Medical Care

Antipsychotic medications

• mainstay of treatment for schizophrenia 2 Types of Antipsychotics• Conventional or 1st generation– Dopamine 2 receptor antagonists

• Atypical or second generation– Serotonin dopamine antagonists– Block other dopamine receptors (D1 & D5) and

serotonin receptors

Conventional antipsychotics

Butyrophenones• Haloperidol (Haldol, Serenace) • Droperidol (Droleptan) Thioxanthenes• Chlorprothixene • Flupenthixol (Depixol, Fluanxol) • Thiothixene (Navane) • Zuclopenthixol (Clopixol, Acuphase)

Conventional Antipsychotics• Phenothiazines• Chlorpromazine (Thorazine, Largactil) • Fluphenazine (Prolixin) • Perphenazine (Trilafon) • Prochlorperazine (Compazine) • Thioridazine (Mellaril, Melleril) • Trifluoperazine (Stelazine) • Mesoridazine • Periciazine • Promazine • Triflupromazine (Vesprin) • Levomepromazine (Nozinan) • Promethazine (Phenergan) • Pimozide (Orap)

Conventional Antipsychotics according to Potency

Low potency• Chlorpromazine (Largactil, Thorazine) • Thioridazine (Mellaril) • Mesoridazine Medium potency• Loxapine (Loxapac, Loxitane) • Molindone (Moban) • Perphenazine (Trilifon) • Thiothixene (Navane) • Trifluoperazine (Stelazine) High potency• Haloperidol (Haldol, Serenace) • Fluphenazine (Prolixin) • Droperidol • Zuclopenthixol (Clopixol)

Atypical Antipsychotics• Clozapine • Olanzapine • Risperidone • Quetiapine • Ziprasidone • Amisulpride • Asenapine • Paliperidone • Iloperidone • Zotepine• Sertindole• Aripiprazole

Non-Neurologic Adverse Effects• Sedation• Orthostatic Hypotension• Anticholinergic response• Endocrine effects (hyperprolactinemia)• Dermatologic effects (atopic dermatititis,

photosensitivity)• Opthalmologic effects (retinal pigmentation)• Cardiac effects (QT interval prolongation)• Weight gain• Hematologic effects (leukopenia, agranulocytosis)• Jaundice

Neurologic Adverse Effects

• Epileptogenic effects• Dystonia• Parkinsonian effects• Akathisia• Tardive dyskinesia• Neuroleptic malignant syndrome

Anticholinergic agents

• often used in conjunction with the conventional antipsychotic agents to prevent dystonic movements or to treat extrapyramidal symptoms

• Ex. benztropine, procyclidine, trihexyphenidyl, diphenhydramine or amantadine

Choice of drug

• Current clinical practice favors the use of high potency antipsychotics due to the unfavorable adverse effects associated with low potency antipsychotics

• Combination therapy– non-sedating high potency during daytime– Sedating low potency at bedtime

• Extremely non-compliant patients : long-acting depot preparations

• Emergency management of extremely agitated patient: Haloperidol 5-10mg + Lorazepam 2 mg IM

Therapeutic drug monitoring• Patients may not always take their medications; checking the level

can be a clue to this. • Patients often have other medical illnesses; medicines used in these

illnesses can interact with psychotropic medications. • Patients may not always be the best reporters of their symptoms,

and medication levels can occasionally detect clinically silent toxicity.

• Smoking tobacco products induces the liver enzyme CYP1A2, which metabolizes clozapine. Patients who stop smoking while being treated with clozapine often experience an increase in their clozapine levels. (Nicotine patches and nicotine inhalers and chewing tobacco do not induce this enzyme.)