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PR3136 > Antipsychotics > Flashcards

Antipsychotics Flashcards

1
Q

Schizophrenia:

  • Acute or chronic?
  • Time of onset
  • Consequence on individual
A
  • Chronic disease
  • Onset in late adolescence/ early adulthood
  • Highly disabling to social and vocational functioning
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2
Q

The five symptom domains of schizophrenia

A
  1. Positive sx
  2. Negative sx
  3. Anxiety/depression
  4. Aggressive sx
  5. Cognitive sx

(focus on positive and negative sx)

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3
Q

Examples of “Positive sx” in schizophrenia and its “function” in the disease

A
  1. Delusion
  2. Hallucinations
  3. Abnormal behaviours (E.g. stereotypical)
  4. Thought disorder, incl. feeling that thoughts are controlled by outside agency

Function: Presentation of these sx most disturbing, leads to referral to psychiatrist and detection of schizo

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4
Q

Negative sx in Schizophrenia and its impact on the patient

A
  1. Withdrawal from social contacts
  2. Flattening of emotional responses

Impact: Negative sx most distressing (while positive sx characterised by lack of insight)

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5
Q

As Schizo progresses, which of the five symptoms of schizophrenia becomes dominant?

A

Negative sx

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6
Q

In 10% schizo cases, suicide occurs. Why is this so?

A

Schizo is frequently associated with depression

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7
Q

What are some possible secondary causes of negative sx?

A
  1. Depression
  2. Extrapyramidal sx (EPS)
  3. Environmental deprivation
  4. Positive sx
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8
Q

What are some examples of cognitive dysfunction of schizo. What is the cause of cognitive dysfunction in schizo patients?

A
  1. Impaired selective attention (unable to focus and retain info)
  2. Impaired working memory

Cause: The disease itself (i.e. persistent core feature of disease, no iatrogenic)

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9
Q

Why is the level of cognitive dysfunction important in treatment of schizo?

A

Helps predict level fo social and vocational functioning, hence treatment outcome. It is a better predictor than positive sx.

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10
Q

Factors that may lead to Schizo

A
  1. Genetic factors (mutationof various genes)

2. Environmental factors: related to neurodevelopmental abnormalities (e.g. maternal viral infections during preg)

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11
Q

What are some possible evidence showing “neurodevelopmental abnormalities” in Schizo Patients?

A
  • Onset in late adolescence/ early adulthood
  • Myelination of cortico-cortical pathways is abnormal
  • Enlarged ventricles, abnormalities in laminar organisation of cortical cells
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12
Q

State the three neurochemical theories of Schizo. What characteristic of Schizo do these theories attempt to explain?

A
  1. Dopamine Theory
  2. 5-HT Theory
  3. Glutamate Theory

These theories proposed are primarily theories of positive sx

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13
Q

Describe Dopamine Theory. How did dopamine theory come about?

A

D2 receptor activity is associated with Schizo

  1. Amphetamine, a dopaminergic, produces sx of acute schizo
  2. Drugs are D2 antagonists
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14
Q

Four dopamine pathways of the Brain and their functions. What pathways are the proposed drug targets?

A
  1. Nigrostriatal: Part of extrapyramidal motor system (affected in PD)
  2. Mesolimbic: Reward and emotion
  3. Mesocortical: Cognition and attention
  4. Tuberoinfundibular: Prolactin secretion into blood circulation

Drug targets: 2 and 3

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15
Q

Describe the 5-HT Theory in Schizo

A
  • Lysergic acid diethylamide (LSD), a 5-HT2 agonist, produces sx similar to acute Schizo
  • Many atypical antipsychotics have 5-HT2 antagonism
  • Hence excess 5-HT is associated with Schizo
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16
Q

Describe the Glutamate Theory in Schizo

A
  • Drugs blocking NMDA receptor chanel (e.g. PCP, ketamine) produce sx similar to acute Schizo
  • Hence NMDA receptor associated with Schizo
  • No clinically useful drugs yet
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17
Q

One of the most widely used TYPICAL antipsychotic

A

Haloperidol

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18
Q

Some examples of ATYPICAL antipsychotics

A
  1. Amisulpride
  2. Clozapine
  3. Olanzapine
  4. Risperidone
19
Q

Similarity between Typical and Atypical antipsychotics

A

Control positive symptoms

20
Q

One important difference between Atypical Antipsychotics over Typical Antipsychotics

A

Atypical produce less extrapyramidal SE

21
Q

Other than D2 receptor, what are other receptor that Chlorpromazine binds to, hence its side effects and loss in popularity as an atipsychotic?

A
  1. M1 receptor: Parasympatholytic effects (dry mouth, constipation, blurred vision)
  2. H1 receptor: Sedation, Weight gain
  3. Alpha-1 receptor: postural hypotension, dizziness (body unable to respond to orthostatic changes)
22
Q

Advantage of Haloperidol over Chlorpromazine

A
  • Haloperidol does not block M1 and H-1 receptor

- Hence less SE

23
Q

Three examples of extrapyramidal SE in antipsychotic drugs. What is the mechanism leading to these SE?

A
  1. Acute Dystonias (involuntary contraction of muscles)
  2. Tardive Dyskinesia (involuntary stiff and jerky movements)
  3. Akathisia (inner restlessness)

Mechanism: Actions on extrapyramidal motor pathways (affects basal ganglia –> Striatum and substantia nigra)

24
Q

Describe acute dystonias caused by antipsychotics. During treatment, when does it occur? How does it occur? Is it reversible?

A
  • Parkinsonism-like syndrome (e.g. cogwheel rigidity, tremor at rest)
  • Occurs within first few weeks of treatment and reversible when drug is stopped
  • May be caused by D2 antagonism in nigrostriatal pathway
25
Q

Similarties and differences between Tardive Dyskinesia and Akathisia caused by antipsychotics?

A

Similarties:

  • Irreversible
  • Caused by upregulation or supersensitivity of D receptors in nigrostriatal system (due to initial blockade)

Differences:
- Akathisia, but not dyskinesia, correlates directly with duration on medication

26
Q

Main difference between ATYPICAL and TYPICAL antipsychotics

A

Atypical has LESS severe extrapyramidal SE (but still have)

27
Q

Other characteristics of ATYPICAL antipsychotics

A
  1. Greater affinity at 5HT2 receptors
  2. Greater affinity at D4 receptors
  3. Mixed antagonism at a-adrenoceptors, H1-histamine receptors, M receptrs and 5-HT2 receptors
28
Q

“Core” of most ATYPICAL antipsychotics (i.e. their main MoA)

A

Serotonin-dopamine antagonism (SDA)

29
Q

Are there common receptor affinity between ATYPICAL antipsychotic drugs?

A

No. They have complex mixtures of actions

30
Q

Rare but significant and fatal AE of Clozapine

A

Clozapine-induced agranulocytosis

31
Q

SEs of ATYPICAL antipsychotics. Which drugs exhibits most of which SE?

A
  1. Parasympatholytic: Clozapine, Olanzapine
  2. Sedation due to H1 receptor antagonism: Clozapine, Olanzapine
  3. Postural hypotension, reflex tachycardia: Risperidone
32
Q

Describe the receptor binding of Amisulpride, which has an atypical pattern of receptor affinities for an atypical antipsychotic

A
  • Selective D2/D3 antagonist

- (some 5-HT7 antagonism)

33
Q

What advantages does the unique receptor affinities of amisulpride gives?

A
  • Less SE due to selective D2/D3 antagonism

- Little a-adrenoceptor block, antihistaminergic and anticholinergic SE

34
Q

Adverse effects of amisulpride

A
  1. Increased prolactin secretion (due to blocked D2/D3 receptors in anterior pituitary gland)
  2. Breast swelling, pain and lactation
  3. Gynaecomastia in males
35
Q

What is Aripiprazole’s MoA?

A
  • Partial Agonist of D2 & D3 receptors

- In presence of agonist, it exhibits antagonistic effects

36
Q

An AE of ATYPICAL antipsychotics, that is significant and not reversible.

  • Which drugs may cause it?
  • Mechanism?
A

New onset or exacerbation of diabetes

  • Drugs: clozapine, Olanzapine, Risperidone
  • Exception: Amisulpride
  • Unknown mechanism
37
Q

Which ATYPICAL antipsychotics causes Drug-induced Weight Gain? What is the possible mechanism(s)?

A

Drugs:

  1. Clozapine
  2. Olanzapine
  3. Risperidone

Possible mechanisms:

  • Sedation by H1 histamine antagonism = sedentary lifestyle
  • a-adrenoceptor and 5-HT2 antagonism on hypothalamus = altered feeding behaviour (does NOT explain for chlorpromazine)
38
Q

Drug that is currently in experimental use to treat anorexia nervousa

A

Olanzapine

39
Q

Ways in which ATYPICAL antipsychotics produce less EPS, and which drugs correspond to which way?

A
  1. Potent 5-HT2A vs weak D2 antagonism: lower EPS, higher efficacy against negative sx
    - Clozapine, Olanzapine
  2. High D4:D2 antagonism ratio favour actions in prefrontal cortex over striatum
    - Clozapine
  3. High D3:D2 antagonism ratio favour actions on nucleus accumbens over striatum
    - Amisulpride
  4. High D2:D1 antagonism ratio reduce impact of antagonism in striatum
    - Amisulpride, Risperidone
40
Q

How does higher D2:D1 antagonism ratio confer less blockade on dopaminergic function?

A
  • Presynaptic D2 are autoreceptors
  • Blockage of D2 inhibits negative feedback, allowing more dopamine to be released
  • Hence less complete blockade of dopaminergic function
41
Q

Additional benefits of ATYPICAL antipsychotics compared to typical antipsychotics, and drugs that exhibit them

A
  1. More effective against negative sx
    - Clozapine, Olanzapine, Risperidone
  2. Better at mood stabilisation
    - Clozapine, Olanzapine, Risperidone
  3. Ameliorate cognitive dysfunction better
    - Clozapine, Risperidone

Note: These effects are still weak, only suitable for patients who start out with more severe negaitve sx

42
Q

How effective are antipsychotic treatment?

A
  • Some do not respond
  • Some remain severely disabled in social and occupational function
  • Some recover to near pre-illness levels of function
  • Few can have meds discontinued and retain near pre-illness levels of function

Hence there is still need for improved antipsychotic drugs

43
Q

Among the EPS SE caused by antipsychotics, which is/are reversible when the drug is stopped?

A

Dystonias

44
Q

Examples of TYPICAL antipsychotics

A
  1. Haloperidol
  2. Chlorpromazine
  3. Fluphenazine
  4. Trifluoperazine

PR3136 (18 decks)

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