Kirkpatrick: Antipsychotics

Question 1

What are antipsychoticcs used for?

Answer 1

psychosis
non-psychotic mania
autism
with antidepressants
behavioral probs in patients with dementia and delirium (2nd and 3rd line)

Question 2

Is schizophrenia entirely due to too much dopamine?

Answer 2

nooo!

Question 3

T/F: All cases of psychosis respond to antipsychotics

Answer 3

false

Question 4

Psychotic symptoms have a transient increase with infusion of low doses of ketamine (NMDA antagonist), MCPP (5HT antagonist), and cannabis. Why is this important to consider?

Answer 4

this fact refutes the dopaminergic hypothesis of schizophrenia

**schizophrenia not just a disease of dopamine overactivity

Question 5

There are two dopaminergic pathways. What are they? Which one do antipsychotics act on? Which pathway is associated with extrapyramidal side effects of antipsychotic meds?

Answer 5

1. mesocorticolimbic **target of antipsychotic meds

2. nigrostrital **extrapyramidal side effects

Question 6

What is one 1st generation antipsychotic we should know about?

Answer 6

haloperiodol (Haldol)

Question 7

What are 5 2nd generation antipsychotics we should know about?

Answer 7

Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperidal)
Ziprasidone (Geodon)

Question 8

T/F: All of the 2nd generation antipsychotics have superior efficacy, esp for negative symptoms

Answer 8

False!!

**no established superiority for negative symptoms

Question 9

T/F: 2nd generation drugs have no risk of EPS

Answer 9

False!!

**it varies by drug and is dose related

Question 10

T/F: More is better… If a patient isn’t responding to an antipsychotic, raise the dose! If a patient has symptoms in the gray zone, they should get a lower dose.

Answer 10

Just false

**there is a dose-response curve which shows that all antipsychotics hit a plateau at which point increasing the dose does not increase effectivity

Question 11

What are the 3 efficacy groups of antipsychotics?

Answer 11

1. Clozapine
2. Risperidone and Olanzapine
3. Everything else

Question 12

What are side effects of 1st generation drugs?

Answer 12

EPS
orthostatic hypotension
liver probs
neuroleptic malignant syndrome

Question 13

What are side effects of 2nd generation drugs?

Answer 13

metabolic side effects: weight gain, diabetes

some cause EPS

Question 14

Which second gen drugs can cause EPS?

Answer 14

risperidone (at high doses)

geodon and abilify

Question 15

This drug is in a class of its own; has superior efficacy but is difficult to use

Answer 15

Clozapine

Question 16

What are the side effects of Clozapine? The main side effect we should be concerned about?

Answer 16

agranulocytosis: it's reversible but requires that the pt get their blood drawn frequently
sustained tachycardia
weight gain
orthostatic hypotension
hypersalivation
sedation

Question 17

What are extrapyramidal side effects? What are these referred to as?

Answer 17

rigidity
tremor
bradykinesia
hypersalivation
neuroleptic malignant syndrome
akathisia (can't sit still)

**these are known as pseudoparkinsonian symptoms

Question 18

What are three ways you can treat extra pyramidal symptoms? What symptom is an exception to these treatment modalities?

Answer 18

• decrease dose or change med
• anticholinergic drugs, like diphenhydramine, trihexiphenidyl
• amantadine

**akathisia doesn’t respond to these treatments

Question 19

Two good strategies for treating akathisia (EPS). Will anticholinergics work?

Answer 19

change med
beta-blocker like propranolol;
no, anticholinergics are not effective

Question 20

What did the study on discontinuation of antipsychotics show? Which drug was the most effective?

Answer 20

1st gen antipsychotics were not superior to 2nd gen antipsychotics;
olanzapine was most effective!!

Question 21

What is one downside to olanzpine even though it was discontinued less often than other antipsychotics?

Answer 21

it causes weight gain and metabolic changes

Question 22

Syndrome of involuntary choreo-athethoid movements 
Not just the mouth and face 
Dose-related, time-related 
Especially first-generation drugs
Other EPS mark greater risk 
Male gender, African-American

Answer 22

tardive dyskinesia

Question 23

What happens when you stop meds that are causing tardive dyskinesia?

Answer 23

transient worsening of symptoms, then improvement

Question 24

T/F: Tardive dyskinesia worse for 1st gen antipsychotics

Answer 24

True

Question 25

What is a huge problem with Clozapine, olanzapine, and resperidone?

Answer 25

weight gain!!

Clozapine > olanzapine > resperidone

Question 26

How can you treat the weight gain associated with antipsychotic use?

Answer 26

change meds?
decrease dose?
exercise?
nutrition?
metformin

Question 27

Which receptor must you block to get EPS?

Answer 27

D2

Question 28

Which receptor must you block to get cognitive deficits, dry mouth, constipation, increased HR, urinary retention, and blurred vision?

Answer 28

M1

Question 29

Which receptor must you block to get sedation, weight gain, and dizziness?

Answer 29

H1

Question 30

This is increased in patients on antipsychotics and can lead to sudden death

Answer 30

QT interval

Question 31

What are 3 other risk factors for increased QT interval?

Answer 31

hypokalemia
hypomagnesemia
hypocalcemia

Question 32

This antipsychotic increases the QT interval by 30 sec!!!

Answer 32

thioridazine

Question 33

What two things are used to treat behavior problems and dementia?

Answer 33

antipsychotics

benzos

Question 34

Why are benzos bad for treating dementia?

Answer 34

they can lead to increased confusion and thus, increased falls :(

Question 35

What can be used instead to treat the behavioral problems and dementia?

Answer 35

citalopram

• *antidepressant
• *equal efficacy to risperidone

Question 36

How is abilify different from the other 2nd generation antipsychotics?

Answer 36

it is a partial dopamine agonist, which apparently has the same effect as a dopamine antagonist…