Psychiatry: Pharmacology - Antipsychotics and mood stabilisers Flashcards
Define neuroleptic agent
Subtype of antipsychotic that produces high incidence of EPSE at clinically effective doses
Define atypical antipsychotic
Antipsychotic that dissociates antipsychotic actions from EPSEs
Explain the serotonin hypothesis of schizophrenia. What class of drugs supports this hypothesis?
5HT(2A) receptor blockade reduces psychotic symptoms
Main class of atypical antipsychotics (e.g. clozapine, quetiapine) act as inverse agonists at 5HT(2A) receptors
Explain the dopamine hypothesis of schizophrenia. What drugs support this hypothesis?
Excessive limbic dopamine release is involved in schizophrenia (however this is no longer considered sufficient to explain all symptoms)
Antipsychotics antagonise D2 receptors
Drugs that increase dopamine (e.g. levadopa, amphetamines) can produce psychosis
Explain the glutamate hypothesis of schizophrenia. What class of drugs supports this hypothesis?
Hypofunction of NMDA receptors on inhibitory GABAergic interneurons leads to decreased inhibitory influences on neuronal function
Drugs that inhibit NMDA receptors (e.g. PCP, ketamine) exacerbate schizophrenia
Five structural classes of antipsychotic drugs with an example of each
- Phenothiazines (e.g. chlorpromazine, thioridazine, fluphenazine)
- Thioxanthenes (e.g. thiothexene)
- Butyrophenones (e.g. haloperidol)
- Miscellaneous (e.g. pimozide, molindone)
- Second-generation (atypical; e.g. clozapine, olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole)
Adverse effects of phenothiazines
Produces weight gain and sedation
Describe the potency and side effect profile of butyrophenones (e.g. haloperidol)
Tend to be more potent
Fever autonomic effects but more EPSEs
Describe the mechanism of action of atypical antipsychotics
Alter 5HT2A activity more than D2 activity
Most are partial 5HT1A agonists, which produces synergistic effects with 5HT2A antagonism
Five important dopaminergic pathways involved in schizophrenia, and the role of each
- Mesolimb-mesocortical: related to behaviour and psychosis
- Nigrostriatal: coordination of voluntary movement (blockade of D2 receptors in this pathway causes EPSEs)
- Tuberoinfundibular: dopamine release from these neurons inhibits prolactin secretion (causes hyperprolactinaemia when antagonised by antipsychotics)
- Medullary-periventricular: may be involved in eating behaviour
- Incertohypothalamic: regulates anticipatory motivational stage of copulatory behaviour
Describe the mechanism of action of antipsychotics
Effect dose of typical antipsychotics correlates with D2 (but not D1) receptor affinity
Most are D2 antagonists but some are partial agonists (e.g. aripiprazole)
Atypical antipsychotics also act as 5HT2A receptor antagonists (and so have good efficacy despite lower D2 receptor occupancy than typical antipsychotics)
Some also antagonise a2-adrenoceptors
Five examples of antipsychotics which antagonist a2-adrenoceptors
- Risperidone
- Olanzapine
- Quetiapine
- Clozapine
- Aripiprazole
What autonomic adverse effects are seen with antipsychotic use and what are the underlying mechanisms of these?
Muscarinic cholinoceptor blockade: loss of accommodation, dry mouth, difficulty urinating, constipation
a-adrenoceptor blockade: orthostatic hypotension, impotence, failure to ejaculate
What CNS adverse effects are seen with antipsychotic use and what are the underlying mechanisms of these?
Dopamine receptor blockade: Parkinson’s syndrome, akathisia, dystonias
Supersensitivity of dopamine receptors: tardive dyskinesia
Muscarinic blockade: toxic-confusional state
What endocrine adverse effects are seen with antipsychotic use and what are the underlying mechanisms of these?
Dopamine receptor blockade resulting in hyperprolactinaemia: menorrhoea-galactorrhoea, infertility, impotence
What is the mechanism of antipsychotic-associated weight gain?
Possibly combined H1 and 5HT2 blockade
What causes neuroleptic malignant syndrome?
Believed to be related to excessively rapid blockade of postsynaptic dopamine receptors
What is the clinical presentation of neuroleptic malignant syndrome?
Marked muscle rigidity (“lead pipe”)
Fever if sweating impaired due to anticholinergic effect
Stress leukocytosis
Elevated CK
Autonomic instability with altered BP and HR
May progress to catatonia, cardiovascular lability, hypothermia and myoglobinaemia if untreated
What is the mortality of neuroleptic malignant syndrome?
> 10%
How is neuroleptic malignant syndrome managed?
Supportive care
Antiparkinsonism drugs to counter EPSEs
Muscle relaxants (e.g. diazepam)
Cooling
After recovery should be switched to an atypical drug
What 7 symptoms are seen in antipsychotic overdose? How commonly is antipsychotic overdose fatal?
Rarely fatal
1. Drowsiness -> intervening period of agitation -> coma
2. Neuromuscular excitability -> convulsions
3. Miosis
4. Decreased deep tendon reflexes
5. Hypotension
6. Hypothermia (fever may occur in later stage)
7. Risk of cardiac arrhythmias specific to thioridazine and mesoridazine
Describe the general pharmacokinetics of antipsychotics
Absorption: most readily but incompletely absorbed, undergo extensive first-pass metabolism
Distribution: most highly lipid soluble and protein bound with large Vd (>7L/kg), have a longer duration of action than estimated from t1/2
Metabolism: by oxidation or demethylation catalysed by CYP450 enzymes, with major isoforms involved including CYP2D6, CYP1A2 and CYP3A4
What is the oral bioavailability of chlorpromazine compared with haloperidol? What accounts for this difference?
Chlorpromazine 25%, haloperidol 65% due to lesser degree of first-pass metabolism
How long after last injection do depot antipsychotics continue to produce D2 blockade?
3-6 months