Antipsychotics

Question 1

Second generation anitpsychotic examples

Answer 1

Clozapine
Amisulpride
Quetiapinne
Aripiprazole
Olanzapine
Risperidone

Question 2

Examples of first generation antipsychotics

Answer 2

Haloperidol
Zuclopenthixol
Sulpiride
Chlorpromazine
Flupenthixol

Question 3

How do first gen anitpsychotics work? e

Answer 3

Block dopamine 2 receptors

Question 4

four dopamine pathways

Answer 4

Mesocortical
Mesolimbic
Nigrostriatal
Tuberoinfundibular

Question 5

What dopamine pathway is ass with EPSE?

Answer 5

Nigrostriatal

Question 6

Which dopamine pathway is ass with hyperprolactinaemia?

Answer 6

Tuberoinfundibular

Question 7

Side effect profile of 1st generation antipsychotics

Answer 7

EPSE
Hyperprolactinaemia
Antimuscarininc side effects

Question 8

Risks from antipsychotics

Answer 8

Sedations
EPSE - dystonia, arkathisia, parkinsonism, tardive dyskinesia
Neuroleptic malignant syndrome

Question 9

Risks from antipsychotics

Answer 9

Sedations
EPSE - dystonia, arkathisia, parkinsonism, tardive dyskinesia
Neuroleptic malignant syndrome

Question 10

How to manage dystonia

Answer 10

Anticholinergics eg procyclidine

Question 11

How to manage akathisia?

Answer 11

Reduce the dose/change to an alternative antipsychotic drug
Reduction of symptoms - addition of low dose eg propanolol

Question 12

Antipsychotics and physical health long term risks

Answer 12

Cardiovascular
Dyslipidemia
Weight gain
Diabetes
Hyperprolactinaemia
ESPSE

Question 13

How can affect on cardiac conduction from antipscyhotics present?

Answer 13

Increased QT interval
Torsades de pointes
Ventricular fibrillation
Sudden death

Question 14

What counts as a prolonged QTc intervl?

Answer 14

> 450ms is concerning
(women <470, men <440ms)
500ms - unquantifiable risk of leading to torsade de pointes - review and action

Question 15

What antispychotics are ass with the highest risk of dyslipidemia?

Answer 15

Olanzapine and clozapine

Question 16

What monitor with olanzapine and clozapine esp?

Answer 16

Lipid levels

Question 17

How often monitor lipid levels on olanzapine and clozapine?

Answer 17

Full lipid profile at baseolinne
3 months
Then annually

Question 18

When do you add atorvastatin 20mg daily on olanzapine or clozapine treatment>

Answer 18

CVD risk score >10% or >NICE guiidanve

Question 19

What use to determine primary CV prevention if necessary (statins)>

Answer 19

QRISK3 tool

Question 20

When is risk of weight gain on antipsychotics highest

Answer 20

first 6 months treatment

Question 20

Why do antispychotics cause weight gain?

Answer 20

Unknown but related to sedative effect of H1 receptor binfing affinity/insulin resistance

Question 21

What causes hyperprolactinaemia in antispychotics?

Answer 21

Dopamine inhibits prolactin release, so dopamine antagonsits increase plasma prolactin levels

Question 22

What antipsyhcotics do not increase prolactin above normal range at standard dose?

Answer 22

Clozapine, olanzapine, quetiapine and aripiprazole

Question 23

What determines if an antipsychotic causes hyperprolactinaemia?

Answer 23

Dose realted - all have potnetual

Question 24

What are the symptoms of hyperprolactinaemia?

Answer 24

Galactorrhea, amernorrhea, gynaecomastia, hypogonadism, sexual dysfunction, reduction in BMD

Question 24

What are the symptoms of hyperprolactinaemia?

Answer 24

Galactorrhea, amernorrhea, gynaecomastia, hypogonadism, sexual dysfunction, reduction in BMD

Question 25

What does hyperprolactinaemia increase the risk of?

Answer 25

Osteoporosis and breast cancer

Question 26

What are depot antipsychptics>

Answer 26

Long acting formulation of antipsychotics

Question 27

How often are depot anitpsychotics used?

Answer 27

1-4 weekly, monthly and 3 monhtly deoending only certain medciations availale as depot

Question 28

Advantages of depot antipsychotics

Answer 28

Useful in non complicant patients Convenient who struggle with oral formulations

Question 29

Disadvantages of depot antipsychotic medications

Answer 29

Plasma lecels maintained for long time - ADRs, interactions Unable to sitch antipsychotics quickly

Question 30

How long does it take for a drug to be eliminated?

Answer 30

5 half lives

Question 30

How long does it take for a drug to be eliminated?

Answer 30

5 half lives

Question 31

How long is half life of haloperidol?

Answer 31

21-28 dyas minimum of 105 days

Question 32

What differentials would you have for: * Patient has diaphoresis, tremor, rigidity, unsteady gait * Tachycardia 125bpm * Temp 38.3 C * BP 120/84 * CK 6763 (25-200) * CRP 54 (0-5) * ESR 33 * AST 244 (0-40) * ALT 102(0-40)

Answer 32

Neuroleptic Malignant Syndrome * Malignant catatonia * Serotonin syndrome * Thyrotoxicosis * Heatstroke * CNS infection

Question 33

Cuases of neuroleptic malignant syndrome

Answer 33

Dopaminergic antagonism + context of physiological stressors/genetic predisposition first (more common) and second gen antipsyhcotics, antidepressatns (SSRIs, lithium) Combo

Question 33

Cuases of neuroleptic malignant syndrome

Answer 33

Dopaminergic antagonism + context of physiological stressors/genetic predisposition first (more common) and second gen antipsyhcotics, antidepressatns (SSRIs, lithium) Combo

Question 34

What combination of psychiatric drugs increases risk of NMS>

Answer 34

Antipsychotics and SSRIs

Question 35

Signs and symptoms of NMS?

Answer 35

Fever Diaphoresis Rigidity Confusion Fluctuating consciousness Fluctuating BP Tachycardia Elevated creatinine kinase Altered LFTs

Question 35

Signs and symptoms of NMS?

Answer 35

Fever Diaphoresis Rigidity Confusion Fluctuating consciousness Fluctuating BP Tachycardia Elevated creatinine kinase Altered LFTs

Question 36

How uquizkly can NMS be fatal?

Answer 36

1-3 dyas

Question 37

Risk factors for NMS - drug realted

Answer 37

High potency typical drigs Recent or rapid dose increase Rapid dose reduction Abrupt withdrawal of anticholinergics Genetic vulnerability

Question 38

Other risk factors for NMS (not drug related)

Answer 38

Catatonia - prodromal Pscyhosis Organic brain disease Alcoholism Parkinsons disease agitated/overactive and/or in need of restraint or seclusion

Question 39

Diagnostic tests for NMS?

Answer 39

Raised CK CK - elevated > 1000 AST/ALT Few signs /symptoms

Question 40

How to treat NMS?

Answer 40

aNTIPSYCHOTICS, lithium, antidepressant withdrawal Monitor temp, pulse, BP Benzodiazapine - lorazepam Correct any dehydration, hyperpyrexia Med unit/A+E - rehydration, bromocriptine + dantrolene

Question 41

When are bromocrpitine and dantrolene used in A+E?

Answer 41

Muscle relaxants - Neuroleptic malignant syndrome

Question 42

How to restart antipsychtics after NMS?

Answer 42

STOP for at least 5 days Reintroduce on v small dose, increase slowly, consider antipsychotic structurally undrealted or with low affinity for dopamine eg clozapine or quetiapine