Antipsychotics-Kirkpatrick Flashcards
What are the appropriate uses of antipsychotics?
psychosis non-psychotic mania autism adjunct to antidepressants sometimes dementia w/ mood & behavioral issues (2nd or 3rd line) delirium (2nd or 3rd line)
What is the MOA of antipsychotics used to treat schizophrenia?
dopamine antagonists
one partial dopamine agonist–works same way tho
variable responses for patients
In double-blind studies, psychotic symptoms have a transient increase with infusion of low doses of:
Ketamine (an NMDA antagonist)
MCPP (a sertonin antagonist)
Cannabis
What are some important dopamine pathways?
Mesocorticolimbic
**Antipsychotic efficacy
Nigrostrital
**Extrapyramidal side effects
What are commonly used 1st gen antipsychotics? aka typical antipsychotics aka neuroleptics
fluphenazine–Prolixin
perphenazine–Trilafon
trifluoperazine–stelazine
haloperiodol–haldol
What are the 2nd gen drugs aka atypical antipsychotics?
aripiprazole (Abilify *) olanzapine (Zyprexa *) quetiapine (Seroquel) risperidone (Risperdal *) ziprasidone (Geodon) iloperidone (Fanapt) asenapine (Saphris) Paliperidone (Invega *) Lurasidone (Latuda)
Which of the 2nd gen drugs are a dopamine partial agonist?
aripiprazole–abilify!
What are the most commonly used 2nd gen antipsychotics?
aripiprazole-abilify
olanzapine-zyprexa
quetiapine-Seroquel
risperidone-risperdal
ziprasidone-geodon
**depot formulation & have to monitor in clinic for several hours
exists for ability, zyprexa, risperdal, invega
T/FAll of the 2nd generation drugs have superior efficacy, especially for negative symptoms
False
No established superiority for negative symptoms
Improvement in neg sx is due to improvement in other psychiatric symptoms and/or motor side effects
T/F 2nd generation drugs have no risk of extrapyramidal side effects.
False.
varies by drug & dose-related
T/F If a patient’s psychotic symptoms haven’t responded you should raise the dose
If a patient has particularly severe psychotic symptoms, he or she needs a higher dose
False
T/F If a patient has symptoms in the grey zone between odd experiences and clearcut psychosis, you should give a lower dose than usual
False.
What is an important thing to keep in mind w/ the shared dose-response curve for antipsychotics?
they all plateau!
What are the 3 efficacy groups for antipsychotics?
- clozapine
- risperidone & olanzapine
- all other antipsychotics
If clozapine is in the #1 efficacy group, why don’t more people prescribe it?
b/c it has greater side effects
& many people it does nothing for them.
What are the side effects of 1st gen drugs?
extrapyramidal side effects
orthostatic hypotension
liver problems
neuroleptic malignant syndrome
What are the side effects of 2nd gen drugs?
Primary: weight gain, diabetes
sometimes–extrapyramidal side effects
Which drugs have extrapyramidal side effects sometimes–2nd gen?
risperidone
geodon–akathisia
abilify-akathisia
What is the side effect profile of clozapine?
agranulocytosis--get blood drawn to check, reversible sustained tachycardia weight gain orthostatic hypotension hypersalivation sedation
What are extrapyramidal side effects?
Rigidity Tremor Bradykinesia Hypersalivation Neuroleptic malignant syndrome Akathisia
How do you treat extrapyramidal side effects? Except akathisia
decrease dose
change medication
anticholinergic drugs: diphenhydramine (benadryl), trihexiphenidyl (artane), benzotropine (cogentin)
amantadine
How do you treat akathisia?
beta blockers-propranolol
high doses of VIt B6
maybe clonazepam
anticholinergics don’t help
What’s the deal with discontinuation of antipsychotics?
74% discontinued w/i 18 mo
b/c of side effects, inadequate symptoms control, or other reasons
Although olanzapine is in class 2 efficacy, what is a bad thing about it?
weight gain! 2nd most weight-gain causing drug.
**efficacy-weight gain trade off with 2nd gen antipsychotics
1st gen-EPS trade off!
What is the extrapyramidal side effect of tar dive dyskinesia?
writhing or jerky movements
syndrome of involuntary choreo-athetoid movements
1st ten drugs have more likelihood of causing this, also dose-related
akathesia may be a precursor to this
male & African American risk factors
Why are many people with schizophrenia overweight?
iatrogenic b/c of antipsychotic side effects
naturally thin
What do you do with treatment of weight gain w/ antipsychotic meds?
exercise
nutritional counseling
metformin
consider decreasing dose or changing medication
Weight gain is probably caused by lack of specificity of antipsychotics, binding which receptor?
histamine-H1
**also causes sedation & dizziness
When D2 is bound…what are the side effects?
EPS
prolactin elevation
When M1 is bound…what are the side effects?
cognitive deficits dry mouth constipation increased heart rate urinary retention blurred vision
IF alpha 1 is bound…SE?
hypotension
What is a QT prolongation?
Electrical depolarization & repolarization of the ventricles
Increased interval a risk factor for
ventricular tachyarrhythmias
especially torsades de pointes (“twisting of the spikes”)
sudden death
**a side effect of some antipsychotics
QT interval is normal based off of heart rate. Normal is roughly ____. What is considered a risk for sudden death in males & females?
Normal: ≤400 ms (some disagreement) Risk of sudden death: Borderline for males: 431-450 Abnormal for males: < 450 Borderline for females: 451 – 470 Abnormal for females: > 470
What are some additional risk factors or increased QTc?
Hypokalemia Hypomagnesemia Hypocalcemia Hypothermia Hep C HIV Myocardial ischemia Post-cardiac arrest Increased intracranial pressure Congenital long QT syndrome Medications
What are some medications that can cause increased QT interval?
Amisulpride Clozapine Fluphenazine Haloperidol Olanzapine Perphenazine Quetiapine Risperidone Thioridazine Ziprasidone
4 ms for risperidone
30 ms for thioridazine
What can be some difficult features of dementia?
psychosis, agitation, suspiciousness, irritability are common
**frequently treated with antipsychotics & benzos
Good treatment: psychosocial intervention
If you treat dementia with benzos…what might happen?
increased confusion
falls! b/c of sedation. could lead to death in an older person.
What is the black box warning of every antipsychotic?
increased mortality in elderly patients with dementia related psychosis
what is an alternative to antipsychotics to treat dementia patients?
citalopram
**may not work in patients with vascular dementia
Focus on which drugs?
haloperidol (haldol)
top 5 2nd gen
abilify-different MOA partial dopamine agonist. still stops dopaminergic transmission
know EPS symptoms
weight gain w/ clozapine & olanzapine
keep in mind agranulocytosis possible w/ clozapine
What is the categorization of clozapine?
2nd gen antipsychotics
