Antipsychotics

Question 1

MOA of first and 2nd generation antipsychotics:

Answer 1

First: Block D2 Receptors

Second: Block D2 and 5HT-2A Receptors

Question 2

Efficacy differences in 1st and 2nd generation antipsychotics =

Answer 2

They both treat positive symptoms to the same degree but atypical antipsychotics treat negative symptoms better.

Question 3

Which are the low potency antipsychotics?

Answer 3

• Chlorpromazine

- Thioridazine

Question 4

Which are the mid-potency antipsychotics?

Answer 4

• Loxapine
• Thiothixene
• Trifluoperazine
• Perphenazine

Question 5

Which are the High Potency antipsychotics?

Answer 5

• Haloperidol
• Fluphenazine
• Pimozide

Question 6

What differentiates a low from a high potency antipsychotic =

Answer 6

affinity for the D2 receptor–the lower the affinity, the lower the potency

Question 7

Difference in terms of side effects between lower and higher potency antipsychotics =

Answer 7

Low potency antipsychotics:

• more likely cause anticholinergic & antihistaminic s/e.
• more likely to cause QTc prolongation
• more likely to cause seizures
• more likely to cause agranulocytosis

High potency antipsychotics:

• more likely to cause EPS and NMS.
• More likely to cause tardive dyskinesia

Question 8

Chlorpromazine:

• Class =
• Common side effects =
• Indications =

Answer 8

• Class =
  • Low potency typical antipsychotic

- Common side effects =
   • Orthostatic Hyptotension
   • Bluish Skin
   • Photosensitivity
   • Obstructive Jaundice

- Indications =
   • Intractable hiccups
   • Nausea
   • Vomiting
   • Antipsychotic

Question 9

Thioridazine

• Class =
• Common side effects =

Answer 9

• Class =
  • Low potency typical antipsychotic
• Common side effects =
  • Retinitis Pigmentosa

Question 10

Loxapine

• Class =
• Common side effects =
• Metabolite acts as a…

Answer 10

• Class =
  • Mid potency typical antipsychotic
• Common side effects =
  • Higher risk of seizure
• Metabolite =
  • Antidepressant properties

Question 11

Thiothixene

• Class =
• Common side effects =

Answer 11

• Class =
  • Mid potency typical antipsychotic
• Common side effects =
  • Ocular pigment changes

Question 12

Trifluoperazine

• Class =
• Indications other than anti psychosis =

Answer 12

• Class =
  • Mid potency typical antipsychotic
• Indications =
  • Anxiolytic

Question 13

Perphenazine

• Class =

Answer 13

• Class =

• Mid potency typical antipsychotic

Question 14

Antipsychotics with decanoate forms available =

Answer 14

• Fluphenazine

- Haldol

Question 15

Pimozide

• Class =
• Common side effects =

Answer 15

• Class =
  • High potency typical antipsychotic
• Common side effects =
  • Heart Block
  • V-Tach
  • Other cardiac effects

Question 16

Fluphenazine

• Class =

Answer 16

• Class =

• High potency typical antipsychotic

Question 17

Brain pathway associated with the positive symptoms of schizophrenia =

Answer 17

Mesolimbic Dopamine Pathway

Question 18

Structures within the mesolimbic pathway =

Answer 18

• Nucleus accumbens
• Fornix
• Amygdala
• Hippocampus

Question 19

Brain pathway associated with the negative symptoms of schizophrenia =

Answer 19

Mesocortical dopamine pathway

Question 20

Brain pathway associated with the EPS of antipsychotics =

Answer 20

Nigrostriatal pathways

Question 21

NMS symptoms =

Answer 21

“FALTERED”

• Fever (most common sx)
• Autonomic Instability
• Leukocytosis
• Tremor
• Elevated CPK
• Rigidity
• Excessive sweating (diaphoresis)
• Delirium

Question 22

“Blue-gray skin discoloration” from…

Answer 22

Chlorpromazine

Question 23

Clozapine

• Class =
• Indications =
• Side effects =
• Effect on Suicide =

Answer 23

Class:
- Atypical Antipsychotic

Indications:

• Treatment refractory Psychosis
• Psychosis + suicidality

Side Effects:

• Agranulocytosis
• Tachycardia
• Hypersalivation
• Anticholinergics
• Myocarditis
  • Seizures

Suicide
- Only antipsychotic which reduces the risk of suicide

Question 24

When to stop clozapine in the case of agranulocytosis =

Answer 24

When PMN count drops below 1500/µL

Question 25

Risperidone - Class = - MOA - Side effects =

Answer 25

Class: - Atypical Antipsychotic MOA: - Blocks 5HT2a, alpha-1, and D2 receptors Side Effects: - Hyperprolactinemia - Orthostatic hypotension - Reflex tachycardia - Weight GAIN

Question 26

Quetiapine - Class = - Indications = - Side effects =

Answer 26

Class: - Atypical Antipsychotic Indications: - Psychosis - Insomnia Side Effects: - Sedation - Orthostatic hypotension

Question 27

Olanzapine - Class = - Indications = - Side effects =

Answer 27

Class: - Atypical Antipsychotic Indications: - Psychosis - Mood stabilization (later line) Side Effects: - Weight Gain - Metabolic Syndrome - Sedation

Question 28

Ziprasidone - Class = - Effect on weight =

Answer 28

Class: - Atypical Antipsychotic Effect on Weight: - Less likely to cause weight gain

Question 29

Aripiprazole - Class = - MOA = - Side effects =

Answer 29

Class: - Atypical Antipsychotic MOA - Partial D2 agonism Side Effects: - Akathisia - Less potential for weight gain - Less Sedating

Question 30

Paliperidone =

Answer 30

Metabolite of risperidone More expensive Also comes in a long acting form

Question 31

Best drug to use in delirious, elderly patients and why:

Answer 31

Haloperidol. This is the strongest antipsychotic there is, and therefore small doses can be used while avoiding the side effects of the antipsychotics, such as the orthostatics, anti-histaminergic, and anti-cholinergic side effects. Haloperidol also has the lowest risk of falls in these patients because it has less anti-adrenergic properties.

Question 32

Reason you cannot use risperidone in elderly, delirious patients =

Answer 32

It only comes in oral formulations--which typically doesn't bode well in delirious patients.

Question 33

How often long-acting depot form of risperidone needs to be administered =

Answer 33

Bi-monthly (twice per month)

Question 34

Which antipsychotics will cause EPS?

Answer 34

All of them, at high enough doses--except for clozapine.

Question 35

Antipsychotics which come in a long-acting injectable form =

Answer 35

Haloperidol Risperidone

Question 36

Sialorrhea = - What causes it?

Answer 36

Excessive salivation / drooling Commonly caused by clozapine

Question 37

Best treatment for sialorrhea =

Answer 37

Clonipine

Question 38

How to deal with the persistent sinus tachycardia seen in some patients on clozapine:

Answer 38

- Usually you can wait and it will go away on its own. | - However, if it just will not go away then you should add a ß-blocker like propanolol.

Question 39

Role of antipsychotics in bipolar disorder =

Answer 39

- Antipsychotics are most commonly used during the first manic episode--which is much more intense than the rest of the episodes. - They are not commonly used for maintenance therapy due to the high risk of side effects.

Question 40

Which atypical antipsychotics are the least likely to cause metabolic syndrome?

Answer 40

Ziprasidone > Ariprazole > Risperidone > Quetiapine

Question 41

Which are the atypical antipsychotics most likely to cause metabolic syndrome?

Answer 41

- Olanzapine | - Clozapine

Question 42

Rabbit Syndrome and what causes it =

Answer 42

Quivering of the mouth without involvement of the tongue. This is commonly caused by high potency antipsychotics like haldol.

Question 43

Signs of pseudoparkinsonism =

Answer 43

- Bradykinesia - Flexed posture - Festinating gait - Resting tremor