side effects of anti psychotics Flashcards
is there difference in efficacy between each antipsychotic drug
little difference (other than clozapine)
is there a 1st line antipsychotic drug
no first line that is suitable for all pt
properties of individual drugs need to be considered and discussed with pt or carers when prescribing
when do extrapyramidal symptoms occur and which drugs are they most likely to occur with
- dose related
- most likely to occur with high doses of high potency 1st gen antipsychotics e.g.
- piperazine G3 phenothiazines - fluphenzine and trifluoperazine
- butyrophenones: benperidol and haloperidol
- 1st gen depot preps
name the two group 3 piperazine phenothiazine 1st gen antipsychotics that you are most likely to get extrapyramidal symptoms with if the pt is taking high doses
trifluoperazine and fluphenazine
name the 5 first gen antipsychotics you are most likely to get extrapyridamol symptoms with if taking high doses
- perazine phenothiazines: trifluoperazine and fluphenzine
- haloperidol and benperifol
- depot 1st gen preps
name the 4 second gen antipsychotics for which extrapyridamol symptoms are less common, as they have lower liaility for both acute and late onset extrapyridamol symptoms
clozapine
quetiapine
olanzapine
aripiprazole
COQA
what are pakinsonian symptoms, and who are they more likely to appear in and when might it happen
includes bradykinesia, tremor
may occur more commonly in elderly females or those with pre-existing neurological damage such as stroke, and may appear gradually
what is dustonia and who is it more likely to occur in and when may it happen
uncontrolled muscle spasm in any part of the body
occurs more commonly in young males
acute dystonia can appear within hours of starting antipsychotics
what is akathisia and when may it occur and what might it be mistaken for
restlessness
characteristically occurs within hours to weeks of starting antipsychotic treatment or on dose increase
may be mistaken for psychotic agitation
the following extrapyramidal symptom may be mistaken for psychotic agitstion
akathisia (restlessness)
what is tardive duskinesia and when may it occur and who is it more likely to occur in
abnormal involuntary movements of lips, tongue, face, and jaw
can develop on long-term or high-dose therapy, or even after discontinuation
in some patients it can be irreversible
more common in elderly females
in some patients, the following extrapyramidal symptom can be irreversible
tardive dyskinesia - abnormal involunaty movement of lips, tongue, face, jaw
name 4 main extrapyramidal symptoms
parkinsonian symptoms (including bradykinesia, tremor)
dystonia (uncontrolled muscle spasm in any part of body)
akathisia (restlessness)
tardive dyskinesia (abnormal involuntary movement of lips, tongue, face, jaw)
what to do when parkinonsian symptoms are identified e.g. bradykinesia, tremor
review treatment with the aim of reducing exposure to high dose and high potency antipsychotics (i.e. piperazine phenothiazines like fluphenazine and trifluoperazine, haloperidol and benperidol and the depot preparations)
this drug class can releiev symptom burden (parkinsonian symptoms with antipsychotics) but they should not be routinely prescribed for prophylaxis
antimuscarinic drugs
what is the most serious manifestation of late-onset extrapyramidal symptoms for which there is no satisfactory treatment
tardive dyskinesia
Tardive dyskinesia is the most serious manifestation of late-onset extrapyramidal symptoms for which there is no satisfactory treatment. it occurs more commonly in
elderly females
what to do with antipsychotic drugs if tardive dyskinesia occurs
Antipsychotic treatment should be carefully and regularly reviewed
Any changes to dose or drug should be made gradually, over weeks or months, to minimise the risk of withdrawal tardive dyskinesia
However, some manufacturers suggest that drug withdrawal at the earliest signs of tardive dyskinesia (fine vermicular movements of the tongue) may halt its full development.
which antipsychotic drugs cause hyperprolactinaemia
most of them - both 1st and 2nd gen
why do antipsychotics cause hyperprolactinaemia
most (both 1st and 2nd gen) increase prolactin conc to some extent because dopamine inhibits prolactin release
the antipsychotics work by blocking dopamine, therefore increasing prolactin
this drug reduces prolactin concentration in a dose dependent manner because it is a dopamine receptor partial agonist
aripiprazole
aripirazole REDUCES prolactin concentration (opposite of hyperprolactinaemia which is a common SE of most antipsychotics) to some extent because …
it is a dopamine receptor partial agonist
1st generation antipsychotics and the following TWO 2nd gen are MOST likely to cause sympomatic hyperprolactinaemia
1st gen (+sulpiride) risperidone, amisulpride,
hyperprolactinaemia is very rare with the following 5 antipsychotics (2nd gen)
- aripiprazole
- asenapine
- cariprazine
- clozapine
- quetiapine
clinical symptoms of hyperprolactinaemia include the following 6
sexual dysfunction
reduced bone mineral density
menstrual disturbances
breast enlargement
galactorrhoea
possible increased risk of breast cancer
sexual dysfunction is a side effect of which antipsychotics?
all
Sexual dysfunction is reported as a side-effect of all antipsychotic medication. What are 3 contributing factors to this?
physical illness
psychiatric illness
substance misuse
Antipsychotic-induced sexual dysfunction is caused by more than one mechanism. explain 3
Reduced dopamine transmission and hyperprolactinaemia decrease libido; antimuscarinic effects can cause disorders of arousal; and alpha1-adrenoceptor antagonists are associated with erection and ejaculation problems in men
these 3 drugs have higher prevalence to cause sexual dysfunction
Risperidone, haloperidol, and olanzapine
HOR
these 2 drugs have the lowest risk of sexual dysfunction
aripiprazole and quetiapine
AQ
what to do with antipsychotic drugs if sexual dysfunction is thought to be antipsychotic induced
Expert sources advise to consider dose reduction or discontinuation (where appropriate), or switching medication
antipsychotic drugs are associated with CV side effects such as … (3)
tachycardia
arrhythmias
hypotension
This CV side effect is a particular concern with pimozide
QT interval prolongation
QT interval prolongation is a particular concern with this drug
pimozide
the overall risk of QT interval prolongation is probably dose related, but there is also a higher probability of QT interval prolongation in pt using …. (3)
pimozide (paricular concern is QT interval prolongation)
pt using any IV antipsychotic drug
any antipsychotic drug or combination or antipsychotic drugs with doses exceeding recommended maximum
Antipsychotic drugs with a low tendency to prolong QT interval include
aripiprazole, asenapine, clozapine, flupentixol, fluphenazine decanoate, loxapine, olanzapine, paliperidone, prochlorperazine, risperidone, and sulpiride.
postural hypotension is a common cardiac side effect of which antipsychotics
all
Postural hypotension is a common cardiac side-effect of antipsychotic drugs, usually presenting acutely during the initial dose titration; however,
it can also be a chronic problem
postural hypotension is bad because it can lead to
syncope and dangerous falls related injuries, especially in the elderly
what are the 2nd gen that are most likely to cause postural hypotension
clozapine
quetiapine
what is used to mimimise postural hypotension
slow dose titration
schizophrenia is associated with these metbaolic disorders
insulin resistance and diabetes
Schizophrenia is associated with insulin resistance and diabetes; do antipsychotics further increase this risk?
the risk of diabetes is probably increased in all patients with schizophrenia who take antipsychotic drugs
these 2 have the lowest risk of diabetes in the 2nd gen antipsychotic class
amisulpride
aripiprazole
AA
some evidence suggests that this generation of antipsychotic drugs are less liekly to cause diabetes than the other generation
1st gen less likely than 2nd gen
of the 1st gen, the following 2 drugs have the lowest risk of diabetes
haloperidol
fluphenazine
which antipsychotics cause weight gain
all
these 2 drugs commonly cause weight gain
olanzapine
clozapine
the following drugs are least likely to cause weight gain
Amisulpride, asenapine, aripiprazole, cariprazine, haloperidol, lurasidone hydrochloride, sulpiride, and trifluoperazine
what is neuroleptic malignant syndrome and which drugs does it occur with?
rare but potentially fatal side-effect of all antipsychotic drugs
what are the symptoms of neuroleptic malignant syndrome
hyperthermia, fluctuating level of consciousness, muscle rigidity, and autonomic dysfunction with fever, tachycardia, labile blood pressure, and sweating
a patient is in A&E. she is in and out of consiousness, has fever, is sweating, has hyperthermia and have tachycardia. when looking at her drug history, you suspect she has the following. What do you do?
these are some symptoms of neuroleptic malignant syndrome
rare but potentially fatal SE of all antipsychotics due to D2 blockade
expert sources advice discontinuation for at least 5 days, pref longer
allow signs and symptoms of NMS to resolve completely
how long is it advised to discontinue antipsychotic drugs for if a patient has neuroleptic malignant syndrome
essential to discontinue for at least 5 days, pref longer
allow for signs and symptoms of NMS to resolve completely
these two drugs have been used in the treatment of neuroleptic malignant syndrome
bromocriptine
dantrolene
hyperglycaemia is more likely with these antipsychotics (CROQ)
clozapine
risperidone
olanzapine
quetiapine
Hypotension more likely with CQ
clozapine and quetiapine
QT prolongation most common with these two
pimozide
haloperidol
extrapyrimdal SE most likely in these 2 groups of 1st gen
group 3 phenothiazine
butyrophenones