Antipsychotics

Question 1

most worrying S/E of clozapine?

Answer 1

agranulocytosis resulting in neutropenia
(↓ wbc, neutrophils, lymph)

(all patients are monitored with at least monthly blood tests)

requires immediate cessation of the drug and referral to a haematologist

Question 2

extrapyramidal S/E?

mostly 1st gen + haloperidol

Answer 2

• parkinsonian (tremor, appears gradually)
• acute dystonia + dyskinesia (young ppl, after few doses)
• akathisia (restlessness) after large initial doses
• tardive dyskinesia (rhythmic, involuntary movements of tongue, face, and jaw), normally w/ long-term therapy

Question 3

most serious manifestation of extrapyramidal symptoms?

Answer 3

tardive dyskinesia
may be irreversible on withdrawing therapy
Tx is usually ineffective

Question 4

main S/E of antipsychotics?

Answer 4

• EPSE
• ↑ prolactin (risperidone)
• sexual dysfunction (Risperidone and haloperidol)
• cardiac (↑ QT with haloperidol)
• hyperglycaemia and weight gain (clozapine, olanzapine, quetiapine, and risperidone)
• postural hypotension (clozapine, chlorpromazine, quetiapine)
• neuroleptic malignant syndrome
• agranulocytosis (clozapine)

Question 5

Sx of neuroleptic malignant syndrome?

Answer 5

POTENTIALLY FATAL
fever
confusion
muscle rigidity
autonomic dysfunction
↑ HR and ↑ CK
labile blood pressure
sweating
urinary incontinence

Question 6

best antispychotic to avoid EPSE, ↑ QT interval, sexual dysfunction, ↑ glucose?

Answer 6

aripiprazole

Question 7

what to prescribe for Tx-resistant schizophrenia?

Answer 7

clozapine

weekly bloods for 18 weeks

Question 8

how to monitor antipsychotics in general?

Answer 8

• FBC, U+E, LFT at start and then annually
• blood lipids and weight at baseline, 3 months then yearly
• Fasting blood glucose at baseline, at 4–6 months, and then yearly

Before initiating, ECG (if cardiovascular risk) & BP monitoring advised

Question 9

how to Tx acute dystonic EPSE?

Answer 9

Procyclidine

Question 10

Tx alzheimers?

Answer 10

mild/moderate: AChE inhibitors
● only started by specialist doctors
● 3 licenced drugs: donepezil, rivastigmine and galantamine
● If moderate/severe dementia then treat with NMDA antagonist (memantine).

Question 11

Tx acute dystonia secondary to antipsychotic treatment?

Answer 11

procyclidine hydrochloride 5 mg/mL injection

antimuscarinics 1st line
5-10mg IM/IV (preferred over PO as unsafe swallow)

Question 12

first line treatment of anti-psychotic-induced parkinsonism, particularly Sx of tremors?

Answer 12

procyclidine (anti-cholinergic)