Antipsychotics

Question 1

What should you do before starting an antipsychotic?

Answer 1

ask about personal/
family history of diabetes, hypertension, and cardiovascular disease.
Give advice
on diet, weight control and exercise.
Perform BP, weight, fasting blood glucose, lipid profile, FBC, ECG if on clozapine or zotepine.

Question 2

Monitoring when on antipsychotics?

Answer 2

6-monthly

monitoring of LFT, U&E, prolactin, weight, HbA1c is recommended

Question 3

How do typical antipsychotics and atypical antipsychotics exert there effect?

Answer 3

typical - D2 antagonism

atypical - interact with several receptors (e.g., D2, D3, D4, 5-HT)

Question 4

Are extrapyramidal symptoms associated with typical or atypical antipsychotics?

Answer 4

typical

Question 5

What side effects are associated with atypical antipsychotics?

Answer 5

metabolic disturbances - weight gain, insulin resistance

Question 6

What is a potentially life-threatening side effect of both first-generation and second-generation antipsychotics? What are the signs and symptoms of this?

Answer 6

neuroleptic malignant syndrome - fever, muscle rigidity, autonomic instability, and mental status changes

Question 7

Examples of typical antipsychotics?

Answer 7

chlorpromazine, haloperidol

Question 8

Extrapyramidal symptoms?

Answer 8

bradykinesia, dystonia, rigidity, athetosis, akathisia, ballimus, chorea, tics and tremors

Question 9

high potency typical antipsychotic SEs?

Answer 9

hyperprolactinaemia,
extrapyramidal symptoms (esp. in high-potency typicals eg. haloperidol, fluphenazine, perphenazine, trifluoperazine, pimozide)
prolonged QT syndrome
neuroleptic malignant syndrome

Question 10

low-potency typical antipsychotic SEs?

Answer 10

anticholinergic effects, sympatholytic effects (orthostatic hypotension - due to alpha 1 blockade), metabolic effects, sedation

Question 11

why do typical antipsychotics cause hyperprolactinaemia?

Answer 11

Dopamine inhibits the release of prolactin via the D2 receptor in the tuberoinfundibular pathway. Therefore, dopamine antagonists increase the effects of prolactin.

Question 12

Hyperprolactinaemia symptoms?

Answer 12

galactorrhea in women, gynecomastia in men, and symptoms of hypogonadotropic hypogonadism (due to ↓ FSH and LH secretion) in both sexes.

Question 13

atypical antipsychotic examples?

Answer 13

Clozapine
Olanzapine
Risperidone

Question 14

atypical antipsychotics SEs?

Answer 14

Metabolic effects (usually weight gain, hyperglycemia, dyslipidemia) most prominent

sedation, prolonged QT, hyperprolactinaemia (less pronounced than typical), neuroleptic malignant syndrome

clozapine can cause agranulocytosis

Question 15

Clozapine specific SE?

Answer 15

agranulocytosis

Neutropenia

Question 16

symptoms of hypogonadotropic hypogonadism?

Answer 16

women: amenorrhea, reduced libido, infertility
Men: erectile dysfunction, reduced libido, infertility

Question 17

Anticholinergic symptoms?

Answer 17

Can’t spit can’t shit can’t see can’t pee

Dry mouth, blurred vision, mydriasis, constipation, urinary retention, and tachycardia

Question 18

neuroleptic malignant syndrome symptoms? Dx? Tx?

Answer 18

FALTER - Fever, Autonomic instability, Leukocytosis, Tremor, Elevated enzymes (creatine kinase, transaminases), Rigor

Muscle rigidity, akinesia, tremor
Hyperthermia
Autonomic instability (tachycardia, labile blood pressure, tachypnea, diaphoresis, dysrhythmias)
Mental status change: confusion, delirium, reduced vigilance, stupor

sign raised creatine kinase and leukocytosis

discontinue drug. Supportive care - ICU
Dantrolene (ryanodine receptor antagonist) - prevents calcium release from sarcoplasmic reticulum of striated muscle.

Question 19

1st and 2nd line for acute psychosis?

Answer 19

1st: atypical
2nd: typical

Question 20

1st and 2nd line for bipolar affective disorder or acute mania?

Answer 20

1st: atypical
2nd: typical

Question 21

antipsychotic for delirium?

Answer 21

typical

Question 22

Antipsychotic for Psychotic symptoms caused by medication for Parkinson disease (dopamine agonists)

Answer 22

Clozapine

Question 23

Antipsychotic for psychosis during pregnancy?

Answer 23

typical (eg. haloperidol)

Question 24

antipsychotic for postpartum psychosis?

Answer 24

atypical(e.g., quetiapine, risperidone, olanzapine)

Question 25

Which class of antipsychotics should be used in elderly to avoid anticholinergic SEs?

Answer 25

high-potency substances (e.g., haloperidol, risperidone) or melperone are preferred

Question 26

Define akathisia

Answer 26

refers to a feeling of inner restlessness that is reduced or relieved by movement. When sitting, a person may caress their scalp, cross and uncross their legs, rock or squirm in their chair, get out of the chair often and pace back and forth and even make noises such as moaning. When standing, a person with akathisia may involuntarily march in place. 

Question 27

Akinesia vs bradykinesia vs hypokinesia

Answer 27

Akinesia means absence of movement. Bradykinesia means slowness of movement. Hypokinesia means decreased amplitude or range of movement. These three terms are commonly grouped together and referred to as bradykinesia.

Question 28

Define athetosis

Answer 28

Athetosis means slow, writhing, continuous, involuntary movements. Athetosis sometimes resembles slow dance-like movements, changing randomly in a flowing pattern. It is a term often used to describe the movements of someone with cerebral palsy (CP).

Question 29

Define chorea

Answer 29

Chorea refers to involuntary, irregular, purposeless, non-rhythmic, abrupt, rapid or unsustained movements that seem to flow from one body part to another. A characteristic feature of chorea is that the movements are unpredictable in timing, direction and body parts affected

Question 30

Define dyskinesia and tardive dyskinesia

Answer 30

Dyskinesia is a general term for any abnormal involuntary movement. “Tardive dyskinesia” is a term used for abnormal involuntary movements that begin after taking certain medications used to treat nausea or emotional problems. Tardive dyskinesia sometimes resembles chorea, dystonia, myoclonus, tics or tremor

Question 31

How should you describe dyskinesias?

Answer 31

it is important that dyskinesias are very precisely described by the examiner in terms of rhythm, speed, duration and pattern. It is very important for the individual to tell the examiner what brings on or helps control the dyskinesia and when during the day the dyskinesia is easier or more difficult to control