ANTI-PSYCHOTICS

By: PGI Viktoria Ines P. Matibag

CLASSIFICATION
TYPICAL
Phenothiazines
Chlorpromazine, thioridazine, fluphenazine
Thioxanthenes
Thiothixene
Butyrophenones
Haloperidol

ATYPICAL
Heterocyclics
Clozapine, Loxapine, Olanzapine, Risperidone, Quetiapine, Ziprasidone, Aripiprazole
SEROTONIN HYPOTHESIS OF
SCHIZOPHRENIA
5-HT2A-receptor blockade is a key factor in the mechanism of action of the main class
of atypical antipsychotic drugs, of which clozapine is the prototype
Inverse agonists of the 5-HT2A receptor; that is, they block the constitutive activity of
these receptors
Receptors modulate the release of dopamine, norepinephrine, glutamate, GABA and
acetylcholine, among other neurotransmiters in the cortex, limbic region, and striatum
Stimulation of 5-HT2A receptors leads to depolarization of glutamate neurons, but also
stabilization of N-methyl-D-aspartate (NMDA) receptors on postsynaptic neurons.
Stimulation of 5-HT2C receptors leads to inhibition of cortical and limbic dopamine
release.
DOPAMINE HYPOTHESIS OF
SCHIZOPHRENIA
Schizophrenia is caused by excess of dopamine in specific neuronal tracts
Relevant to positive and negative symptoms (emotional blunting, social withdrawal,
lack of motivation), cognitive impairment, and possibly depression
Antipsychotic drugs block brain dopamine receptors D2 receptors
Dopamine agonists exacerbate schizophrenia
DOPAMINE HYPOTHESIS OF
SCHIZOPHRENIA
Several lines of evidence suggest that excessive limbic dopaminergic activity plays a role in psychosis.
(1) Many antipsychotic drugs strongly block postsynaptic D2 receptors in the central nervous system,
especially in the mesolimbic and striatal-frontal system; this includes partial dopamine agonists, such as
aripiprazole and bifeprunox.
(2) Drugs that increase dopaminergic activity, such as levodopa, amphetamines, and bromocriptine
and apomorphine, either aggravate schizophrenia psychosis or produce psychosis de novo in some
patients.
(3) Dopamine-receptor density has been found postmortem to be increased in the brains of
schizophrenics who have not been treated with antipsychotic drugs.
(4) Some but not all post- mortem studies of schizophrenic subjects have reported increased dopamine
levels and D2-receptor density in the nucleus accumbens, caudate, and putamen.
(5) Imaging studies have shown increased amphetamine-induced striatal dopamine release, increased
baseline occupancy of striatal D2 receptors by extracellular dopamine, and other measures consistent
with increased striatal dopamine synthesis and release.
Dopaminergic Tracts
Mesocortical-Mesolimbic
Regulates mentation & mood
Nigrostriatal
Extrapyramidal function
Tuberoinfundibular
Control of prolactin release
Medullary-Periventricular
Eating behavior
Incertohypothalamic
Anticipatory motivational phase of copulatory behavior
GLUTAMATE HYPOTHESIS OF
SCHIZOPHRENIA
Glutamate is the major excitatory neurotransmitter in the brain
Hypofunction of NMDA receptors, located on GABAergic interneurons, leading to
diminished inhibitory influences on neuronal function, contributed to schizophrenia
Diminished GABAergic activity can induce disinhibition of downstream glutamatergic
activity, which can lead to hyperstimulation of cortical neurons through non- NMDA
receptors
The NMDA receptor, an ion channel, requires glycine for full activation
In patients with schizophrenia, the glycine site of the NMDA receptor is not fully saturated
Toxicities
TYPE MANIFESTATIONS
AUTONOMIC NERVOUS Loss of accommodation, dry
SYSTEM mouth, difficulty urinating,
constipation
Orthostatic hypotension,
impotence, failure to ejaculate
CENTRAL NERVOUS SYSTEM Parkinsons syndrome, akathisia,
dystonia
Tardive dyskinesia
Toxic-confusional state
ENDOCRINE SYSTEM Amenorrhea-galactorrhea,
infertility, impotence
OTHERS Weight gain
MECHANISM
Muscarinic cholinoceptor
blockade
Alpha-adrenoceptor blockade
Dopamine-receptor blockade
Supersensitivity of dopamine
receptors
Muscarinic blockade
Dopamine-receptor blockade
resulting in hyperprolactinemia
Possibly combined H2 and 5-HT2
blockade
NEUROLEPTIC MALIGNANT
SYNDROME
Fever
Encephalopathy
Vitals are unstable
Elevated CPK
Rigidity
TYPICAL ANTI-PSYCHOTICS
Phenothiazines
Chlorpromazine, thioridazine, fluphenazine
Thioxanthenes
Thiothixene
Butyrophenones
Haloperidol
CHLORPROMAZINE
Mechanism of Action: Blocks D2 receptors >> 5HT-2 receptors
Uses: Schizophrenia, other psychotic disorders
Side Effects: Extrapyramidal dysfunction, tardive dyskinesia, hyperprolactinemia,
atropine-like effects, failure of ejaculation, postural hypotension, marked sedation,
corneal and lens deposits, neuroleptic malignant syndrome, contact dermatitis
THIORIDAZINE
Mechanism of Action: Blocks D2 receptors >> 5HT-2 receptors
Uses: Schizophrenia, other psychotic disorders, antiemetic (prochlorperazine)
Side Effects: Extrapyramidal dysfunction, tardive dyskinesia, hyperprolactinemia,
atropine-like effects, failure of ejaculation, postural hypotension, retinal deposits,
cardiotoxicity (arrythmias)
HALOPERIDOL
Mechanism of Action: Blocks D2 receptors >> 5HT-2 receptors
Uses: Schizophrenia, other psychotic disorders, Huntingtons disease, Tourettes
syndrome
Side Effects: Extrapyramidal dysfunction, tardive dyskinesia, hyperprolactinemia,
neuroleptic malignant syndrome
WEAKEST autonomic effects
Least sedating among typical antipsychotics
ATYPICAL ANTI-PSYCHOTICS
ATYPICAL
Heterocyclics
Clozapine
Loxapine
Olanzapine
Risperidone
Quetiapine
Ziprasidone
Aripiprazole
CLOZAPINE
Mechanism of Action: Blocks 5HT-2 receptors >> D2 receptors
Uses: Schizophrenia (refractory, suicidal), other psychotic disorders
Side Effects: Extrapyramidal dysfunction, hyperprolactinemia, postural hypotension,
weight gain, hyperglycemia (DM), hyperlipidemia, myocarditis, agranulocytosis,
seizures, ileus, hypersalivation
ONLY antipsychotic that REDUCES RISK OF SUICIDE
OLANZAPINE
Mechanism of Action: Blocks 5HT-2 receptors >> D2 receptors
Uses: Schizophrenia and other psychotic disorders, Bipolar disorder, Anorexia nervosa,
Depression
Side Effects: Extrapyramidal dysfunction, hyperprolactinemia, postural hypotension,
weight gain, hyperglycemia (DM), hyperlipidemia
QUETIAPINE
Mechanism of Action: Blocks 5HT-2 receptors >> D2 receptors
Uses: Schizophrenia and other psychotic disorders, Bipolar disorder (Manic episode)
Side Effects: Extrapyramidal dysfunction, hyperprolactinemia, postural hypotension,
weight gain, somnolence, fatigue, sleep paralysis, hypnagogic hallucinations,
cataracts, priapism
RISPERIDONE
Mechanism of Action: Blocks 5HT-2 receptors >> D2 receptors
Uses: Schizophrenia and other psychotic disorders, bipolar disorder, depression,
intractable hiccups, Tourette syndrome
Side Effects: Extrapyramidal dysfunction, hyperprolactinemia, weight gain, insomnia,
photosensitivity
ONLY antipsychotic that is approved for SCHIZOPHRENIA in the YOUTH
ZIPRASIDONE
Mechanism of Action: Blocks 5HT-2 receptors >> D2 receptors
Uses: Schizophrenia and other psychotic disorders, bipolar disorder (acute mania)
Side Effects: Extrapyramidal dysfunction, postural hypotension, QT prolongation
(Torsades de pointes)
No atropine-like effects
Little or no tendency to cause hyperglycemia, hyperprolactinemia, or weight gain
Increased mortality in elderly patients with dementia-related psychosis
ARIPIPRAZOLE
Mechanism of Action: Blocks 5HT-2 receptors >> D2 receptors
Partial D2 receptor agonist
Uses: Schizophrenia and other psychotic disorders, bipolar disorder, depression, autism,
cocaine dependence
Side Effects: Extrapyramidal dysfunction, GI upset, tremor, hypersensitivity
Least sedating atypical antipsychotic
No atropine-like effects
Little or no tendency to cause hyperglycemia, hyperprolactinemia, or weight gain