Psych 1 Flashcards
What are the 2 categories of antipsychotics?
Typical antipsychotics (first generation antipsychotics; FGA)
Atypical antipsychotics (second-generation antipsychotics; SGA)
Uses for antipsychotics
delusions, hallucinations, paranoid behavior, non-psychiatric disorders (nausea and intractable hiccups)
What causes the antipsychotic action in meds?
antipsychotic action comes from their blocking of CNS dopamine receptors in the mesocortical/mesolimbic dopamine tracts of the brain
Blocking of dopamine can lead to?
Extrapyramidal effects
Hypersecretion of prolactin
Antiemetic action
Sedation and weight gain
High doses - confusion, memory loss, delirium, tachycardia, and dry skin
Which antipsychotics block histamine receptors and cause sedation/ weight gain?
quietiapine and olanzapine
EPS is caused by?
Result of accumulated use of antipsychotics over several years of exposure
Akathisia
Inability to sit still, tapping of feet, restlessness
Dystonia
A state of muscle spasms of face, tongue, back, and neck
When can dystonia occur w/ antipsychotics?
first 5-30 days of use of the medication
Parkinson-like symptoms
Mask-like face, tremors, shuffling gait, and hypersalivation, which mimic the four classic signs of Parkinson’s disease
Tardive dyskinesia (TD)
characterized by rhythmic tongue protrusion, puffing of cheeks, and puckering of mouth
When can TD occur with antipsychotic use?
may occur after 3 months of exposure to an antipsychotic, but usually occurs after several years
Neuroleptic malignant syndrome (NMS)
emergency (can be fatal) that includes a combination of hyperthermia, rigidity (extrapyramidal effect), and autonomic dysregulation
NMS characteristics
Characterized by body temperature exceeding 100.4°F (may go as high as 107°F), altered level of consciousness, tachycardia, labile BP, diaphoresis, tachypnea, urinary or fecal incontinence, rigidity, stupor, coma, and acute renal failure
Tx of NMS
Stop offending drug
Supportive tx - hyperthermia and ventilation
Dantrolene, bromocriptine or amantadine - can be used to reverse dopamine blockage and free up the rigidity
Long term affects of antipsychotics
Other long-term use can affect weight, cholesterol, and glucose metabolism (exacerbate metabolic syndrome)
Why should antipsychotics be tapered off in most cases?
may experience nausea, vomiting, dizziness, tremors, and withdrawal dyskinesia if stopped cold turkey
Which antipsychotic drugs produce the greatest EPS?
haloperidol, fluphenazine
Which antipsychotics cause the greatest anti-cholinergic and antihistamine effects?
thioridazine, chlorpromazine
Antipsychotic Black Box warning
elderly patients with dementia-related psychosis may have an increased risk of mortality
Phenothiazines examples
1st gen
haloperidol
chlorpromazine
fluphenazine
prochlorperazine
Phenothiazines MOA
Block dopamine at the chemoreceptor trigger zone, and peripherally inhibit the vagus nerve in the GI tract
Phenothiazines use
Acute, idiopathic psychotic illnesses marked by agitation
Bipolar disorder
Schizophrenia
Management of nausea and vomiting
Migraines
Intractable hiccups (Chrlorpromazine)
Phenothiazines SE
orthostatic hypotension, QT prolongation
Hyperglycemia, weight gain
Dry mouth, constipation, increased appetite
Decreased libido, inhibited ejaculation, urinary retention
Extrapyramidal syndrome (EPS), drowsiness, neuroleptic malignant syndrome
Amphetamines + phenothiazides result in what?
Decrease antipsychotic effect of the phenothiazides
Phenothiazides can do what to DM?
Increase BS thus result in weaker control of DM
Dopaminergic antiparkinson drugs (Levodopa) + phenothiazides?
Antagonize the antipsychotic effect of the phenothiazides
Phenothiazines contraindications
Parkinsonism
Blood dyscrasias
Severe liver impairment
Severe cardiac disease - Avoid use with other drugs that cause QT prolongation
Severe CNS depression
Why are Atypical Antipsychotics atypical?
Considered atypical because of their superior ability to not induce extrapyramidal side effects (EPSE) or elevation of prolactin levels
What is special about clozapine?
Clozapine is the only atypical antipsychotic with clear evidence of efficacy in treatment-resistant schizophrenia.
Clozapine increases risk of what?
increased risk of agranulocytosis, seizures, and myocarditis
Atypical Antipsychotics examples
aripiprazole
clozapine
lurasidone
olanzapine
paliperidone
quetiapine
risperidone
ziprasidone
Atypical Antipsychotics MOA
Partially interfere with the binding of serotonin at its receptor sites in the cortex, blocking serotonin, which inhibits the release of dopamine
Atypical Antipsychotics use
Psychosis in patients with schizophrenia
Depression or mania with psychotic features
Bipolar disorder
Severe agitation and delusions in patients with dementia
Atypical Antipsychotics SE
QT prolongation, orthostatic hypotension, reflux tachycardia
Clozapine can cause agranulocytosis
Weight gain
Atypical Antipsychotics Black Box warning
Clozapine - agranulocytosis, orthostatic hypotension, bradycardia, syncope, and increased mortality in demented geriatrics
Atypical Antipsychotics contraindications
Liver impairment
When switching antipsychotic meds, what methods are available?
“wash out” or a “cross-titration.”
Miscellaneous Antipsychotics examples
pimozide
loxapine
molindone
thiothixene
Miscellaneous Antipsychotics MOA
Competitively block postsynaptic dopamine receptors and increase turnover of dopamine in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla
Miscellaneous Antipsychotics use
Psychotic episodes when a tranquilizing effect also needed (good for agitated pts)
Tourette’s syndrome (pimozide)
Miscellaneous Antipsychotics SE
Orthostatic hypotension
Weight gain
decreased sexual functioning
barbiturates, hypnotics, narcotics, alcohol, or antihistamines + Miscellaneous Antipsychotics can cause?
CNS depressants (barbiturates, hypnotics, narcotics, alcohol, or antihistamines) taken with a typical antipsychotic further increase CNS depression.
Miscellaneous Antipsychotics contraindications
Parkinsonism
Blood dyscrasias
Severe liver impairment
Severe cardiac disease
Severe CNS depression
What is the Abnormal Involuntary Movement Scale (AIMS)?
Scale used to monitor motor function in pts taking antipsychotics to monitor for early signs of EPS
How is acute psychosis tx?
In cases of acute psychoses, rapid and effective sedation is usually achieved by combining an antipsychotic with a benzodiazepine (IM or IV) - Haldol + lorazepam
Atypical antipsychotics are better because?
Fewer anticholinergic effects
Less dystonia and parkinsonism
Lower risk of tardive dyskinesia
Potential minimization of other adverse effects (orthostatic hypotension)
In addition to medication tx, what is another important factor in schizophrenia tx?
A support structure is important
How long do antidepressants need to start working?
Therapeutic effects may take 4-8 weeks to manifest.
Third-line agents to tx depression?
MAOIs
MAOIs must be stopped for 14 days before switching meds, why?
Irreversibly inhibit monoamine oxidase; before any other drugs are administered for depression, the MAOIs must be stopped for 14 days
MAOI examples
tranylcypromine
Phenelzine
isocarboxazid
MOAI MOA
Irreversible, nonselective inhibitors of the enzyme monoamine oxidase in its CNS storage sites
MAOIs use
Refractory unipolar depression
MAOI SE
Orthostatic hypotension
Constipation, nausea
dizziness, headache, insomnia
MAOI interactions
Amphetamines, antidiabetic drugs, SSRIs
SSRI + MAOI can lead to what?
SSRIs, tricyclic antidepressants, and other drugs/alcohol with CNS effects when interacting with MAOIs can cause serotonin syndrome and increased risk of hypertensive crisis.
MAOI contraindications
Liver impairment
Renal impairment
Cardiovascular disorders
Foods high in Tyramine
aged cheese, beer, wine, pickled products, liver, raisins, bananas, figs, avocados, chocolate, yogurt, and meat tenderizer
TCAs are considered _____ line agents
2nd
TCA examples
amitriptyline
doxepin
nortriptyline
TCA MOA
increasing levels of norepinephrine and serotonin in the synaptic cleft
TCA uses
Depression
Neuropathic pain (amitriptyline)
Enuresis
Obsessive compulsive disorder
Panic disorder
Fibromyalgia
Headache
Irritable bowel syndrome
TCA SE
dry mouth, urinary retention
Orthostatic hypotension, prolonged QT
weight gain
Sedation, engaging in unusual or dangerous activities
TCA black box warning
increased suicidality in adolescents (up to age 24)
In which pts is Doxepin contraindicated in?
Glaucoma or urinary retention
How long does it take TCAs to work?
Therapeutic/beneficial effects may take 2 to 3 weeks.
Abrupt TCA d/c can cause what?
Abrupt discontinuation after long-term use may lead to withdrawal syndrome in 36-72 hours, including dizziness, nausea, paresthesias, anxiety/insomnia lasting for 3-7 days.
Which TCA is the least sedating?
Nortriptyline
Which TCAs are the most sedating?
amitriptyline, and doxepin
