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105 Cards in this Set
- Front
- Back
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2 Main types of Antipsychotics:
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-Typicals
-Atypicals |
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What are the 2 subdivisions of Typical Antipsychotics?
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-High potency
-Low potency |
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How do the mechanisms of Typicals vs Atypicals differ?
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Typicals - D2 blockers
Atypicals - D2 and 5HT2 blockers |
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How does the mechanism of the Typical antipsychotics explain the etiology of Schizophrenia?
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Blocking D2 receptors decreases the Dopamine overactivity in the mesolimbic areas, but makes the Dopamine hypoactivity in Mesocortical areas worse; thus the Negative Sx
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So what is the hypothesis of how Schizophrenia develops called?
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The Dopamine hypothesis
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What are the 4 important Dopamine pathways in the brain? How does each relate to Schizophrenia and psychosis?
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-Mesolimbic (overactive - psychosis)
-Mesocortical (underactive - neg sx) -Nigrostriatal - Extrapyramidal sx -Tuberohypophyseal (Prolactin inhib) |
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So how do ANTIpsychotics affect the Dopamine pathways in the brain?
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-Block psychotic symptoms
-MAke negative symptoms worse -Cause EPS movement disorders -Disinhibits Prl secretion so increased prolactin results |
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What are the 5 highest potency Typical antipsychotics?
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-Pimozide
-Haloperidol -Fluphenazine -Thiothixine -Trifluoroperazine |
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What are the lowest potency Typical Antipsychotics?
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-Chlorpromazine
-Thioridazine |
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What is the major difference in High vs Low potency antipsychotics?
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Types of side effects
-Hi potency cause EPS -Lo potency cause Anticholinergic effects |
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When are the TYPICAL antipsychotics indicated for use?
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-Acute psychotic episodes w/ Hx of GOOD response with no s/e's, or poor response to atypicals
-Delirium |
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In what conditions that have psychotic symptoms can the Typicals be used?
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-Schizophrenia
-Schizoaffective disorder -Bipolar mania w/ psychosis (w/ MS) -Depression with psychosis (w/ AD) |
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What are the 6 major ATYPICAL antipsychotics to know?
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QCROZA
-Quetiapine -Clozapine -Risperidone -Olanzepine -Ziprasidone -Aripiprazole |
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Brand name for Quetiapine
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Seroquel
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Brand name for Clozapine
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Clozaril
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Brand name for Risperidone
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Risperdal
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Brand name for Olanzepine
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Zyprexa
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Brand name for Ziprasidone
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Geodon
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Brand name for Aripiprazole
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Abilify
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And what is the mechanism of action of the Atypical Antipsychotics?
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Block both D2 and 5HT2 receptors
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Why are the Atypical antipsychotics so much better than the Typicals?
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-Nigrostriatal/Tuberohypophyseal block is much less so fewer side effects
-5HT2 blockade mediates D2 block in underactive mesocortical pathways so much less worsening of negative sx |
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When are the Atypicals indicated and which one is the exception?
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In acute psychotic episodes - before the typicals, except for CLOZAPINE
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What are the 2 main Atypicals indicated for BIPOLAR MAINTAINENCE?
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-Aripiprazole (abilify)
-Olanzapine (Zyprexa) |
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What are the 2 main atypicals indicated for PSYCHOTIC AGITATION?
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-Ziprasidone (Geodon)
-Olanzepine (Zyprexa) |
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Why isn't Clozapine a first line antipsychotic agent?
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Becuase of its severe SIDE EFFECT profile
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When IS Clozapine indicated? 4 things
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-Treatment resistant patients
-When pts show severe Tard Dyskines -In patients w/ Polydipsia - HypoNa syndrome -In SUICIDAL patients w/ psychotic disorders |
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Why is Clozapine indicated in Treatment-resistant patients?
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Because 60% of patients unresponsive to other drugs show response to it
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Why is Clozapine indicated in patients with Severe TD?
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Clozapine is the LEAST likely to cause Tardive dyskinesia
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Why is Clozapine indicated in patients with Polydipsia-Hyponatremia syndrome?
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Clozapine causes REDUCED WATER DRINKING BEHAVIOR in these patients
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Why is Clozapine indicated in SUICIDAL patients with psychotic disorders?
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Clozapine shows a WELL DEMONSTRATED anti-SUICIDE effect
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What type of dose of Antipsychotics should be given for control of psychosis? How long?
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-MODERATE fixed dose for the first 4-6 WEEKS
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How should doses differ for patients with FIRST-BREAK psychotic episodes vs those with CHRONIC episodes?
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-First-break psychosis responds better so use LOWER doses
-Chronic patients need higher doses |
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What would happen if you RAPIDLY escaled the dose of antipsychotics?
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More sedation and more EPS may help control behavior better, but may reduce compliance due to side effects; won't affect the change in psychotic sx.
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What increases the chance of a better outcome of psychosis?
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Earlier treatment!
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What antipsychotics are available in DEPOT form? What is Depot?
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Fluphenazine/Haloperidol
Risperidone Depot is the drug suspended in OIL, injected IM and slowly released. |
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How often are the depot forms readministered?
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Every 2-4 weeks
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When are the long-acting Depot injection forms of antipsychotics used?
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-Court ordered medication
-Patients who have trouble remembering to take their meds |
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So what side effects are more typically seen with the HIGH-POTENCY typical antipsychotics?
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EPS
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What side effects are more typically seen with the LOW-POTENCY typical antipsychotics
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Anticholinergics - opposite of SLUD
Dry mouth/Dry eyes Urinary Retention Constipation Sedation, Weight gain, Low BP |
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What are 4 things All Typical Antipsychotics can cause regardless of potency?
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-Increased Prolactin
-Poikilothermia -Pigmented retinopathy -EKG changes |
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Which typical antipsychotic is particularly associated with the Pigmented Retinopathy?
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Thioridazine
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What are the 3 main symptoms of Hyperprolactinemia?
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-Galactorrhea
-Gynecomastia -Amenorrhea |
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What are the 5 major EPS side effects to be concerned about with the High Potency typicals? When do they tend to develop?
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-Dystonia - first 4 days
-Akathisia -Parkinsonian symptoms - 4 wks -Tardive dyskinesia - Late -NMS |
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What are the 4 common sites of Dystonia? Which are emergencies?
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-Tongue
-Back -Neck -Eyes Emerg - Ocular/Laryngospasm |
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What are 4 risk factors for developing Dystonia with a hi-potency typical antipsychotic?
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Young, Black, Muscular, Male
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What should be done for all patients under 30 yo who are put on a high-pot typical like Haloperidol or Fluphenazine?
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PROPHYLACTIC BENZTROPINE for first 10 days then taper
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What can happen if the prophylactic benztropine is continued beyond 10d?
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Actually increased Tard Dyskinesia
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What are 3 treatments for Dystonia?
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-Benztropine Intramuscular
-Diphenhydramine -Diazepine |
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How is Dystonia related to the ATYPICAL antipsychotics?
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Less common
-NONE with Clozapine |
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What is Akathisia?
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Dose related restlessness in the lower extremities that is very uncomfortable
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What are 3 treatment approaches for Akathisia?
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-Lower the dose
-Change to an Atypical -Treat w/ Benztropine, BDZs, or B-Blocker |
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When does Parkinsonism tend to develop as a side effect of Typical antipsychotics?
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First 4 WEEKS of treatment
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What is a risk factor for developing Parkinsonian symptoms as a side effect of Typical antipsychotics?
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Being ELDERLY
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What are treatment options for developing Parkinsonian symptoms as a side effect of Typical antipsychotics?
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-Lower the dose
-Change to an atypical -Use Benztropine or Amantadine |
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What are the Parkinsonian symptoms?
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-Resting tremor
-Cogwheel rigidity -Bradykinesia -Postural instability |
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What is Benztropine?
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An anticholinergic drug
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What is Tardive Dyskinesia?
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The late-developing, involuntary but suppressible choreoform movement disorder seen with long-term use of hi-potency typical antipsychotics
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How much does the risk of developing TD increase with each YEAR of exposure?
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4-5%
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What are 6 risk factors for developing TD?
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-Female
-Older -Hx of parkinsonism side effects -Larger doses -Affective disorder -Diabetes |
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What 3 antipsychotics do NOT cause tardive dyskinesia?
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-Seroquel (quetiapine)
-Olanzepine -Clozapine |
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3 treatment options if a patient does develop Tardive dyskinesia:
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-Lower the dose
-Switch to an atypical (SOC) -Vitamin E |
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So what meds could be given to treat
-Dystonia -Akathisia -Parkinsonian symptoms -Tardive dyskinesia |
Dyst - Benztropine/Diphenhy/Diazpam
Akth - Benztropine/BDZ/B-blocker Park - Benztropine/Amantadine TD - Vit E |
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Which EPS is NOT reversible?
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Tardive dyskinesia
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What medical emergency can develop with ANY antipsychotic?
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NMS - neuroleptic malignant syndrome
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What are 6 symptoms of NMS?
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HADCIM
-Hyperthermia -Autonomic instability -Diaphoresis -Confused -Increased CPK -Muscle lead-pipe rigidity |
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What are the 4 steps in TREATING NMS?
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1. Stop antipsychotic
2. Rehydrate 3. Control temperature 4. Dantrolene or Bromocriptine |
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How long after a patient has NMS should you wait before trying antipsychotics again?
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2 WEEKS
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With the Atypical Antipsychotics, what side effects are:
-Less common -More common |
Less EPS
More Diabetes/Weight gain |
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What is an additional side effect of the atypicals?
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QTc Prolongation!
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Which atypical is effective for treatment resistant patients?
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Clozapine
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What are the 4 beneficial features of Clozapine especially?
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-Prevents relapse
-Improves polydypsia -Reduces aggression -Reduces suicide risk |
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What is the bad thing about Clozapine?
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Many serious side effects!
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What are 6 serious side effects of Clozapine?
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SATSAD
-Sedation -Agranulocytosis -Tachycardia -Seizures -Anticholinergic effects -Drooling |
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How can you test for and avoid serious side effects if you do have to give Clozapine?
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Increase the dose SLOWLY
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What can cause toxicity w/ Clozapine?
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Cyp1A2 and Cyp3A4 inhibitors
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What are 4 things that inhibit Cyp1A2 and Cyp3A4
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Haldol
Antidepressants Luvox Quinolones |
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When during the course of Clozapine treatment do patients tend to develop Agranulocytosis?
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Between weeks 4-18
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So how is agranulocytosis avoided with Clozapine?
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-Weekly CBC for first 6 mo
-Twice weekly for next 6 mo -Monthly thereafter |
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At what WBC count should Clozapine be STOPPED?
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If less than 2000
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How long should you wait after Clozapine induced agranulocytosis before rechallenging?
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NEVER rechallenge
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Which Atypical Antipsychotic is considered a "Partial" atypical and why?
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Risperidone - because it becomes more like a Typical at higher doses like 6 mg
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What are 3 particular side effects more commonly seen with Risperidone than other atypicals?
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-Orthostatic hypotension
-EPS -Weight Gain and Diabetes (mod) |
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What feature is unique to Risperidone in contrast to the other atypicals?
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Only one available in depot form for long acting IM injections
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Which atypical has SUBSTANTIAL ANTIDEPRESSANT AND ANTI-MANIC EFFECTS?
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Olanzapine! Ole! aka Zyprexa
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So what is Olanzepine approved for?
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Bipolar depression along with Fluoxetine (Symbiax)
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Which side effects does Olanzepine cause
-Less -More |
Less: orthostatic hypotension
More: Diabetes/Weight gain/ VERY SEDATING |
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Which atypical antipsychotic is particularly ANTI-MANIC and ANXIOLYTIC?
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Quetiapine
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What side effects of Quetiapine are
-Less common -More common |
Less - Diabetes/Weight gain
More - SEDATING/orthostatic hypotension |
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Why does Quetiapine cause prominent orthostatic hypotension?
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Because of Potent alpha-1 blockade
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For what disorders is quetiapine often used?
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-Insomnia
-Borderline PD -Agitation/anxiety dt ventilator weaning |
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Which of the atypical antipsychotics is the LEAST sedating?
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Ziprasidone (Abilify)
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What effect is particularly seen with Ziprasidone?
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Potent antidepressant
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What else is seen least with Ziprasidone compared to the other atypicals?
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Weight gain
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What is Ziprasidone MOST NOTORIOUS for however?
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QTc prolongation
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What is Ziprasidone used for in its IM form?
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Acute agitation
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Why is QTc prolongation bad?
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It can lead to arrythmia and sudden death
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Which atypicals are most vs less likely to cause QTc prolongation?
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Most - Ziprasidone
Mid - Quetiapine Mid - Risperidone Least- olanzepine |
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Which of the Typicals are more vs less likely to cause QTc prolongation?
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Most - low potency (thioridazine)
Less - high potency |
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How do you monitor for QTc prolongation?
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Check K and Mg
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Which of the Typicals are more likely to cause Metabolic syndrome consisting of Weight gain?
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Low potency more than high
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What is the order of likelihood of the Atypicals causing metabolic syndrome and weight gain?
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High: Clozapine/Olanzepine
Med: Quetiapine/Risperidone Low = Aripiprazole/Ziprasidone |
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What 2 atypicals are the MOST COMMON causes of diabetes?
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Clozapine and Olanzepine
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When should weight be checked when patients are put on Antipsychotics?
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-4, 8, 12 weeks
-4 times per year after that |
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What weight gain should prompt a change in antipsychotic agent?
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Greater than 5% increase
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When should you check fasting glucose/lipids/BP?
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-3 months
-Annually |
