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DR T. IBRAHIM
ANTI-PSYCHOTICS
(NEUROLEPTICS/MAJOR TRANQUILISERS)
Psychosis
It is a term used to describe a group of severe mental illness characterized by
hallucination, delusions, extreme abnormalities of behavior including marked over-
activity, retardation, catatonia and usually a lack of insight.
Anti-psychotic drugs
These are group of drugs used to treat psychiatric disorders characterized by
disturbed thought and behavior-primarily Schizophrenia.
Note: These drugs are notcurative and do not eliminate the chronic thought
disorder but they often decrease the intensity of hallucinations, delusions and
permit the person with Schizophrenia to function in a supportive environment.
Hallucinations
A hallucination is a perception in the absence of apparent stimulus that has qualities
of real perception. It may affect all the five senses. Auditory hallucination is very
common while visual hallucination is abit rare.
Illusion
It is a wrong or mis-interpreted perception of a sensory experience.
Delusion
A false belief that cannot be dislodged even by solid proof of contradictory evidence
or by reasoning the subject.
Schizophrenia
It comes from the Greek word meaning split and mind.
People with Schizophrenia are split off from the reality and cannot distinguish
between real and not real. It is the most common and debilitating form mental
illness.
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Epidemiology
Schizophrenia occurs in 1% of the population world-wide. It usually affects during
late adolescence or early adulthood. It has a strong genetic predisposition.
Risk factors
Environmental factors: prenatal exposure to viral infections, pre-natal poor nutrition,
per-natal hypoxia, advanced paternal age, birth rank, season of birth.
Pathogenesis
1. Dopamine Hypothesis of Schizophrenia
(no longer considered adequate to explain all aspects of Schizophrenia but enough
to understand positive and negative symptoms).
Excessive limbic dopaminergic activity plays a role in psychosis.
Post-mortem studies of Schizophrenia subjects have reported increased
dopamine levels and D2-receptor density in nucleus accumbens, caudate and
putamen.
Diminished cortical and hippocampal dopaminergic activity underlie cognitive
impairment and negative symptoms of Schizophrenia.
2. Glutamate hypothesis
Abnormal concentration of glutamate in hippocampus and pre-frontal cortex (PFC)
occurs in Schizophrenia subjects.
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Anti-psychotics
A. Phenothiazines: 3 groups
Group I
They are characterized by profound sedation and moderate anti-muscarinic and
Extra pyramidal side-effects, EPS.
Drugs Chlorpromazine levomeproma Promazine
zine
Dose/ro Oral/IM/PR 25-100 mg/day 100-200mg
ute Initial oral dose: 25 mg TDS (75-300 QID
mg/day)
IM: 25-500 mg q 6-8 hours
PR: 100 mg q 6-8 hours.
Group II
Fewer EPS compared to Group I and group III; moderate sedative effects.
Drugs Pericyazine Pipotiazine Mesoridazine
Dose 15-75 mg/day IM at 4 weeks interval 50-400nmg/day
Group III
Fewer sedative and anti-muscarinic effecs; more EPS compared to GP I and II.
Dru Fluphenazine Perphenazine Prochlorperazi Tri
gs decanoate ne fluoperazin
e
Dos 25 mg IM q 2 weeks Oral: 75-100 5-10 mg/day
e mg/day
IM: 12.5-25 mg
TDS
B. Butyrophenones
Benperidol
Haloperidol (3-5 mg, 2-3 times/day, max: 30 mg/day); depot preparation also
available.
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D. Piperazine
Fluphenazine
E. Thioxanthene
Thiothixene
Moderate potency
Molindone: 15-20 mg/day
2. Clozapine
It is a di benzo-diazepine derivative.
Dose: initially 12.5-25 mg /day; maintenance of 300-600 mg by gradual titration;
25, 100mg tabs.
It has high affinity for D4 receptor; it also blocks D1, D2, 5 HT2A, -adrenoceptor and
muscarinic receptors.
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3. Olanzapine
It is a thiene-benzodiazepine derivative.
It causes D1, D2, D4, 5HT2 antagonism.
Dose: 5-10 mg/day.
T1/2: 33 hours.
Weight gain/ hyperglycemia: +++
It is associated with the greatest risk of stroke in elderly patient.
4. Risperidone
Best effects seen at doses less than 6 mg/day; dose range: 0.5-10 mg/day.
Depot preparation available.
5. Paliperidone
It is the active metabolite of Risperidone.
Dose: 6 mg OD.
6. Amisulpride
Selective dopamine antagonist with high affinity for mesolimbic D 2 and D3 receptors.
Dose: 400-800 mg daily.
7. Asenapine
It is a dibenzo-oxepriopyrrole
Available for oral and sublingual use.
Dose: 10-20 mg/day; 5, 10 mg tabs.
Approved for treatment of Bipolar disorder.
8. Quetiapine
It is D1, D2, 5HT2, - receptor, H1 receptor antagonist; 5HT1A partial agonist.
Short T1/2: 6 hours
Dose: 300-450 mg/day (max:750 mg/day); start with 50 mg/day and titrate up.
Practically no EPS
Other drugs
Ziprasidone, Remoxipride, Zotepine, Sertindole (cause nasal congestion and risk of
ventricular arrhythmia), Iloperidone, Lurasidone.
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Mechanism of action
1. All the older (first generation) and most of the newer neuroleptics block
dopamine receptors in the brain and its periphery.
Dopamine receptors: 5 types (D1, D2, D3, D4, D5)
D1andD5 receptors activate adenylyl cyclase, often exciting neurone.
D2, D3, D4 receptors: inhibit adenylyl cyclase and mediate membrane K + channel
opening leading to neuronal hyperpolarization.
Note:
Clozapine and Risperidone cause substantial blockade of -receptors which may
account for their beneficial effect on negative symptoms of Schizophrenia.
Pharmacological actions
Anti-psychotics actions are due to blockade of dopamine receptors and serotonin
receptors. However, these drugs also block muscarinic, adrenergic and
histaminergic receptors, H1.
1. Anti-psychotic actions
Decreases the positive symptoms of Schizophrenia by causing D 2-
receptor blockade in mesolimbic system of brain.
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5. Anti-emetic effects
Most anti-psychotics (except Aripiprazole and Thioridazine) have anti emetic
action which is mediated by D2-receptor blockade in the CTZ.
6. Anti-muscarinic effects
Common with Thioridazine, Chlorpromazine, Clozapine, Olanzapine. They
lead to adverse effects such as blurring of vision, urinary retention,
constipation, dry mouth (except clozapine which despite having anti-
muscarinic action causes hypersalivation).
Pharmacokinetics
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Short-acting
t1/2 Quetiapine: 6 hours
t1/2 Ziprasidone: 8 hours
Some depot preparation are also available for slow release and their duration
of action varies from 2-4 weeks.
Example Fluphenazine decanoate: 2-3 weeks.
Indications
Psychiatric
1. Schizophrenia
Note: catatonic Schizophrenia is best treated managed by IV anti-psychotics.
Depot preparation can also be used for maintenance when compliance with
oral treatment is a problem.
Examples: Flupentixol decanoate.
3. Schizo-affective disorders.
4. Psychotic depression
Other uses
1. Anti-emetic
To treat nausea and vomiting or to prevent nausea and vomiting which
is drug induced.
Vertigo in Menieres disease.
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Labyrinthitis
Migraine
Drugs used:
Prochlorperazine: 5-20 mg/day (stemetil)
Haloperidol: 1-2 mg IM/IV
Levopromazine: 6 mg oral/sc
Benzquinamide
2. Intractable hiccups
Chlorpromazine: 10-25 mg oral q 4-6 hourly (25-50 mg IM)
Haloperidol: 1.5 mg tds
6. Huntingtons chorea
Haloperidol/Risperidone (2-8 mg/day), Olanzapine
Clozapine: 50-600 mg/day
Quetiapine: 50-600 mg/day
8. Autism
They decrease the disruptive behaviour and irritability.
Risperidone: 0.25 mg (<25 kg); 0.5-3 mg/day (>25 kg)
Aripiprazole: 30 mg/day.
9. Pruritus
Trimeprazine is useful because of its high anti-histaminic and sedative action.
10.Anxiety disorders
Obsessive Compulsive disorder, OCD and Post Traumatic Stress Disorder,
PTSD
Drug used: olanzapine/Risperidone/Quetiapine along with SSRI
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Prophylactic uses
1. Droperidol: prevention and treatment of post-operative nausea and vomiting
2. Promethazine (avomine): motion sickness.
Adverse effects
All anti-psychotics produce adverse effects that are extension of their
pharmacological action.
1. pseudo depression with older anti-psychotics due to drug induced akinesia
(respond to anti-parkinson treatment).
5. Dopaminergic agonists
Bromocriptine: Dosage very much from 2.5-5 mg TDS, the suitable
dose is 5-15mg/day to maximum 35mg/day. Every patient therapy is to
be individualized.
Other drug used is Amantadine 100-300mg/day (D1/D2 agonist).
7. Treatment of complications
Hemodialysis: For preventing renal failure to occur from
rhabdomyolysis a
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7. Anti-muscarinic effects
Blurring of vision, dryness of mouth (except clozapine which causes
hypersalivation- can be controlled by giving Hyoscine butyl bromide).
Urinary retention
Constipation
Increase in intra-ocular pressure.
Tachycardia with risk of arrhythmia (least with aripiprazole).
Drug interactions
Important drug interaction occurs when they are combined with sedatives, -
adrenergic blocking agents, anti-cholinergics and quinidine.
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Contra-indications
References
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