Snapshot A 23-year-old male is brought into the inpatient psychiatric hospital after a suicide attempt. When talking with the patient he seemed to be responding to internal stimuli at times. He states that he heard voices telling him to kill himself. He said he has heard these voices for over a year now but within the past month they have become louder, more persistent and convincing. Overview 2 classes typical older stronger D2 receptor antagonism ↑ [cAMP] atypical newer weaker D2 receptor antagonism and stronger 5-HT2, α, and H1 antagonism Targets dopaminergic neurons specific pathways affected include: nigrostriatal (extrapyramidal motor) mesolimbic (mood and reward) tuberoinfundibular (prolactin release) Typical Antipsychotics Overview Typical AntipsychoticsHigh Potency Antipsychotics (in Descending Order)AdvantagesDisadvantagesUnique FeaturesHaloperidol •Fewer side effects of sedation and hypotension •High association with extrapyramidal symptoms •Able to use as long-acting depot injections •Can be given IM in acute situationsFluphenazinePerphenazineChlorpromazine •Lower frequency of extrapyramidal side effects •Greater incidence of anticholinergic side-effects, hypotension, sedation •Corneal depositsThioridazine •Retinal depositsQT prolongation Introduction Overview also known as neuroleptics highly fat soluble results in storage for long time in body fat Drugs ("haloperidol + -azines") high potency - low dose needed haloperidol trifluoperazine fluphenazine low potency - high dose needed thioridazine chlorpromazine Clinical uses schizophrenia primarily positive symptoms acute mania psychosis temporary treatment because lithium has slow onset Tourette syndrome hiccups (persistent > 48 hours and intractable > 1 month) haloperidol chlorpromazine Toxicity high potency ↑ extrapyramidal system (EPS) side effects due to high affinity for D2 receptor has characteristic time course early onset/reversible symptoms 4 hours = acute dystonia spasm of face, neck, tongue, and extraocular muscles treat with benztropine or diphenhydramine 4 days = Parkinsonism muscle rigidity, ankinesia, tremor, shuffling gait 4 days to 4 weeks = akathisia urge to move late onset/irreversible symptoms 4 months = tardive dyskinesia involuntary, repetitive movements of facial, tongue, neck muscles anticholinergics worsen! must reduce dose or switch to an atypical antipsychotic can be treated with valbenazine a vesicular monoamine transporter 2 inhibitor ↓ non-specific side effects fluphenazine has been implicated in causing hypothermia in select cases low potency ↓ EPS side effects ↑ non-specific side effects due to low affinity to D2 receptors and high concentrations needed to achieve effect muscarinic receptor antagonism dry mouth and constipation vision problems α receptor antagonism orthostatic hypotension sexual dysfunction histamine receptor antagonism sedation chlorpromazine can cause corneal deposits thioridazine can cause retinal deposits endocrine side effects dopamine normally inhibits prolactin secretion antagonism of receptor may result in hyperprolactinemia can cause galactorrhea neuroleptic malignant syndrome (NMS) presentation high fever, hypertension, tachycardia, “lead pipe” rigidity, elevated CPK, leukocytosis, metabolic acidosis treatment discontinue offending agent use of muscle relaxant (e.g., dantrolene) Side Effects of High Potency Antipsychotics Extrapyramidal Side Effects of High Potency D2 Blockers (Haloperidol, Fluphenazine, Perphenazine)3 Hours: Acute Dystonia3 Days - Weeks: Bradykinesia (Pseudo-Parkinsonism)3 Months: Akathisia3 Years: Tardive DyskinesiaEmergency: Neuroleptic Malignant Syndrome •Muscle spams (neck, eye, diffuse) •Trouble swallowing •Symptoms of Parkinson's disease: tremors, bradykinesia, rigidity •Sustained feeling of motion/restlessness •Uncontrollable repetitive, stereotypical writhing movements, usually of the tongue •High fever •Muscle rigidity •Unstable vitals •Increased CK, K+, and WBC'sTreatment of Side Effects •Anticholinergic medications:(benztropine, diphenhydramine, trihexyphenidyl) •β-blockers •Benzodiazepines •Stop high potency D2 blockers and switch to atypicals (clozapine preferred) •Can be treated with valbenazine •Stop antipsychotic •IV fluids •Cooling •DantroleneNOTE: You can always decrease the dose or switch to a different antipsychotic – choose the drug with the side-effect profile that the patient can tolerate. Atypical Antipsychotics Overview Atypical AntipsychoticsMedicationUnique features and side effectsRisperidone •High potency •Usually first line •Hyperprolactinemia •Weight gainOlanzapine •Severe weight gain •Very sedatingZiprasidone •Minimal to no weight gain •Increased QTcQuetiapine •Low potency •Sedating •Weight gain •Useful in bipolar depression and augmentation of major depression therapyLurasidone •Minimal weight gain •Useful in biploar depressionClozapine •Weight gain •Most effective anti-psychotic •Decreased suicide risk •Agranulocytosis •Myocarditis •Sialorrhea •Orthostatic hypotension •Increased seizuresAripiprazole •D2 partial agonist •Augmentation of major depression therapy Introduction Drugs olanzapine clozapine quetiapine risperidone aripiprazole ziprasidone Mechanism antagonist at 5-HT2, α, H1, and dopamine receptors Clinical use schizophrenia both positive and negative symptoms olanzapine OCD anxiety disorder depression mania Tourette's syndrome Toxicity less EPS and anticholinergic side effects as compared to traditional antipsychotics olanzipine weight gain monitor weight, blood lipids, blood glucose, and HbA1C clozapine agranulocytosis requires patients to have weekly WBC monitoring treat with drug cessation, neutropenic protocol, possibily filgrastim weight gain ziprasidone prolonged QT and possible resultant torsades risperidone EPS tardive dyskinesia
QUESTIONS 1 of 13 1 2 3 4 5 6 7 8 9 10 11 12 13 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.PY.17.4817) A 27-year-old man arrives to your walk-in clinic complaining of neck pain. He reports that the discomfort began two hours ago, and now he feels like he can’t move his neck. He also thinks he is having hot flashes, but he denies dyspnea or trouble swallowing. The patient’s temperature is 99°F (37.2°C), blood pressure is 124/76 mmHg, pulse is 112/min, and respirations are 14/min with an oxygen saturation of 99% O2 on room air. You perform a physical exam of the patient's neck, and you note that his neck is rigid and flexed to the left. You are unable to passively flex or rotate the patient's neck to the right. There is no airway compromise. The patient's was recently diagnosed with schizophrenia, and he denies current auditory or visual hallucinations. He appears anxious, but his speech is organized and appropriate. Which of the following is the best initial step in management? QID: 109375 Type & Select Correct Answer 1 Change medication to clozapine 10% (3/29) 2 Dantrolene 7% (2/29) 3 Diphenhydramine 83% (24/29) 4 Lorazepam 0% (0/29) 5 Propranolol 0% (0/29) M 7 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.PY.17.4867) A 24-year-old woman presents to her primary care physician for bilateral nipple discharge. She states that this started recently and seems to be worsening. She denies any other current symptoms. The patient states that she is not currently sexually active, and her last menstrual period was over a month ago. Her medical history is notable for atopic dermatitis and a recent hospitalization for an episode of psychosis. Her temperature is 99.5°F (37.5°C), blood pressure is 110/65 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 98% on room air. Cardiopulmonary and abdominal exam are within normal limits. Which of the following is the most likely cause of this patient's symptoms? QID: 109605 Type & Select Correct Answer 1 Alteration of the tuberoinfundibular pathway 25% (1/4) 2 Alteration of the nigrostriatal pathway 50% (2/4) 3 Alteration of the mesolimbic pathway 25% (1/4) 4 Prolactin-secreting mass 0% (0/4) 5 Normal pregnancy 0% (0/4) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (M2.PY.17.4681) A 23-year-old male is brought by police officers from a social gathering due combative behavior and altered mental status. The police say that phencyclidine was found on the premises. The patient is alone, and acquiring an accurate history proves difficult. However, you do learn that the patient is having visual hallucinations. Vital signs show a blood pressure of 155/95 mmHg, pulse is 103/min, respirations is 20/min, oxygen saturation of 99%. Airway, breathing, and circulation are intact. The patient appears violent, and is trying to remove his clothes. Multiple hospital staff are needed to restrain the patient in bed. A finger-stick glucose show 93 mg/dL. The team is unable to place an IV, and thus intramuscular midazolam is administered to achieve sedation; however, he is still agitated. What is the mechanism of action of the best alternative sedative drug for this patient? QID: 107295 Type & Select Correct Answer 1 Increases duration of chloride channel opening of GABA-A receptors 0% (0/3) 2 Alpha-2 and H1 receptor antagonist 67% (2/3) 3 Competitive opioid receptor antagonist 0% (0/3) 4 Antagonist of D2 receptors 33% (1/3) 5 Mu-opioid receptor partial agonist 0% (0/3) M 7 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.PY.16.4681) A 35-year-old male patient is brought into the emergency department by emergency medical services. The patient has a history of schizophrenia and is on medication per his mother. His mother also states that the dose of his medication was recently increased, though she is not sure of the specific medication he takes. His vitals are HR 110, BP 170/100, T 102.5, RR 22. On exam, he cannot respond to questions and has rigidity. His head is turned to the right and remains in that position during the exam. Labs are significant for a WBC count of 14,000 cells/mcL, with a creatine kinase (CK) level of 3,000 mcg/L. What is the best treatment for this patient? QID: 107296 Type & Select Correct Answer 1 Diazepam 0% (0/3) 2 Morphine 0% (0/3) 3 Dantrolene 100% (3/3) 4 Valproate 0% (0/3) 5 Lamotrigine 0% (0/3) M 7 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M2.PY.15.49) A 35-year-old woman is diagnosed with schizophrenia after nine months of experiencing auditory hallucinations and persecutory delusions. Over the next year, she fails to experience symptom relief from separate and appropriately dosed trials of olanzapine, quetiapine, and risperidone. At this point, which of the following treatment options is most likely to be effective? QID: 105049 Type & Select Correct Answer 1 Aripiprazole 0% (0/21) 2 Haloperidol 14% (3/21) 3 Clozapine 81% (17/21) 4 Clonidine 0% (0/21) 5 Cognitive behavioral therapy 0% (0/21) M 7 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (1) Login to View Community Videos Login to View Community Videos Dystonia Thomas Heineman Psychiatry - Antipsychotics D 11/9/2012 88 views 5.0 (3) Psychiatry | Antipsychotics Psychiatry - Antipsychotics Listen Now 21:8 min 10/14/2021 65 plays 0.0 (0)