Antipsychotics

Question 1

What are the two types of antipsychotics?

Answer 1

1) First generation (FGA) / typical

2) Second generation (SGA) / atypical

Question 2

What are three examples of FGA?

Answer 2

1) Haloperidol
2) Chlorpromazine
3) Flupentixol

Question 3

What are 7 examples of SGA?

Answer 3

1) Olanzapine
2) Quetiapine
3) Risperidone
4) Aripiprazole
5) Lurasidone
6) Amisulpiride
7) Clozapine

Question 4

How do antipsychotics work?

Answer 4

Dopamine (D2) antagonists

Question 5

What brain activity is schizophrenia associated with?

Answer 5

Increased activity in the dopaminergic mesolimbic and mesocortical pathways

Question 6

What are side effects of antipsychotics?

Answer 6

1) QTc prolongation
2) Metabolic syndrome (central obesity, diabetogenic, dyslipidaemia)
3) Hyperprolactinaemia
4) Some have sedative effect (due to action on histamine and serotonin receptors)
5) Extrapyramidal side effects (EPSEs)

Question 7

Which side effect of antipsychotics is notoriously difficult to treat?

Answer 7

EPSEs

Question 8

What investigations do you need to do in someone before starting on antipsychotics?

Answer 8

• ECG (before initiation and monitor)
• Prolactin levels
• Blood glucose
• Lipid levels

Question 9

What can prolonged QT syndrome/QTc prolongation lead to?

Answer 9

Heart block/arrhythmias

Question 10

What are symptoms of hyperprolactinaemia?

Answer 10

• Galactorrhoea
• Infertility
• Amenorrhoea
• Oligomenorrhoea

Question 11

What are EPSE symptoms?

Answer 11

1) Acute dystonia
2) Parkinsonism
3) Akathisia
4) Neuroleptic malignant syndrome
5) Tardive dyskinesia

Question 12

What is acute dystonia?

Answer 12

• Uncontrolled muscle spams mostly over face, tongue, neck

- Occurs 1-5 days after drug initiation

Question 13

What is akathesia?

Answer 13

• Restlessness, irresistible desire to move around

- Occurs 5-60 days after drug initation

Question 14

What is neuroleptic malignant syndrome?

Answer 14

• Muscle rigidity, fever, unstable BP, myoglobinaemia (dark urine) - medical emergency
• Occurs weeks to months after drug initiation

Question 15

What is tardive dyskinesia?

Answer 15

• Involuntary painless movements of face and upper limbs
• Occurs months to years after drug initiation
• Doesn’t go away even if stop antipsychotic

Question 16

How do you treat neuroleptic malignant syndrome?

Answer 16

Stop antipsychotic

Question 17

What is first-line treatment for schizophrenia and other psychotic disorders?

Answer 17

SGA - often olanzapine

Question 18

Give 3 reasons why SGAs are now first line over FGAs?

Answer 18

1) Less side effects esp. EPSES
2) Less likely to cause hyperprolactinaemia
3) More effective for the negative symptoms of schizophrenia

Question 19

How can you treat EPSEs?

Answer 19

1) Switch the drug/reduce the dose

2) Give procyclidine

Question 20

What receptors to SGAs act on?

Answer 20

Dopamine and 5-HT receptors

Question 21

When is olanzapine good and why?

Answer 21

Acute setting bc has rapid onset

Question 22

What is there a higher risk of with olanzapine?

Answer 22

Weight gain and sedation

Question 23

What monitoring needs to be done in people on antipsychotics?

Answer 23

• Prolactin
• BMI
• Blood glucose
• Lipids
• Regular physical health checks incl. CV risk

Question 24

When and how would you use procyclidine?

Answer 24

• To treat drug-induced Parkinsonism and akathisia

- Would be on it long term alongside antipsychotics

Question 25

For what symptoms of schizophrenia do antipsychotics generally work better for?

Answer 25

Positive symptoms

Question 26

When is clozapine used?

Answer 26

1) Treatment-resistant schizophrenia (floridly psychotic) | 2) If patient gets EPSEs

Question 27

Why does clozapine need close monitoring upon initiation?

Answer 27

Risk of hypotension and convulsions

Question 28

What is the main risk/side effect of clozapine?

Answer 28

Agranulocytosis - high risk of infection

Question 29

What do you have to do when a patient is on clozapine due to the risk of agranulocytosis?

Answer 29

Regular bloods - Measure WBC weekly for the first 18 weeks, then fortnightly for the first year, then monthly - Other parameters also need more frequent monitoring compared to other antipsychotics

Question 30

What do you need to have done to prescribe clozapine?

Answer 30

Tried at least 2 SGAs

Question 31

Why are people often first prescribed olanzapine?

Answer 31

- First presentation of psychosis in acute setting bc acts v quickly - Then will be changed to another one long term that is better for them

Question 32

How are antipsychotics given?

Answer 32

Either orally or monthly IM injection (adherence)

Question 33

How do you treat psychotic depression?

Answer 33

Olanzapine short term but long term treat depression