Atypical (2nd Generation) anti-psychotics

Question 1

There are a number of dopamine pathways. What does the mesocortical pathway regulate?

1 - motivation and desire
2 - emotions
3 - involuntary movements and coordination
4 - prolactin
5 - vomiting reflex
6 - eating

Answer 1

2 - emotions

Question 2

There are a number of dopamine pathways. What does the mesolimbic pathway regulate?

1 - motivation and desire
2 - emotions
3 - involuntary movements and coordination
4 - prolactin
5 - vomiting reflex
6 - eating

Answer 2

1 - motivation and desire

Question 3

There are a number of dopamine pathways. What does the chemoreceptor trigger zone regulate?

1 - motivation and desire
2 - emotions
3 - involuntary movements and coordination
4 - prolactin
5 - vomiting reflex
6 - eating

Answer 3

5 - vomiting reflex

Question 4

There are a number of dopamine pathways. What does the medullary periventricular pathway regulate?

1 - motivation and desire
2 - emotions
3 - involuntary movements and coordination
4 - prolactin
5 - vomiting reflex
6 - eating

Answer 4

6 - eating

Question 5

There are a number of dopamine pathways. What does the nigostriatal pathway regulate?

1 - motivation and desire
2 - emotions
3 - involuntary movements and coordination
4 - prolactin
5 - vomiting reflex
6 - eating

Answer 5

3 - involuntary movements and coordination

• which contains motor neurons that bypass the medullary pyramids, to control involuntary movements and coordination

Question 6

There are a number of dopamine pathways. What does the mes tuberoinfundibular pathway regulate?

1 - motivation and desire
2 - emotions
3 - involuntary movements and coordination
4 - prolactin
5 - vomiting reflex
6 - eating

Answer 6

4 - prolactin

Question 7

Which dopamine pathway has increased levels of dopamine causing positive symptoms like hallucinations, delusions and disorganised thoughts?

1 - mesolimbic
2 - nigostriatal
3 - mesocorticol
4 - tuberoinfundibular

Answer 7

1 - mesolimbic

• motivation and desire

Question 8

Which dopamine pathway has increased levels of dopamine causing negative symptoms like lack of motivation, social withdrawal and flat affect (no emotions)?

1 - mesolimbic
2 - nigostriatal
3 - mesocorticol
4 - tuberoinfundibular

Answer 8

3 - mesocorticol

• responsible for emotions

Question 9

What effect do atypical drugs have on D2 dopamine receptors?

1 - inhibit dopamine release
2 - increase dopamine release
3 - increase serotonin release
4 - decrease serotonin release

Answer 9

1 - inhibit dopamine release

• in mesolimbic pathway less dopamine means less positive thoughts such as delusions, hallucinations and disorganised thought

Question 10

In addition to inhibiting dopamine release at D2 receptors on post synapse, some atypical drugs also have another effect on pre-synaptic receptors. What are these drugs able to do here?

1 - inhibit dopamine release
2 - increase dopamine release
3 - increase serotonin (5-HT2A) release
4 - decrease serotonin (5-HT2A) release

Answer 10

4 - decrease serotonin (5-HT2A) release

• 5-HT2A receptors are generally inhibitory
• if 5HT2A receptors have less inhibition, this means more dopamine is released
• more dopamine in the mesocortical pathway means reduced negative symptoms

Question 11

Aytipical drugs generally have less side effects than the earlier typical drugs when binding with D2 receptors. Why is this?

1 - bind to different binding site
2 - looser binding
3 - stronger binding
4 - all of the above

Answer 11

2 - looser binding

• competes with dopamine for binding
• looser binding means less risk of adverse events

Question 12

There are a large number of atypical drugs that we need to be aware. Which of the following is NOT a atypical core drug?

1 - clozapine,
2 - haloperidol
3 - risperidone
4 - lurasidone
5 - olanzapine
6 - paliperidone
7 - quetiapine
8 - aripiprazole

Answer 12

2 - haloperidol

Question 13

Atypical drugs generally inhibit D2 dopamine receptors and 5-HT2A receptors. However, one core atypical is also able to partially stimulate D2 dopamine receptors and 5-HT2A receptors. Which drug is this?

1 - clozapine,
2 - risperidone
3 - lurasidone
4 - aripiprazole

Answer 13

4 - aripiprazole

• controls how much dopamine binds post-synaptically (not too much or too little, so good for all round effects of psychosis)

Question 14

There are 2 key indications for the use of atypical (2nd gen) anti-psychotics. Which 2 of the following re correct?

1 - schizophrenia
2 - personality disorder
3 - bipolar disorder
4 - rapid tranquillisation

Answer 14

1 - schizophrenia
- when typical anti-psychotics have failed typically due to extra-pyramidal effects

3 - bipolar disorder
- especially for acute mania and hypomania
- generally 1st line for mania

Question 15

A key adverse effect of atypical antipsychotics is inhibition of dopamine receptors in the tuberoinfundibular pathway, which is responsible for prolactin release. Dopamine inhibits this until women are ready to breast feed. Which of the following does NOT occur as an adverse effect of atypical antipsychotics on the tuberoinfundibular pathway?

1 - hyperprolactinaemia
2 - high GnRH, LH and FSH
3 - oligomenorrhea, galactorrhea
4 - gynecomastia

Answer 15

2 - high GnRH, LH and FSH

• these would all be low due to hyperprolactinaemia
• risperidone is most likely cause

Question 16

Although less than in typical antipsychotics, extra-pyramidal can still occur in atypical antipsychotics. Reduction in the levels of dopamine release in which pathway is affected to cause extra-pyramidal effects?

1 - mesolimbic
2 - nigostriatal
3 - mesocorticol
4 - tuberoinfundibular

Answer 16

2 - nigostriatal

• not as common as in typical antipsychotics though

Question 17

A key side effect of atypical antipsychotics is development of metabolic disturbances, including weight gain, diabetes, and lipid changes. Which 2 drugs have the largest risk of causing these metabolic disturbances?

1 - clozapine
2 - risperidone
3 - olanzapine
4 - aripiprazole

Answer 17

1 - clozapine
3 - olanzapine

• body weight, lipid profile and fasting blood glucose should be measured at baseline and then intermittently monitored

Question 18

Atypical antipsychotics can also lead to QT interval prolongation. This is dangerous and can lead to all of the following EXCEPT:

1 - ventricular repolarisation
2 - arrhythmias
3 - sudden cardiac death
4 - pericarditis

Answer 18

4 - pericarditis

• QT interval = time from Q wave to end of T wave
• all of ventricular depolarisation and repolarisation

Question 19

There is one drug that can cause agranulocytosis, which is a severely low WBC which increases the patients risk of infection. Which drug is most associated with agranulocytosis?

1 - clozapine
2 - risperidone
3 - olanzapine
4 - aripiprazole

Answer 19

1 - clozapine

• must monitor patients WBC and ensure safety netting

Question 20

Antipsychotics should only be used with caution in cardiovascular disease. Which 2 of the following conditions must clozapine specifically NOT be used in?

1 - malignancies
2 - neutropenia
3 - severe heart disease
4 - hypertension

Answer 20

2 - neutropenia
- can cause agranulocytosis

3 - severe heart disease
- prolong QT interval, increase risk of arrhythmias and sudden cardiac death

Question 21

Atypical antipsychotics must NOT be used in combination with all of the following EXCEPT:

1 - amiodarone, macrolids, SSRI
2 - metoclopramide and chlorpromazine
3 - cyclizine
4 - all of the above

Answer 21

3 - cyclizine
- anti-emetic acting as H1 receptors blocker

• amiodarone, macrolids and SSRI can all increase QR interval
• metoclopramide and chlorpromazine are antiametics that block D2 antagonists

Question 22

How are atypical antipsychotics generally administered?

1 - oral
2 - IV
3 - IM
4 - SC

Answer 22

1 - oral
- BUT IM if needed

Question 23

How should atypical drugs typically be administered?

1 - any point each day
2 - only in the mornings
3 - only in the evenings
4 - anytime, but the same time

Answer 23

4 - anytime, but the same time

• if patients get drowsiness, then evenings may be best

Question 24

Hyperprolactinaemia is an adverse event of atypical antipsychotics. How often should prolactin be monitored once people start these medications?

1 - weekly then annually
2 - at start, weekly then monthly
3 - annually
4 - start of treatment, 6 months and then annually

Answer 24

4 - start of treatment, 6 months and then annually

Question 25

If a patient needs to stop their antipsychotics, can they be stopped immediately or do they need to be tapered?

Answer 25

• tapered
• reduces risks of withdrawal

Question 26

Clozapine is atypical (2nd generation) drug that is a core anti-psychotic drug. It is generally used as a last line drug treatment for psychosis. How many other drugs must have been tried before a patient is prescribed clozapine?

1 - 2 drugs (1 typical and 1 atypical)
2 - 4 drugs (1 typical and 3 atypical)
3 - 2 drugs (2 typical)
4 - 2 drugs (2 atypical)

Answer 26

1 - 2 drugs (1 typical and 1 atypical)

• constipation, which can ultimately kill patients
• neutropenia (low neutrophils)

Question 27

If a person is admitted to hospital on clozapine, we should always liaise with the psychiatry team on dosing. Why is this?

1 - may have stopped taking the medication and become dangerous
2 - may have overdosed on the medication and is the reason for admission
3 - may be at increased risk of infection
4 - toxicity and adverse events may increase due to lower metabolism of clozapine

Answer 27

4 - toxicity and adverse events may increase due to lower metabolism of clozapine

• acute illnesses are associated with reduced clozapine metabolism by cytochrome P450 and can cause increased risk of toxicity and adverse events