pharmacology of antipsychotic drug pharmacology of antipsychotic drugs

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Pharmacology of Antipsychotic drug Pharmacology of Antipsychotic drugs Slide 2 Antipsychotic drugs, neuroleptic or anti- schizophrenic drugs are used mainly to manage psychosis (including delusions or hallucinations and disordered thought ) particularly in schizophrenia and bipolar depression Slide 3 Schizophrenia Slide 4 It is a chronic disabling disorder which affects people during late adolescence or early adulthood Schizophrenia has a strong genetic component and is probably due to biochemical abnormality (dysfunction of D-ergic neurons) There is some evidence for involvement of 5-HT Slide 5 Patients with schizophrenia have problems with seeing things, hearing voices, imagining things, having terrifying thoughts (positive symptoms) Apathy, blunted emotions, anhedonia and reduced ability to react with people social withdrawal (Negative symptoms) Slide 6 Positive Symptoms Hallucinations Delusions Thought disturbances Negative Symptoms Blunted emotions Social withdrawal Loss of motivation impaired personal hygiene Schizophrenia: Symptoms Slide 7 Dopamine hypothesis Schizophrenia has a strong genetic component and probably reflects too much dopamine activity in the mesolimbic system which is the part of brain that controls seeing, hearing, imaging etc.. Slide 8 Dopamine hypothesis - Evidences Drugs that increase dopamine may produce positive psychotic symptoms (e.g. Cocaine, amphetamine) All known antipsychotics drugs capable of treating positive psychotic symptoms block the dopamine receptors (D2) Slide 9 Antipsychotic Drugs Slide 10 Antipsychotics are broadly divided into two groups: The typical = 1 st generation and the atypical = 2 nd generation antipsychotics Atypical drugs are preferred as a first line treatment because they: 1- have fewer side effects 2- have additional benefits for the -ve symptomsof schizophrenia Slide 11 Mechanism of Action Slide 12 All antipsychotic drugs block D 2 receptors in the brain & periphery Atypical antipsychotics exert part of their action through blocking of 5-HT 2A receptors Antipsychotics take days or weeks to work, suggesting that secondary effects (e.g. increase in number of D2-receptors in limbic structure) may be more important than direct effect of D2- receptor block. Slide 13 Many antipsychotics block other receptors e.g. acetylcholine (M), noradrenaline ( ) and histamine (H1) receptors Slide 14 Typical antipsychotic Drugs 1- Phenothiazine derivatives : Chlorpromazine, promethazine, Fluphenazine 2- Butyrophenone derivatives: Haloperidol, droperidol Atypical antipsychotic drugs Risperidone, Clozapine, Olanzapine Aripiprazole Slide 15 Pharmacological Actions Slide 16 1- Antipsychotic effects Though blocking D 2 receptors in the mesolimbic system, antipsychotic drugs relieve hallucination, improve thoughts. The additional blocking effects of atypical antipsychotics on 5-HT 2 receptors can treat the negative symptoms of schizophrenia 2- Autonomic effects: Anticholinergic effects, dry mouth, constipation and blurred vision Blocking of adrenergic receptors hypotension Slide 17 3- Exrapyramidal effects Blocking of D2 receptors in the nigrostriatal pathway causes unwanted parkinsonian-like symptoms; rigidity and tremors. Clozapine and risperidone exhibit a low incidence of these symptoms ( block D4) 4- Antiemetic effect Blocking D2 receptors both centrally in the CTZ in the medulla and peripherally in the stomach Slide 18 5- Endocrine effects: Amenorrhea- galactorrhea, falsepositive pregnancy tests in women and decreased libido and gynecomastia in men (due to blockade of D2 in the pituitary leading to an increase in prolactin release) 6- Antipsychotics block H1 receptors causing sedation and confusion 7- Antipsychotic depress the hypothalamus affecting thermo- regulation (hypothermia) Slide 19 Therapeutic Uses Slide 20 1- Treatment of schizophrenia Typical antipsychotics are most effective in treating positive symptoms Atypical antipsychotics with serotonin blocking activity are effective in many patients resistant to the traditional agents, especially in treating negative symptoms Slide 21 2- Treatment of other psychotic disorders e.g. mania and mood (bipolar) disorders 3- Prevention of severe nausea and vomiting (drug-induced nausea) 4- Droperidol is used in combination with fentanyl in neuroleptanalgesia Slide 22 5- Due to its antihistaminic effects, promethazine is used in cases of pruritus and as a preoperative sedative 6- To induce hypothermia in certain major operations (Chlorpromazine) 7- Chlorpromazine is used to treat intractable hicough Slide 23 Adverse Effects Slide 24 Extrapyramidal Symptoms (EPS) Dopamine Vs Acetylcholine Dopamine (inhibitory) and ACh (excitatory) have a reciprocal relationship in the Nigrostriatal pathway A delicate balance allows for normal movement Dopamine blockade by antipsychotic drugs results in relative increase in cholinergic activity causing EPS When high potency antipsychotics are chosen, we often prescribe anticholinergic medication like benztropine Slide 25 Antipsychotics have a wide range of side effects 1- Sedation (drowsiness) is a common side effect of antipsychotics (?) This can be dealt with by taking medication at night just before going to bed 2- Movement disorders; Extrapyramidal side effects are common with the typical antipsychotics ; include dystonia, akathisia parkinsonian- like syndrome Treatment: anticholinergic drugs (benztropine) Slide 26 It is the most important adverse effect of long-treatment with typical antipsychotic drugs and is characterized by excessive movement of the lips, tongue and jaw, limbs Tardive dyskinesia may be irreversible and is postulated to result from increased number of dopamine receptors that are synthesized in response to long-term dopamine receptor blockade, which leads to neuronal supersensitivity to dopamine Tardive dyskinesia Slide 27 Atypical drugs have lower incidence of EPS & tardive dyskinesia as they block 5-HT 2A receptors and have less D 2 receptor blocking effect Slide 28 3-Autonomic effects:Orthostatic hypotension !!!!, (-adrenoceptor blockade) and anticholinergic adverse effects (urinary retention, constipation, ppt of glaucoma,..) 4- Endocrine and metabolic effects: hyperprolactinemia in the form of galactorrhea, amenorrhea in women, gynecomastia and changes in libido & impotence in men Slide 29 5- Allergic reactions: Agranulocytosis (common with clozapine), cholestatic jaundice and skin eruptions 6-Occular complications: may cause retinal pigmentation, corneal and lens opacities (Chlorpromazine) 7- Clozapine and chlorpromazine tend to lower an individuals seizure threshold Slide 30 Neuroleptic Malignant Syndrome An idiosyncratic, life-threatening neurological disorder associated with antipsychotic therapy Idiosyncracy: An unusual or unexpected sensitivity exhibited by an individual to a particular food or drug. Idiosyncrasy is usually determined genetically and it may be due to a biological deficiency (e.g. an inability to metabolize a drug). Slide 31 Neuroleptic Malignant Syndrome Clinical manifestations include: Encephalopathy, Hyperpyrexia, delirium Autonomic instability (BP) Rigidity of muscles Elevated creatine phosphokinse (CPK) due to increased muscular activity and rhabdomyolysis (destruction of muscle tissue ) Slide 32 Pathophysiology The mechanism is thought to depend on dopamine activity due to: Dopamine receptor blockade Genetically reduced function of dopamine receptor There is an increased calcium release from the sarcoplasmic reticulum of muscle cells which can result in rigidity and cell breakdown Slide 33 Treatment involves: Immediate discontinuation of antipsychotic drug Treat hyperthermia Hydration, maintain vital functions Dantrolene sodium: a muscle relaxant that acts by abolishing excitation contraction coupling in muscle cell Slide 34 Typical antipsychotics Slide 35 Chlorpromazine Phenothiazine class Increased prolactin (gynaecomastia) Hypothermia Anticholinergic effects Hypersensitivity reactions Obstructive jaundice Ocular complications EPS Slide 36 Fluphenazine Phenothiazine class but: does not cause jaundice causes less hypotension causes more EPS Slide 37 Halopirodol Butyrophenone class As chlorpromazine but does not cause jaundice Fewer anticholinergic side effects Strong EPS tendency Slide 38 Atypical Drugs Slide 39 Differences between typical and atypical groups receptor profile Serotonin receptors (5-HT 2A ) are involved incidence of extrapyramidal side effects (less in atypical group) efficacy (specifically of Clozapine in treatment of resistant group of patients efficacy against negative symptoms Slide 40 Dibenzodiazepine class Potent antagonist at D 4 -receptors Selectively blocks 5-HT 2A receptors Sedation Extrapyramidal side effects are minimal Low incidence of Tardive dyskinesia Increased risk for seizures (2-3%) Clozapine Slide 41 Agranulocytosis in 1% (regular granulocyte counts weekly is required) Agranulocytosis risks increase when co- administered with carbamazepine Anticholinergic side effects Weigh gain Shows efficacy in 'treatment-resistant' patients Effective against negative and positive symptoms Clozapine Slide 42 Largely replacing clozapine. No risk of agranulocytosis Low incidence of EPS and minimal sedation Weight gain Resperidone is approved for the treatment of autism and bipolar depression Risperidone Slide 43 Recently approved drug Long acting (plasma half-life 3 days) No effect on prolactin secretion No weight gain Less incidence of dystonias and Tardive dyskinesia D2 partial agonist profile may account for paucity of side effects Aripiprazole Slide 44 Advantages & disadvantages of Clozapine Advantages Effective in the treatment of negative and positive symptoms of schizophrenia More effective than classical agents for resistant cases Disadvantages Clozapine has the risk of indu