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PHARMACOLOGY
November 4, 2017 1
Psychosis
Psychosis is a thought disorder characterized
by disturbances of reality and perception,
impaired cognitive functioning, and
inappropriate or diminished affect (mood).
1) Levodopa
2) CNS stimulants
a) Cocaine
b) Amphetamines
c) Khat, cathinone, methcathinone
3) Apomorphine
4) Phencyclidine
November 4, 2017 3
Schizophrenia
Pathogenesis is unknown.
Onset of schizophrenia is in the late teens early
twenties.
Genetic predisposition -- Familial incidence.
Multiple genes are involved.
Positive Symptoms.
Hallucinations, delusions, paranoia, ideas of reference.
Negative Symptoms.
Apathy, social withdrawal, anhedonia, emotional blunting,
cognitive deficits, extreme inattentiveness or lack of
motivation to interact with the environment.
These symptoms are progressive and non-responsive to medication.
November 4, 2017 6
Etiology of Schizophrenia
Idiopathic
Biological Correlates
1) Genetic Factors
2) Neurodevelopmental abnormalities.
3) Environmental stressors.
November 4, 2017 7
Etiology of Schizophrenia
November 4, 2017 9
Dopamine Theory of Schizophrenia
Dopamine Correlates:
Antipsychotics reduce dopamine synaptic activity.
These drugs produce Parkinson-like symptoms.
Drugs that increase DA in the limbic system cause
psychosis.
Drugs that reduce DA in the limbic system
(postsynaptic D2 antagonists) reduce psychosis.
Increased DA receptor density (Post-mortem, PET).
Changes in amount of homovanillic acid (HVA), a
DA metabolite, in plasma, urine, and CSF.
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Pharmacodynamics
Frontal cortex DA
Amygdala DA
Hippocampus DA
Nucleus accumbens DA
Limbic Cortex DA
November 4, 2017 11
Dopamine Theory of Schizophrenia
November 4, 2017 13
THE DOPAMINERGIC SYSTEM
November 4, 2017 14
Catecholamines
Tyrosine
Tyrosine hydroxylase
L-Dopa
Dopa decarboxylase
Dopamine (DA)
Dopamine hydroxylase
Norepinephrine (NE)
(Noradrenaline) Phenylethanolamine-
-N-methyltransferase
Epinephrine (EPI)
(Adrenaline)
November 4, 2017 15
Tyrosine
Dopamine Synapse
Tyrosine
L-DOPA
DA
November 4, 2017 16
Dopamine System
DOPAMINE RECEPTORS
(in green) inside the cell. [Sometimes the signal can decrease
November 4, 2017 20
Antipsychotic treatments
There is no remission
November 4, 2017 21
Antipsychotic treatments
Schizophrenia has been around perhaps, since the
beginning of humankind, however, it was not until
the last century that it was established as a separate
entity amongst other mental disorders.
Many treatments have been devise:
Hydrotherapy:
The pouring of cold water in a stream, from a height of
at least four feet onto the forehead, is one of the most
certain means of subsiding violent, maniacal excitement
that we have ever seen tried... wrote an anonymous
physician in the early 1800s.
November 4, 2017 22
Antipsychotic treatments
Lobotomies (Egaz Moniz received the Nobel Prize).
November 4, 2017 25
Antipsychotics/Neuroleptics
NON-compliance
is the major reason for relapse.
November 4, 2017 26
Antipsychotic/Neuroleptics
November 4, 2017 27
Antipsychotics/Neuroleptics
Tyrosine
Dopamine Synapse
Old
Tyrosine
antiphsychotics
L-DOPA
/neuroleptics are D2
DA
dopamine
receptor
dopamine receptor
antagonist
antagonists.
Although they are
also effective
D2 antagonists at ACh,
5-HT, NE receptors.
November 4, 2017 28
Antipsychotics/Neuroleptics
It appears that the specific interaction of
antipsychotic drugs with D2 receptors is
important to their therapeutic action.
November 4, 2017 29
Antipsychotic/Neuroleptics
Correlations between therapeutic potency and
affinity for binding D2 receptors.
[3H]Haloperidol binding
promazine
chlorpromazine
IC50 (mol/L)
clozapine
thiothixene
haloperidol
spiroperidole
November 4, 2017 30
Clinical dose of drug [mg d-1]
Antipsychotics/Neuroleptics
Both D1 and D2 receptors are found in high
concentrations in the striatum and the nucleus
accumbens.
Metabolism
Most antipsychotics are almost completely
metabolized.
Most have active metabolites, although not
important in therapeutic effect, with one exception.
The metabolite of thioridazine, mesoridazine, is
more potent than the parent compound and
accounts for most of the therapeutic effect.
November 4, 2017 34
Pharmacokinetics
Excretion
Antipsychotics are almost completely metabolized
and thus, very little is eliminated unchanged.
Elimination half-lives are 10-24 hrs.
November 4, 2017 35
Antipsychotic/Neuroleptics
1) Phenothiazines
Aliphatic Piperidine Piperazine*
Chlorpromazine Thioridazine Fluphenazine
Trifluopromazine Piperacetazine Perfenazine
Mesoridazine Acetophenazine
Carphenazine
Prochlorperazine
Trifluoperazine
Piperidine
Aliphatic
Effect
[Drug dose]
November 4, 2017 37
Antipsychotic/Neuroleptics
2) Thioxanthines
Thiothixene
Chlorprothixene
November 4, 2017 38
Antipsychotic/Neuroleptics
3) Butyrophenones
Haloperidol
Droperidol*
November 4, 2017 39
Antipsychotic/Neuroleptics
Butyrophenone d.
Phenothiazine d.
Thioxanthene d.
Effect
[Drug dose]
November 4, 2017 40
Antipsychotics/Neuroleptics
Newer drugs have higher affinities for D1, 5-
HT or -AR receptors.
November 4, 2017 41
Antipsychotics/Neuroleptics
The acute effects of antipsychotics do not explain why
their therapeutic effects are not evident until 4-8
weeks of treatment.
Blockade of D2 receptors
Short term/Compensatory effects:
Firing rate and activity of nigrostriatal and
mesolimbic DA neurons.
DA synthesis, DA metabolism, DA release
November 4, 2017 42
Antipsychotics/Neuroleptics
Presynaptic Effects
Blockade of D2 receptors
Compensatory Effects
Firing rate and activity of nigrostriatal and mesolimbic DA
neurons.
DA synthesis, DA metabolism, DA release.
Postsynaptic Effects
Depolarization Blockade
Inactivation of nigrostriatal and mesolimbic DA neurons.
November 4, 2017 43
Receptor Supersensitivity
Antipsychotic/Neuroleptics
Newer Drugs / Atypical
Pimozide
Molindone
Loxapine
Clozapine
Olanzapine
Qetiapine
Risperidone
Sertindole
Ziprasidone
Olindone
November 4, 2017 44
Antipsychotic/Neuroleptics
Clinical Ex. Py.
Drug Potency toxicity Sedation Hypote.
Chlorpromaz. Low Medium Medium High
Haloperidol High Very High Very High Low
Thiothixene High Medium Medium Medium
Clozapine Medium Very low Low Medium
Ziprasidone Medium Very Low Low Very low
Risperidone High Low Low Low
Olanzapine High Very Low Medium Very low
Sertindole High Very Low Very low Very Low
November 4, 2017 45
Antipsychotic/Neuroleptics
GABA
- neuron
Inhibition
of
Motor Activity
November 4, 2017 48
Antipsychotic/Neuroleptics
dry mouth
blurred vision
urinary retention
constipation
Clozapine, Chlorpromazine
Haloperidol, Thioridazine
November 4, 2017 49
Antipsychotic/Neuroleptics
Some antipsychotics have effects at
adrenergic receptors:
orthostatic hypotension
Chlorpromazine
Thioridazine
November 4, 2017 51
Antipsychotic/Neuroleptics
November 4, 2017 52
Antipsychotic/Neuroleptics
Neuroleptic Malignant Syndrome
Occurs in pts. hypersensitive to the Ex.Py. effects of
antipsychotics.
Due to excessively rapid blockade of postsynaptic
dopamine receptors.
The syndrome begins with marked muscle rigidity.
If sweating is impaired, a fever may ensue. The
stress leukocytosis and high fever associated with this
syndrome may be mistaken for an infection.
Autonomic instability with altered blood pressure and
heart rate is another midbrain manifestation.
Creatine kinase isozymes are usually elevated,
reflecting muscle damage.
November 4, 2017 53
Antipsychotic/Neuroleptics
Treatment
Vigorous treatment with antiparkinsonian drugs is
recommended as soon as possible.
Muscle relaxants such as diazepam, dantrolene or
bromocriptine may be helpful.
November 4, 2017 54
Antipsychotic/Neuroleptics
Drug Interactions
Additive effects with sedatives.
Additive effects with anticholinergics.
Additive effects with antihistaminergics.
Additive effects with -AR blocking drugs.
Additive effects with drugs with quinidine-like
action (thioridazine).
November 4, 2017 55
REFERENCES
1. Katzung, B.G. (2001) Basic and Clinical
Pharmacology, Chapter 29, 8th Ed. Lange. 478-
497pp.
2. Kandell, E.R. and Schwartz, J.H. (1981).
Principles of Neuroscience. Elsvier/North
Holland. N.Y.
3. Wingard et al., (1991) Human Pharmacology.
Molecular to Clinical. Mosby Year Book.
November 4, 2017 56