psychopharmaca sulistia 1209. classification i. antipsychotics ii. antidepressants iii. antianxiety...
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PSYCHOPHARMACA
Sulistia 1209
classification
• I. Antipsychotics• II. Antidepressants• III. Antianxiety and Drug for insomnias• IV. Drug for bipolar disorder
I. ANTIPSYCHOTIC (AP)
• SYNONIMS: antischizophrenic drug, neuroleptics, mayor tranquilizer
• CLASSIFICATION:Typical AP : chlorpromazine, fluphenazine
haloperidol, thioridazine
Atypical AP :
clozapine,olanzapine,risperidone quetiapine, aripriprazol
• MECHANISM OF ACTION
- Blocking the D2-receptors > D1 (mesolimbic / mesocortical dep. pathway)
- ! Atypical : clozapine
weak D2 blocker ,potent antipsychotic block D4-receptor and 5-HT2
- Varying pattern of selectivity in rec. blocking effect
- Take several weeks to clinical response even
though their rec. blocking is immediate
- The connection between rec. block. activity to clin. response : remains unclear
PHARMACOLOGICAL EFFECTS
Slow response to external stimuli :- apathy- reduce initiative- display few emotion- tend to drowse off but easily arouse, and respond to question- strongly inhibit aggressive tendencies- < hallucination & delusion
• Antiemetic activity : ~ block. D3 rec.
Th/effect70% of pts30% resistant
EFFECT ON RECEPTRS• Vary among different AP * Chlorpromazine: α1=5-HT2A>D2>D1
* Haloperidol:
D2> α1>5-HT2A>D1>H1
* Clozapine: D4= α1>5-HT2A>D2=D1
* Olanzapine:
5-HT2A>H1> D4>D2 > α1 >D1
* Aripiprazole: D2= 5-HT2A>D4> α1=H1>>D1
* Quetiapine :
H1> α1>M1,3>D2>5-HT2A
PSYCHOLOGICAL EFFECTS
• In nonpsychotic patients Sleepiness, restlessness, autonomic effect
unlike sedative-hypnotics and impaired performance in psychomotor and psychometric tests
In Psychotic patients: alleviate psychosis and improve performance
ELECTROENCEPHALOGRAPHIC EFFECTS
• Shift the pattern of EEG frequencies: slowing and increasing their synchronization → erroneous
diagnostic interpretation• some lower seizure threshold , but can be use
safely in epileptic patients with careful dosage titration
PharmacokineticAbsorption and Bioavailabily
• Chlorpromazine absorption erratic interindividual variation up to 90 fold ,
• bioavailability: chlorpromazine: 25% thioridazine 35%,both undergo first pass metabolism haloperidol 65%
- relation between plasma conc – clin. effect : highly variable tailored individually!
- long t½ (15-30 hours) 1 2 dd.- Depot preparation : heptanoic or decanoic
acid in oil : IM given each 2-4 weeks overcome compliance problems
DISTRIBUTION
• Highly lipid soluble • widely distributed. Vd >7L/kg• Highly protein bound(92-99%)• Prolonged binding to receptors duration of action> than plasma t 1/2
Metabolism and Excretion
• Most AP are completely metabolized• Metabolites usually not active except
mesoridazine which is more active than thioridazine
• Excreted in the urine as inactive metabolites
ADEA. 2 kind of motor disturbance :
1) Acute dystonias & Parkinson-like symptoms ~ nigrostriatal block D2 rec., tremor, rigidity (esp. eck muscle), akatisia(uncontrollable restlessness)
Th/ anticholiergic drugs: trihexyphenidyl beperiden ,
diphenhydramine * Levodopa and dopaminergic agonist should never be use (why?)
ADE
2) Tardive diskinesia- involuntary movement of face
& limbs, appearing months/years after treatment
Th/ usually unsuccessful
Extrapyramidal ADE are less likely to occur with atypical AP clozapine : strong antimusc. more selective D block in
mesolimbic vs nigrostriatal
B.Cardiovascular adverse effects
• Chlorpromazine, thioridazine: orthostatic hypotension;mean arterial pressure, peripheral resistance and stroke volume <;
• H Rate ↑, prolonged QT interval sertindole, withdrawn from the market ziprazidone warning about the risk
C.Endocrine ADE
• In women : amenorrhoea-galactorrhea, increase libido and false positive pregn. Test.
• In men: decrease libido, gynecomastia a part cause by hyperprolactinemia due to
dopaminergic blocking effect and increase peripheral conversion of androgens to estrogens(>typical AP)
D. Other ADE antimuscarinic adverse effects :
! - Alzheimer (memory impairment)- prostate hypertrophy- glaucoma,
orthostatic hypotension : associated w alfa
adrenergic blocking effect ~ fall and fracture in the elderly
weigh gain : > atypical agranulocytosis : clozapine to be monitored by
blood count idiosyncratic : antipsychotic malign. syndrome,
rare but dangerous
relation of chemical structure to potency & toxicity Table 29-1. p 461.Bertram G Katzung 10th ed.
- Indonesian population : as common with other drug tolerate AP less than caucasian
- ? poor metabolizer- ! Start with lower dose
DRUG CHOICE
• Based mainly on differences and ADE• In using typical AP knowledge of
chlorpromazine and haloperidol remains relevant
• One should be familiar w 3 subfamily of phenothiazine,a member of thioxanthine and butyrophenone group and all the newer compound
• A representative group of AP drugs is presented in:
Table 29-1. p 461.Bertram G Katzung 10th ed.
Summary
• AP are very useful : for pats & care givers less hospitalization
• Effective in 70% of pts
• Atypical : problem with dystonia S.E.
• Atypical :- sign less motor disturbance- claimed > effective to control neg.
symptoms :* emotional flattening * social withdrawal and
* lack of motivation
Summary
• Atypical :- > metabolic side effects :
* weight gain* hyperglycemia
- clozapine : efficacy in treatment resistant pts.
- not more effective in every patients - first line drug for those who could afford the costAP are safe in acute overdose compare to hypnotic-
sedatives and tricyclic antidepressant
Cytochrome P450 enzymes involved in psychopharmacological drug
2D6 : - amitriptyline, desipramine, imipramine, haloperidol, nortriptyline
- risperidone, thioridazine- venlafaxine
3A4 : amitriptyline, imipraminebupropionclonazepam, diazepamfluoxetine, sertralinezolpidem
2C19 : amitriptyline, clomipramine, imipramin, diazepam, moclobemide
Question to be answered
• 1. mention classification of AP(antipsychotic) and 3 examples of each class
• 2. explain the differences of pharmacodynamic action of each class
• 3. explain important pharmacokinetic issue of AP
• 4. Explain difference in ADE of special drugs
• 5. Explain factors influencing the use of drugs
I. ANTIDEPRESSANT
CLASSIFICATION
A.First Generation Tricyclic AD Imipramine Amitriptyline
* ClomipramineB. Second Generation: * Amoxapine, Maprotiline, Trazodone, Bupropion C. Third Generation:Venlafaxine, Mirtazapine, Nefazodone &
Duloxetine
• D. Selective Serotonin Reuptake Inhibitor (SSRI)
Fluoxetine, Sertraline, Fluvoxamine, Citalopram
• E. Monoamine Oxydase Inhibitors Phenelzine, Tranylcypromine,
moclobemide
A. Tricyclic Antidepressant
Mechanism of action
• Block the amine transporters (uptake pump)
• Block reuptake of NE (NET), 5HT (SERT) (<< dopamin) catecholamine: mania;
catecholamine :depression• Not clearly understood why blocking transporter
occurs rapidly but clinical result is delayed for a few weeks
B.. Second generation of Antidepressant
• AD that exhibit less CVS side effects * desimipramine: metabolit of imipramine * nortriptyline: metabolit of triptyline• AD that exhibit less CVS side effects but more
sedation: trazodone and bupropion• Amoxapine a metabolite of antipsychotic
loxapine: retain AP action of the parent drug
• Maprotyline,structure resembles desimipramine is a potent NE reuptake inhibitor, causing <sedation,antimuscarinic and CVS side effects .
C. Third Generation of AD
• Venlafaxine: - potent inhibitor of serotonin transporter; & weak inhibitor of NE transporter; in low dose= SSRI, high doses (> 225 mg/d) mild-moderate increase HR & BP• Nefazodone: as trazodone, but less sedation.
potent inhibitor of CYP 3A4• Duloxetine=SSRI,free of autonomic SE and sedation
Mirtazapine more rapid in action no more efficacious than
other AD likely to cause weight gain substantial sexual side effect
>> sedating because of strong antihistaminergik effect
• ADE
Interference with autonomic control
- Atropine like : dry mouthblurred visionconstipationurinary retention
- Orthostatic hypotension : central NE effect
- CNS : * sedation, seizure * diff. in concentrating
- CVS : prolongation Q-T interval : risk of sudden cardiac †
Cytochrome P450 enzymes involved in psychopharmacological drug
2D6 : - amitriptyline, desipramine, imipramine, haloperidol, nortriptyline
- venlafaxine
3A4 : amitriptyline, imipraminebupropionclonazepam, diazepamfluoxetine, sertralinezolpidem
2C19 : amitriptyline, clomipramine, imipramin, diazepam, moclobemide
• Drug Interaction
highly protein bound : free drug in comb. : aspirin, phenylbutazone
inhibitor of Cyp 2D6 :- nortriptyline- desipramin
TCA + alcohol severe Resp. depression
TCA + antihypertensive adrenergic neuron
blocking agents (guanadrel): BP
! Should be monitored clinically
conc. by- fluvoxamine- paroxetine
D. SSRI (Selective Serotonin Reuptake Inhibitor)
Fluoxetine Fluvoxamine Paroxetine Sertralin
Mechanism of action More selective 5 HT-reuptake Inhibitor
more 5 HT at rec.
desensitization of autorec normal firing rt. No influence to cholinergic nerves / NE, dopamin
less side effects
ADE
<< than TCA : CVS, antimusc.
acute toxicity : << dangerous than TCA
combination with MAOI serotonin syndrome: tremor, hyperthermia, CVS collaps † reported
common : nauseaanorexiainsomnialoss of libido, failure of orgasm
Indication : major depression anxiety disorder panic attacks obsessive-compulsive disorder
(OCD)
ADE
• Paroxetine: highest affinity to serotonin receptors….indirectly
result in a net decline in dopaminergic transmission leading to extrapyramidal side effects (distonia, akathisia)
• Sexual function(delayed ejaculation and anorgasmia)
paroxetine>fluoxetine, sertraline> flufoxamine
D. Monoamine oxidase Inhibitors
Moclobemide : selective MAOI ( type A),reversible less interaction less CNS ADR
Main ADR :- postural hypotension- atropin like action- weight gain- CNS stimulation
acute overdose convulsions- cheese reaction : severe hypertension
(tyramine containing food > 10 mg) - hyperpyrexia hypotension
Than older MAOI :- pargiline- tranylcypromine
in comb. with pethidine
III. ANXIOLYTIC & HYPNOTIC DRUGS A. BENZODIAZEPINES
Mechanism of action- facilitate GABA action (≠ receptor binding) :
hyperpolarization, Cl channel opening- safe because its action depend on endogenous
GABA ≠ barbiturate : direct action in overdose
Pharmacological effects- reduction of anxiety and aggression- sedation and induction of deep- reduction of muscle tonus and coordination- anticonvulsant effect
• ADE Acute overdosage
- less dangerous, only rarely †- in the present of other CNS depressant
esp. alcohol : severe resp. disorder or in COPD! could be counteract by antagonist flumazenilCommon side effect :
- drowsiness- confusion- impaired coordination- amnesia esp. with long acting drug
impairment of job performance and driving skill
• Chronic use :
Tolerance : less than barbiturate
Dependence demonstrate by- symptoms of anxiety- tremor- dizziness
withdrawal symptoms : slower in onset than barbiturates
with triazolam : a short acting BDZoccurred within a few hours :
- early morning insomnia- daytime anxiety
Addiction : not a mayor problem
after withdrawal
Indication
Hypnotic :- lorazepam- temazepam
! not for chronic use tolerance
Anxiolytic :acute anxiety state e.g. panic disord. agoraphobia
choice : alprazolam 2-3 times daily 0.25-0.5 mgaltern. : diazepam 2 times daily 2-5 mg
Muscular relaxant in muscle spasm : diazepam
Other :- Alprazolam : anxiety in major depressive disorder- Clobazam : claimed to cause less sedation as
antianxiety drug
short acting