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Neuroleptics
Anxiolytics
(Abstract)
Schizophrenia
(DA)
Phenothiazines
R
This is a three-ring compound structurally related
to phenothiazine but having the nitrogen atom at
position 10 replaced by a carbon atom with a
double bond. Thioxanthenes have nearly
equivalent potency with phenothiazines.
•Chlorprothixene
•Flupenthixol
•Zuclopenthixol
Butyrophenones
•Droperidol
•Benperidol
•Haloperidol:
•Clozapine
They cause
•Olanzapine
•Quetiapine little extrapyramidal toxicity.
•Risperidone The risperidone is
•Ziprasidone representative of many of the
•Amisulpiride newer agents in having a better
•Zotepine side effect profile.
•Sertindole
Psychiatric indications of neuroleptics
•Benzodiazepines
Lüllmann, Color Atlas of Pharmacology – 2nd Ed. (2000)
•Azapirones (buspirone)
•Benzoxazines (etifoxine)
•Sedative H1-blockers
(hydroxyzine)
•Nonselective
beta-blockers
•SSRIs
Gamma aminobutyric acid (GABA) is probably
the most important inhibitory transmitter in
the CNS. GABA-ergic neurones are distributed
widely in the CNS. GABA controls the state of
excitability in all brain areas and the balance
between excitatory inputs (mostly glutamatergic)
and the inhibitory GABA-ergic activity. If the balance
swings in favour of GABA, then sedation, amnesia,
muscle relaxation and ataxia appear and nervous-
ness and anxiety are reduced. The mildest reduction
of GABA-ergic activity elicits arousal, anxiety, rest-
lessness, insomnia and exaggerated reactivity.
Most drugs used in insomnia act as agonists
at the GABAA-receptor
and have effects other than their direct
sedating action, including muscle relaxation,
memory impairment, and ataxia, which can impair
performance of skills such as driving. Clearly those
drugs with onset and duration of action confined to
the night period will be most effective in insomnia
and less prone to unwanted effects during the day.
Those with longer duration of action are likely to
affect psychomotor performance, memory and
concentration; they will also have enduring
anxiolytic and muscle-relaxing effects.
Benzodiazepines
Bromazepam (t1/2 20 h)
•Chlordiazepoxide
•Cinolazepam
•Clorazepate
•Diazepam (t1/2 40 h)
•Flurazepam
•Flunitrazepam
•Lorazepam
•Nitrazepam: tab. 5 mg
•Medazepam
•Midazolam (t1/2 2 h)
•Triazolam (t1/2 3 h)
•Tetrazepam etc.
When GABA binds with
the GABAA-receptor, the
permeability of the central
pore of the receptor to
chloride ions increases
(hyperpolarization) and
decreasis excitability.
Benzodiazepines (BDZs) enhance the effectiveness
of GABA by increasing the frequency of the opening
of the chloride ions. BDZs are agonists at the receptor
and the flumazenil (antagonist) prevents agonists
from binding at the receptor site.
A model of the GABAA
receptor-chloride ion
channel macromole-
cular complex
Basic & Clinical
Pharmacology –
10th Ed. (2007)
Lüllmann, Color Atlas of Pharmacology – 2nd Ed. (2000)
BDZs enhance GABA-ergic inhibition.
Lüllmann, Color Atlas of Pharmacology – 2nd Ed. (2000)
Advantages of BDZs
BDZs have a high therapeutic index. In hypnotic doses
they do not affect respiration and cardiovascuar
functions. Only in i.v. injection the blood pressure
may fall. BDZs cause less distortion of sleep
architecture. They do not alter disposition of other
drugs by microsomal enzyme induction.
They have lower abuse liability: tolerance is
mild, psycholgical and physical dependence and
withdrawal syndrome are less marked.
A selectve BDZs antagonist flumazenil
(partial agonist of benzodiazepinic receptor)
can be used in case of poisoning.
Chlordiazepoxide Flumazenil
CNS action and classification of BDZs
The action of all BDZs is qualitatively similar, but there
are prominent differences in selectivity and time
course of effect: different members of BDZs are
used for different therapeutic purposes. In contrast
to barbiturates BDZs exert relatively selective
anxiolytic (antianxiety), hypnotic (euhypnotic), muscle
relaxant, and anticonvulsant (antiepileptic) effects.
Anxiolytic effect have all BDZs:
Alprazolam, Bromazepam (Lexotan – tab. 3 mg),
Chlordiazepoxide, Diazepam, Lorazepam,
Мedazepam (daily tranquillisant), Nordiazepam, etc.
Hypnotic (euhypnotic) effect:
Bromazepam, Flurazepam, Flunitrazepam
Nitrazepam, Midazolam, Triazolam, etc.
Anticonvulsive (antiepileptic) BDZs:
Clonazepam, Clorazepate, Diazepam,
Lorazepam, Nitrazepam
Central muscle relaxants:
Diazepam, Tetrazepam
Pharmacokinetics
Biotransformation of benzodiazepines
Lüllmann, Color Atlas of Pharmacology – 2nd Ed. (2000)
Uses
•Benzodiazepines are used for: insomnia;
anxiety; alcohol withdrawal states; muscle spasm
(tetrazepam, diazepam) due to a variety of causes,
including tetanus and cerebral spasticity;
epilepsy (clonazepam, lorazepam, diazepam);
anaesthesia and sedation (diazepam, midazolam,
triazolam) for endoscopies and cardioversion.
•Potent BDZs alprazolam and lorazepam injected
i.m. have an adjuvant role in the management of
acutely psychotic and manic patients.
•The choice of drug as hypnotic and anxiolytic
is determined by their pharmacokinetic properties.
Adverse effects of BDZs
•Common reactions:
Fatigue, drowsiness, ataxia.
•Infrequently reactions:
Constipation, incontinence,
•urinary retention,
•dysarthria, blurred vision,
•diplopia, hypotension,
•nausea, dry mouth, skin rash, tremor.
Tolerance to the anxiolytic effects does
not seem to be a problem.
Studies of subjective sleep quality show
enduring efficacy but about half of
the objective (EEG) studies indicate
decreased effects after 4–8 weeks,
implying that some tolerance develops.
The necessity for dose escalation in sleep
disorders is rare.
Withdrawal of BDZs should be gradual after
as little as 3 weeks’ use but for long-term users
it should be very slow, e.g. about 6–12 weeks. With-
drawal should be slowed if marked symptoms occur
and it may be useful to substitute a long t1/2 drug (e.g.
diazepam) to minimize rapid fluctuations in plasma
concentrations. In difficult cases withdrawal may be
assisted by concomitant use of an antidepressant.
Commonly there is a kind of psychological depend-
ence based on the fact that the treatment works to
reduce patients’ anxiety or sleep disturbance and
therefore they are unwilling to stop. If they do stop,
there can be relapse, where original symptoms return.
BDZs can affect memory
and balance.Hazards with
car driving or operating
any machinery can arise from
amnesia and impaired psychomotor function,
in addition to sleepiness (warn the patient).
Amnesia for events subsequent to administration
occurs with i.v. high doses, for endoscopy, dental
surgery (with local anaesthetic), cardioversion, and
in these situations it can be regarded as a blessing.
Women (1 in 200), may experience sexual fantasies,
including sexual assault, after large doses of BDZs
as used in some dental surgery, and have brought
charges in lawsuits against male staff.
Plainly a court of law has, in the absence of a witness,
great difficulty in deciding whom to believe.
Paradoxical behavior effects and perceptual disorders,
e.g. hallucinations, can occur.
Headache, giddiness, GI upset, skin rashes and
reduced libido can occur too.
Sedative H1-blockers
Hydroxyzine is an H1-blocker
with sedative, antiemetic,
antimuscarinic, and spasmolytic
effects. It is effective
in pruritus, and urticaria.
Etifoxine (Stresam®) produces its anxiolytic effects by binding to β2 and
β3 subunits of the GABAA-receptor. It is used in anxiety disorders.
Nonselective beta-blockers
Many symptoms of anxiety (palpitations, rise in blood
pressure, shaking, tremor, GI hurrying)
are due to sympathetic overactivty and these
symptoms reinforce anxiety. Propranolol and other
nonselective beta-blockers cut the vicious cycle and
provide the symptomatic relief. They do not affect
psychologycal symptoms, such as fear, tension and
worry, but are valuable in acutely stessful situations
(examination fear, unaccustomed public appearance).
SSRIs (selective serotonin reuptake inhibitors)
are effective in obsessive compulsive disorder (OCD),
phobias, panic and many types of sever generalized
anxiety disorders.
Treatment of anxiety
Anxiety is a universal phenomenon, but if it is
frequent and persists in a severe form, it may
cause distress and markedly impair performance.
The established drugs for treatment of excessive
anxiety are BDZs, which must be used in the smallest
possible dose. The usual practice is to give ½ to 2/3 of
DD at bed time to ensure good night’s rest; the remain-
ing part is divided in 2 to 3 doses, given at day time.
Though the plasma half-life of many BDZs, used
in anxiety are longer, divided daytime doses are
required to avoid high plasma peaks.
Buspirone is a nonsedating alternative to BDZs for a
less severe form of generalized anxiety.
The SSRI antidepressants
are now being increasingly used in many forms of severe
anxiety disorders. They produce a delayed but often gratifying
response and combined with BDZs. The SSRIs are now
drugs of choice for treatment of social anxiety in which
BDZs though effective, carry abuse potential on long term use.
Patients with arterial hypertension, angina pectoris,
peptic ulcer, ulcerative colitis, irritable bowel,
gastroesophageal reflux, thyrotoxicosis are often given low
doses of BDZs intermittently in addition to specific
therapy, though anxiety may not be a prominent manifestation.