Antipsychotics (PSYCH DRUGS)

Question 1

Oral First gen/typical antipsychotics

Answer 1

x3
1. Chlorpromazine (100-600mg/day)
2. Haloperidol (5-20mg/day)
3. Trifluoperazine (5-10mg/day)

Question 2

Oral 2nd gen/atypical antipsychotics AND dose

Answer 2

X7
1. Risperidone (0.5-1mg, max 6mg/day)
2. Paliperidone (6mg, max 12 mg/day
3. Aripiprazole (15 mg ON, max 30mg/day)
4. Olanzapine (5-10 mg, max 20 mg/day)
5. Clozapine (25mg ON, max 900mg)
6. Quetiapine (50mg BD, max 800mg/day)
7. Amisulpride (200mg, max 1200mg/day)

Question 3

MOA typical/1st gen antipsychotics

Answer 3

D2 receptor blockade (Dopamine receptor antagonist)

Question 4

Side effects of first gen/typical antipsychotics

Answer 4

X7
1. Extrapyramidal side effects
2. Hyperprolactinemia
3. Sedation
4. Hypotension
5. Weight gain
6. Anticholinergic
7. Sexual side effects

Question 5

Extrapyramidal side effects =?

Answer 5

x4
1. Acute dystonia
2. Pseudoparkinsonism
3. Akathisia
4. Tardive dyskinesia (chronic use of antipsychotics)

Question 6

Acute dystonia symptoms

Answer 6

Involuntary movement/contraction of major muscle groups:
1. Oculogyric crisis (fixed upward or lateral gaze)
2. Torsion dystonia
3. Torticollis
4. Spasm of lip, face, throat muscles
5. Grimacing
6. Exaggerated posturing
7. Trismus (jaw muscle)

Question 7

Mx of acute dystonia

Answer 7

IM benztropine (congentin)
+switch to atypical/2nd gen antipsychotic

Question 8

Akathisia symptoms

Answer 8

1. Restlessness
2. Irritability

Question 9

Mx of Akathisia

Answer 9

Best: propranolol
Acute akathisia: Anticholinergic eg. Benztropine
Chronic akathisia: BZD

Question 10

Pseudoparkinsonism symptoms

Answer 10

more common
1. Resting Tremors
2. Stiffness of muscle, rigidity
3. Akinesia*, mask like facies, psychomotor retardation (bradykinesia)
4. Postural instability
5. Shuffling gait

Question 11

Mx of Pseudoparkinsonism

Answer 11

1. Gradual dose reduction
2. Switch to 2nd gen/atypical antipsychotic
3. Anticholinergic (eg. benzhexol)

Question 12

Tardive dyskinesia Symptoms

Answer 12

1. Oro-bucco-lingual and facial dyskinesia eg. Fly catching tongue protrusion
2. Athetosis
3. Choreiform pill rolling hand movements
4. Hip thrusting

Question 13

Mx of Tardive dyskinesia

Answer 13

1. Switch to 2nd gen/atypical antipsychotic
2. Maintain pt on lowest effective dose of antipsychotic
3. Vitamin E may help alleviate symptoms

Question 14

Onset of individual EPS symptom

Answer 14

1. Acute dystonia: few hrs
2. Akathisia: most common after 5 days of initiation
3. Pseudoparkinsonism: gradual
4. Tardive dyskinesia: at least 6 months, usu after many years

Question 15

Neuroleptic Malignant Syndrome dx criteria

Answer 15

Associated with use of neuroleptic meds 1. Severe muscle rigidity 2. Elevated temperature 3. 2 or more of the following:
1) diaphoresis
2) dysphagia
3) tremor
4) incontinence
5) changes in level of consciousness ranging from confusion to coma
6) mutism
7) tachycardia
8) elevated or labile BP
9) leukocytosis
10) laboratory evidence of muscle injury (eg. Raised CK)

Question 16

Mx of Neuroleptic Malignant Syndrome

Answer 16

1. Stop antipsychotics
2. Supportive measures (for heat): IV hydration, cooling measures, transfer to ICU
3. Pharmacological: bromocriptine (to reverse dopamine blockade), dantrolene/lorazepam to reduce rigidity
4. After stabilisation, change to a different antipsychotic (less potent eg. Quetiapine)

Question 17

Hyperprolactinemia manifestations

Answer 17

x4 (reversible)
1. Galactorrhea/gynaecomastia
2. Sexual dysfunction
3. Amenorrhea
4. Hypoestrogenism

Question 18

Which antipsychotics have hyperprolactinemia as SE?

Answer 18

1. All first gen/typical antipsychotics
2. Risperidone (the only 2nd gen/atypical antipsychotic)

Question 19

Special features of Chlorpromazine

Answer 19

More sedating among first gen antipsychotics

Question 20

Special features of haloperidol

Answer 20

High potency but more EPS among first gen antipsychotics

Question 21

Depot First gen/typical antipsychotics + Dose

Answer 21

1. Flupenthixol (Fluanxol) - 20-60 mg every month
2. Zuclopenthixol - 200-600mg every month

Question 22

Depot 2nd gen/typical antipsychotics

Answer 22

1. Risperidone (Consta) - 2-weekly IM, unpopular
2. Paliperidone (Sutenna) - monthly

Question 23

Side effect of 2nd gen/atypical antipsychotics

Answer 23

1. X7 of first gen antipsychotics (less of EPSE)
2. Weight gain
3. Prolonged QTc
4. Neuroleptic malignant syndrome

<Aripiprazole least/minimal SE>

Question 24

Indication for 2nd gen/atypical antipsychotics

Answer 24

1. Schizophrenia (positive and negative symptoms)
2. Bipolar disease (with or without psychotic features)
3. Major depression with psychotic features
4. Agitation
5. Delirium

Question 25

MOA of 2nd gen/atypical antipsychotics

Answer 25

1. Blocks D2 2. Blocks 5HT2A *reduced EPSE and also targets negative symptoms in schozophrenia 3. Blocks alpha adrenergic

Question 26

Drug for treatment resistant schizophrenia

Answer 26

Clozapine (2nd gen/atypical antipsychotic)

Question 27

Potential life threatening SE of clozapine

Answer 27

Fatal Agranulocytosis / blood dyscrasia + fatal myocarditis or cardiomyopathy + fatal pulmonary embolism + seizures

Question 28

Before starting and during prescription of clozapine, what must be done?

Answer 28

Frequent RBC monitoring (weekly for first 18 weeks then fortnightly or monthly thereafter until a year)

Question 29

MOA of clozapine (and thus good for treatment resistant schizophrenia)

Answer 29

1. Dopamine (D1, D3, D4) 2. Alpha adrenergic (alpha 1&2) 3. Histaminergic (H1) 4. Muscarinic anticholinergic (M1) 5. Serotonergic (5HT1A, 2C, 6&7)

Question 30

2nd gen/atypical antipsychotics good for negative symptoms of schizophrenia

Answer 30

COCA 1. Clozapine 2. Olanzapine 3. Cariprazine 4. Amisulpride

Question 31

Side effect concern: QTc prolongation 1. Antipsychotic to avoid 2. Antipsychotic to use

Answer 31

1. Avoid: first gen/typical antipsychotic (haloperidol, chlorpromazine) 2. Use: aripiprazole (or lurasidone, brexpiprazole)

Question 32

Side effect concern: EPSE 1. Antipsychotic to avoid 2. Antipsychotic to use

Answer 32

1. Avoid: Haloperidol 2. Use: 2nd gen (Aripiprazole, Olanzapine, Risperidone, Quetiapine, Clozapine)

Question 33

Side effect concern: Weight gain 1. Antipsychotic to avoid 2. Antipsychotic to use

Answer 33

1. Avoid: olanzapine, clozapine 2. Use: Aripiprazole, Haloperidol, Trifluoperazine

Question 34

Side effect concern: Sedation 1. Antipsychotic to avoid 2. Antipsychotic to use

Answer 34

1. Avoid: Quetiapine, Olanzapine, Clozapine 2. Use: Aripiprazole

Question 35

Side effect concern: Seizure 1. Antipsychotic to avoid 2. Antipsychotic to use

Answer 35

1. Avoid: Chlopromazine, clozapine 2. Use: Haloperidol, Sulpride, Risperidone, Aripiprazole

Question 36

Highest risk of metabolic syndrome among 2nd gen/atypical antipsychotics

Answer 36

Clozapine

Question 37

Antipsychotic in ACUTE mx

Answer 37

1. Oral or depot antipsychotics for rapid tranquilisation - oral rapidly dissolvable tablets: PO olanzapine 10 mg STAT or PO risperidone quicklet 2 mg STAT or - IM haloperidol 5 mg STAT 2. Alternatives: 1) IM lorazepam 2mg STAT 2) Antihistamine

Question 38

Ix before and after starting antipsychotics

Answer 38

1. PE - weight (metabolic syn), BP, EPSE 2. ECG - QTc (when initiating rx) 3. labs - fasting blood glucose, fasting lipid (triglycerides, cholesterol) *baseline and at least every 12 months