Psychoses, related disorders and side effects

Question 1

Summarse the advice provided by the Royal College of Psychiatrists on doses of antipsychotic drugs above BNF upper limit (unlicensed) (7)

Answer 1

1) Consider alternative approaches and newer or second-generation antipsychotics such as clozapine
2) Bear in mind risk factors, including obesity; caution is indicated in older patients, especially > 70 years
3) Consider potential for drug interactions
4) Carry out ECG to exclude abnormalities e.g. prolonged QT interval; repeat ECG periodically and reduce dose if prolonged QT interval or other cardiac abnormality develop
5) Increase dose slowly and not more often than once weekly
6) Regular pulse, BP, and temperature checks; ensure that patient maintains adequate fluid intake
7) High-dose therapy to be for limited period and review regularly; abandon if no improvement after 3 months

Question 2

1) When prescribing an antipsychotic for administration on an emergency basis, how will the dose of the IM drug differ from that of the corresponding oral formulation?
2) what information needs to be specified on the Rx
3) how often should the dose be reviewed for an emergency?

Answer 2

1) IM dose should be lower than the oral dose, (esp if patient is very active due to increased blood flow in muscles leads to increased drug absorption)
2) Specify dose for each route
3) The dose for emergency use reviewed at least daily

Question 3

list the negative and positive symptoms of schizophrenia

Answer 3

1) Positive psychotic symptoms : Thought disorder, hallucinations, and delusions
2) Negative symptoms: Apathy and social withdrawal

Question 4

1) Antipsychotic drugs are effective at relieving what type of symptoms in schizophrenia?
2) which patents respond better to antipsychotic drugs; those with acute or chronic schizophrenia?

Answer 4

1) Effective at relieving positive psychotic symptoms, less effective on negative symptoms
2) Those with acute generally respond better

Question 5

why is early treatment of psychotic illness beneficial?

Answer 5

May protect against the development of negative symptoms over time

Question 6

Outline the MoA of the first-generation antipsychotic drugs and explain what side effects they are known to cause.

Answer 6

1) Act predominantly by blocking dopamine D2 receptors in the brain
2) not selective for any of the 4 dopamine pathways so cause many side-effects especially extrapyramidal symptoms and elevated prolactin

Question 7

Phenothiazine derivatives are first-generation antipsychotics which can be divided into 3 main groups. state which drugs are present in each group and the characteristics of each group.

Answer 7

1) Group 1: chlorpromazine , levomepromazine, promazine - pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects
2) Group 2: pericyazine, moderate sedative effects, but fewer extrapyramidal effects than groups 1 or 3
3) Group 3: fluphenazine decanoate, perphenazine, prochlorperazine, and trifluoperazine, fewer sedative and antimuscarinic effects, but more extrapyramidal side-effects than groups 1 and 2

Question 8

Butyrophenones (benperidol and haloperidol) resemble which phenothiazine derivative group with regards to their properties?

Answer 8

Resemble group 3 in their clinical properties- fewer sedative and antimuscarinic effects, but more extrapyramidal side-effects

Question 9

How do second generation antipsychotics (atypical antipsychotic ) differ from first generation drugs?

Answer 9

1) 2nd generation block D2 receptors, but also block 5HT2A receptors - more distinct clinical profiles and side-effects
2) 2nd gen: Higher risk of metabolic side effects vs 1st gen: higher risk of neurological side effects

Question 10

Risks vs benefit should be considered before prescribing antipsychotic drugs in elderly patients. Explain why caution is especially important in this group

Answer 10

1) Patients with dementia, there is a small increased risk of mortality and an increased risk of stroke or TIA
2) susceptible to postural hypotension and to hyper- and hypothermia

Question 11

what are the three recommendations regarding prescribing antipsychotic drugs in the elderly?

Answer 11

1) Not be used to treat mild to moderate psychotic symptoms
2) Initial doses should be reduced (half the adult dose or less), considering factors such as the patient’s weight, co-morbidity, and concomitant medication
3) Treatment should be reviewed regularly

Question 12

In those learning disabilities who are prescribed antipsychotic drugs and not experiencing psychotic symptoms, what considerations should be taken into account? (4)

Answer 12

1) a reduction in dose or the discontinuation of long-term antipsychotic treatment
2) review condition after dose reduction/discontinuation
3) referral to a psychiatrist experienced in working with patients who have learning disabilities and mental health
4) Annual documentation of the reasons for continuing a the antipsychotic if not dose reduced/discontinued

Question 13

which antipsychotic drugs are most frequently known for causing extrapyramidal symptoms?

Answer 13

1) The butyrophenones (benperidol and haloperidol)
2) Piperazine phenothiazines (fluphenazine, perphenazine, prochlorperazine, and trifluoperazine)
3) First-generation depot preparations

Question 14

Outline the 4 different types of extrapyramidal symptoms

Answer 14

1) Parkinsonian symptoms (including tremor), more commonly in adults or elderly and may appear gradually
2) Dystonia (abnormal face/ body movements) and dyskinesia. Commonly in children or young adults and appear after only a few doses
3) Akathisia (restlessness), Occurs after large initial doses
4) Tardive dyskinesia (rhythmic, involuntary movements of tongue, face, and jaw), Develops on long-term therapy or with high dosage. short-lived tardive may occur after withdrawal of the drug

Question 15

outline how parkinsonian symptoms caused by antipsychotics can be managed

Answer 15

1) Remit if the drug is withdrawn and may be suppressed by the administration of antimuscarinic drugs
2) Routine use of antimuscarinic not justified as not everyone is affected and they may unmask or worsen tardive dyskinesia

Question 16

Tardive dyskinesia is the most serious manifestation of extrapyramidal symptoms. Explain when this side effect might occur and which individuals are most at risk

Answer 16

1) In children, more likely to occur when the antipsychotic drug is withdrawn.
2) Frequently, in the elderly, review treatment carefully and regularly

Question 17

Tardive dyskinesia may be irreversible on withdrawing therapy and treatment is usually ineffective. What is recommended in order to halt the full development of this side effect?

Answer 17

Drug withdrawal at the earliest signs of tardive dyskinesia e.g. fine vermicular movements of the tongue, may halt its full development

Question 18

Sexual dysfunction is one of the main causes of non-adherence to antipsychotic medication. which antipsychotic drugs are most likely to cause this and how is it managed?

Answer 18

1) Risperidone and haloperidol

2) dose reduction or switching medication should be considered

Question 19

Most antipsychotic drugs increase prolactin because dopamine inhibits prolactin release.

1) which drugs are most likely to cause hyperprolactinaemia?
2) which antipsychotic drug reduces prolactin levels?

Answer 19

1) Risperidone, amisulpride- most likely to cause hyperprolactinaemia
2) Aripiprazole reduces prolactin because it is a dopamine-receptor partial agonist

Question 20

State the clinical symptoms of hyperprolactinaemia (5)

Answer 20

1) sexual dysfunction
2) Reduced bone mineral density
3) Menstrual disturbances
4) Breast enlargement
5) Galactorrhoea

Question 21

Antipsychotic drugs can cause CV side-effects such as tachycardia, arrhythmias, and hypotension. QT prolongation is a big problem. Which drugs are known to cause QT prolongation?

Answer 21

1) QT-interval prolongation : pimozide and haloperidol

2) more likely if using IV antipsychotics or combination of antipsychotic drugs with high unlicensed doses

Question 22

Hyperglycaemia, diabetes and weight gain can occur with antipsychotic drugs. which drugs are more likely to cause:

1) Hyperglycaemia
2) Weight gain

Answer 22

1) Hyperglycaemia: clozapine, olanzapine, quetiapine, and risperidone.
2) Clozapine and olanzapine commonly cause weight gain

Question 23

Hypotension and temperature regulation can cause falls and hypothermia or hyperthermia in the elderly. which drugs are most likely to cause postural hypotension?

Answer 23

Clozapine, chlorpromazine, lurasidone, and quetiapine can cause postural hypotension. (These are dose-related side effects)

Question 24

list the 8 main side effects of antipsychotic drugs

Answer 24

1) Extrapyramidal symptoms
2) Hyperprolactinaemia
3) Sexual dysfunction
4) Cardiovascular side-effects
5) Hyperglycaemia and weight gain
6) Hypotension and interference with temp regulation
7) Neuroleptic malignant syndrome
8) Blood dyscrasias

Question 25

Neuroleptic malignant syndrome is a rare but potentially fatal side-effect of all antipsychotic drugs. List some of the symptoms associated with this condition

Answer 25

1) labile BP, tachycardia, pallor
2) muscle rigidity, and autonomic dysfunction
3) fluctuating level of consciousness
4) hyperthermia, sweating
5) urinary incontinence

Question 26

Blood dyscrasias is a side effect of antipsychotic medication. Explain how this should be managed

Answer 26

Perform blood counts if unexplained infection or fever develops

Question 27

outline how neuroleptic malignant syndrome should be managed and how long it normally lasts for

Answer 27

1) Discontinuation of drug is essential as there is no effective treatment, but bromocriptine and dantrolene have been used.
2) Usually lasts for 5-7 days after discontinuation, longer in depot preparations