
What are the side effects of clozapine?
Sedation Metabolic syndrome Hypotension Constipation Anti-cholinergic Hypersalivation Agranulocytosis --> FBC monitoring
How is hypersalivatin associated with clozapine treated?
Hyoscine hydrobromide
What might happen if a patient on clozapine stops smoking?
Levels may jump suddenly –> look out for side effects
What are the features of neuroleptic malignant syndrome?
Develops within 2 weeks of starting drug
- hyperthermia
- altered mental status
- muscle rigidity (raised CK)
- dysautonomia: raised HR, labile BP, sweating
What is the drug management for schizophrenia?
1st line: oral (ideally) or depot, 1st or 2nd generation antipsychotic
- if one fails, switch to another
2nd line: Clozapine if 2 different antipsychotics have been ineffective
When are depot antipsychotic injections preferred?
If compliance is poor
Which tests need to be done at baseline and annual check up?
FBC, U+E, LFTs
Metabolic/CV:
- fasting glucose, HbA1c, lipids, weight, waist circumference, BP, ECG
Prolactin
What additional monitoring is required?
Weight: weekly for first 6 weeks, then at 3 months BP, HR, lipids and glucose at 3 months Prolactin at 6 months ECG for haloperidol FBC for clozapine
Which non-drug management should be offered for schizophrenia?
Individual CBT alongside antipsychotic Family intervention Art therapy Lifestyle advice Social support
How regularly does FBC need to be monitored in a patient taking clozapine?
Weekly for first 6 months
Fortnightly for the next 6 months
Then every 4 weeks
For one month after cessation of clozapine
When should you be worried about agranulocytosis?
Sore throat in a patient on clozapine –> get a FBC
Why is ECG monitoring required in patients taking clozapine?
Risk of myocarditis
How should an acutely psychotic patient be managed if they are being difficult?
Non drug approaches first: - use of distraction - seclusion - try talking to them Drug sedation
What are the options for sedating an acutely psychotic patient?
Lorazepam 1-2mg
+/- Haloperidol 5mg
Try oral first, if unsuccessful –> lorazepam IM
