Antipsychotics

Question 1

What are the 5 main dopamine pathways in the brain?

Answer 1

Mesolimbic pathway 
mesocortical pathway 
nigrostriatal pathway 
tuberoinfundibular pathway 
hypothalamospinal pathway

Question 2

What are the dopaminergic side effects?

Answer 2

extra pyramidal side effects + neuroleptic malignant syndrome + hyperprolactinaemia + akathesia/restless legs

Question 3

What are 3 examples of extra pyramidal side effects?

Answer 3

Acute dystonic reaction
parkinsonism
tardive dyskinesia

Question 4

Describe acute dystonia presentation?

Answer 4

• onset in minutes
• increasing muscle tone
• energetic
• torticolis (head to one side as neck muscles contracted)
• oculogyric crisis (eye muscles all contract, eyes deviate upwards)
• tongue protrusion

Question 5

What other drugs other than antipsychotics can cause acute dystonia?

Answer 5

Antihistamines

antiemetics

Question 6

Describe tardive dyskinesia presentation.

Answer 6

often after years of treatment - permanent
involuntary repetitve oro-facial movements
blinking, grimacing, pouting, lip-smacking common
may involve limbs and/or trunk

Question 7

Why are anticholinergic drugs used to treat extra-pyramidal side effects of antipsychotics?

Answer 7

to balance out the acetylcholine and dopamine = there is less dopamine as dopamine has been inhibited and so acetylcholine is in excess in comparison to dopamine

Question 8

List 3 anticholinergic drugs used to alleviate side effects from antipsychotics

Answer 8

procyclidine
trihexyphenidyl
orphenadrine

Question 9

In neuroleptic malignant syndrome what dopamine pathways are affected?

Answer 9

Hypothalamic

Nigrostriatal

Question 10

Tardive dyskinesia is treatable. True/false

Answer 10

False - very difficult to treat once caused by antipsychotics

Question 11

How does neuroleptic malignant syndrome present?

Answer 11

1-3 days onset
gradually increasing muscle tone
hyperpyrexia
autonomic instability
often FATAL!! if not treated

Question 12

How does neuroleptic malignant syndrome lead to death?

Answer 12

increasing muscle tone -> rhabdomyolysis -> Acute renal failure -> coma -> death

Question 13

What is the key investigation for neuroleptic malignant syndrome?

Answer 13

Creatinine Kinase

Question 14

What is the treatment for neuroleptic malignant syndrome?

Answer 14

A&E!!!

• Stop antipsychotic
• renal support
• rapid cooling
• skeletal muscle relaxants e.g. dantroline
• dopamine agonists e.g. bromocriptine

Question 15

What dopaminergic pathway is affected in hyperprolactinaemia side effect of antipsychotics?

Answer 15

Tuberoinfundibular

Question 16

What dopaminergic pathway is affected in akathisia caused by antipsychotics?

Answer 16

Hypothalamic spinal pathway

Question 17

How many patients report akathisia?

Answer 17

1/5

Question 18

How does akathisia present?

Answer 18

within days-weeks
pacing 
rocking from foot to foot
unable to sit still
bad sleep as result 
leads to suicide risk

Question 19

What are the treatments for akathisia?

Answer 19

first line: beta blockers e.g. propranolol

second line: long acting benzodiazepines e.g. clonazepam

Question 20

What are 3 anti-cholinergic effects?

Answer 20

dry mouth
blurred vision
constipation

Question 21

What are 5HT2 side effects?

Answer 21

weight gain -> metabolic syndrome -> T2DM

Question 22

What is an example of anti-adrenergic effect?

Answer 22

Postural hypotension

Question 23

What neurotransmitter do benzodiazepines enhance?

Answer 23

GABA which is a neurotransmitter that suppresses the activity of nerves

Question 24

What are 3 other side effects of antipsychotics?

Answer 24

hepatotoxicity
prolonged QTc interval
photosensitivity

Question 25

Generally first/second generation antipsychotics are thought to cause more weight gain and sedation and first/second generation antipsychotics are thought to cause more extra-pyramidal side effects side effects?

Answer 25

Second gen - weight gain & sedation | First gen - EPSE

Question 26

approx. what percentage of patients experience neuroleptic malignany

Question 27

What is the best antipsychotic including for the negative syndrome?

Answer 27

Clozapine

Question 28

What are the side effects of clozapine?

Answer 28

agranulocytosis - need white cell count monitoring regularly myocarditis - need ECG monitoring regularly constipation (most dangerous side effect!!) weight gain sedation sialorrhoea

Question 29

What approach is used when picking an antipsychotic for treating schizophrenia?

Answer 29

First step: 2nd generation titrate to adequate dose for 6-8wks If not working, next: 1st/2nd generation titrate to adequate dose for 6-8 wks Next: check diagnosis, consider psychological input, check compliance Last: clozapine or combine two antipsychotics

Question 30

Which are considered first line in treating schizophrenia - typical/atypical? Give two examples of both.

Answer 30

Atypical first Atypical examples: risperidone, olanzapine Typical examples: haloperidol, chlorpromazine

Question 31

Which type (typical/atypical) of antipsychotics are better when treating negative syndrome schizophrenia?

Answer 31

Atypical

Question 31

Which type (typical/atypical) of antipsychotics are better when treating negative syndrome schizophrenia?

Answer 31

Atypical

Question 32

What is the main mechanism behind antipsychotics?

Answer 32

Dopamine antagonists - aim to block D2 receptors but block others too

Question 33

What pharmacological options is there for when a patient with schizophrenia becomes agitated, uncooperative, aggressive?

Answer 33

Benzodiazepines: Lorazepam oral/IM Antipsychotics: Haloperidol/olanzapine oral/IM Sedating antihistamines: promethazine oral/IM