Antipsychotic drugs

Under supervision:
Assistant.professor.dr/ Hoda Sayed
Ass.lecturer dr/ Menna_Allah Mohsen
Demonstrator/ Noura Said
Demonstrator/ Nagla Shahein

1. Fatma Ragab Abas
2. Fatma Ali Shazly
3. Fatma Mohammed Mohammed
4. Mostafa Mohammed
5. Maria Reziq
6. Marina Ragay
7. Magdi Ehab
8. Mohammed Abo Srea Sayed
9. Mohammed Esmail Mohammed
10.Mohammed El sayed
Prepared by:

Objectives:
At the end of this lecture the student should be able to:
• Define antipsychotic drugs
• Clarify classification of antipsychotic drugs
• discuss the pharmacokinetic and pharmacodynamics of antipsychotic
drugs
• list the indication of antipsychotic drugs
• Know side effects of antipsychotic drugs
• Enumerate contraindications of antipsychotic drugs
• Implement nursing care plan of antipsychotic drugs
• Realize health education of antipsychotic drugs

Introduction:
• Antipsychotics, also known as neuroleptics, are a class of
psychotropic medication primarily used to manage psychosis
(including: delusions, hallucinations, paranoia or disordered
thought), principally in schizophrenia but also in a range of other
psychotic disorders. They are also the mainstay together with mood
stabilizers in the treatment of bipolar disorder.

Definition:
Are drugs that are used to treat symptoms of psychosis such as
delusions (for example, hearing voices), hallucinations, paranoia, or
confused thoughts. They are used in the treatment of schizophrenia,
severe depression. And severe anxiety. Antipsychotics are also useful at
stabilizing episodes of mania in people with Bipolar Disorder.

Classification of antipsychotic drugs:
•Typical: (first generation) antipsychotics.
•Atypical: (second generation) antipsychotics.

Typical Atypical
Mechanism Block mainly D2 receptors Block D2(less)&
5HT2(more)
Effect More effect on +ve
symptoms
More effect on -ve
Symptoms
Extra pyramidal side Common Less common
Neuroleptic malignant
syndrome
Common Less common
Endocrinal side effect Less common Common
Agranulocytosis Less common Common
Generation First generation
(Oldest/Classical)
Second generation
(New/Novel)
Cost Less More expensive

Common drugs:
1. Typical/ first generation:
Genetic name Trade name
Chlorpromazine Thorazine, Sonazine and
Largactil.
Haloperidol Halodol
,Safinace and
Halonace
Trifluoperazine Stelazine
Thioridazine Mellaril

2
. Atypical /Second generation:
Genetic name Trade name
Amisulpride Solian
Aripiprazole Abilify
Clozapine Clozaril
Olanzapine Zyprexa
Quetiapine Seroquel
Risperidone Risperdal

Pharmacodynamics:
• Antipsychotic drugs tend to block dopamine D2 receptors in the
dopaminergic pathways of the brain so that the dopamine released in
these pathways has less effect.
• Typical antipsychotics are not particularly selective and also block
dopamine receptors in the mesocortical pathway , tuber infundibular
pathway and the nigrostriatal pathway.
• Atypical antipsychotic drugs have a similar blocking effect on D2 receptors,
however most also act on serotonin receptors especially 5-HT2A and 5-
HT2C receptors.

Dopaminergic tracts:
The mesocortical tract:
Is involved in cognitive processes. Antipsychotic block can
intensify cognitive problems “secondary negative symptoms”
while block by atypical agents are thought to liberate
dopamine and thus improve cognitive processes.

The mesolimbic tract:
Is involved in emotional and sensory processes. Antipsychotic blockade
normalize these processes in individual with schizophrenia.

The nigrostriatal tract:
Is involved in movement. Antipsychotic blockade can cause EPSEs.
The Tuber infundibular tract:
Modulates pituitary function. Antipsychotic can lead to elevation in prolactin
levels

Pharmacokinetics:
the pharmacokinetic of antipsychotic drugs goes through 4 phases
• Absorption : Antipsychotic drugs absorbed when it administered
parenteral and orally
• metabolism: antipsychotic drugs are metabolized in liver by the
enzyme called CYP450

• Distribution : plasma concentrations of antipsychotic drugs reach the
peak level from 30to60 minutes when it administered by im injection
but reach the peak level when administered orally from 1 to4 hours
after that they reach the body circulation
• Excretion : antipsychotic drugs excreted by the kidney

Indications:
1. Schizophrenia:
 to reduce the positive symptoms of psychosis that include delusions and
hallucinations.
 To reduce negative symptoms.
1. Blunted affect: showing little emotion.
2. Alogia: a poverty of speech.
3. Anhedonia: an inability to feel pleasure.
4. Asociality: the lack of desire to form relationships.
5. Avolition: a lack of motivation and apathy.

• To reduce cognitive symptoms (memory impairments, reduced ability
to plan and execute tasks).
2.Dementia
3.Bipolar disorder
4.Major depressive disorder

-
5 obsessive–compulsive disorder:
Ex: Frequent and excessive hand washing occurs
in some people with OCD.
-
6 Post-traumatic stress disorder: because of
exposure to a traumatic event.

Side effect of Anti-psychotic medication may be classified into:
A- Neurological effects.
B- Non-neurological effects.

A.Neurological effect:
• 1-Neuroleptic malignant syndrome (NMS)
• NMS is a rare but serious neurological disorder, which means it affects
nervous system it can happen as a side effect of taking antipsychotic

Neuroleptic malignant syndrome (NMS)

The symptoms are:
• Sweating or fever, with a high temperature
• Tremor (shaking), rigidity (feeling stiff and unable to move muscles) or loss
of movement
• Difficulty speaking and swallowing
• Rapid heartbeat, very rapid breathing and changes in blood pressure

• Changes in consciousness, including confusion and lethargy, stupor or
coma.
• Increase CPK level (Creatine phosphokinase is an enzyme a protein that
helps to elicit chemical changes)
• High temperature and rigidity are usually the first symptoms to appear. This
means NMS can sometimes be confused with an infection. But NMS can be
very dangerous if it’s not detected and treated. In rare cases, it can be fatal.

2
. Neuromuscular side effects (extra pyramidal side effect)

• Antipsychotics interfere with the brain chemical dopamine, which is
important in controlling movement. Antipsychotics may therefore
cause movement disorders extra pyramidal side effect. These are most
common with first generation (older) antipsychotics and less likely
with the newer antipsychotics.

They include the following:
1 –pseudo parkinsonism
• When walking, lean forward, take small steps and find it difficult to
start and stop (shuffling gait).
• Escape of saliva (drooling).

2
. Akathisia (restlessness)
Akathisia is subjective feeling of muscular discomfort as a result of intake of
antipsychotics. For example, might:
• Feel intensely restless and unable to sit still
• Rock from foot to foot, shufe legs, cross or swing legs repeatedly, or continuously
pace up and down
• Feel emotionally tense and uneasy.
These symptoms may occur 50-60 days following initiation of therapy psychiatrist
may suggest taking anti cholinergic drugs to reduce its effects, as well as
antipsychotic.

-
3 Tardive dyskinesia
• Tardive dyskinesia Medical term that describes the involuntary sudden
jerky or slow twisting movements of the face and body (bizarre facial
and tongue movements, stiff neck and difficulty swallowing).
Develops after months or years following initiation of therapy. The
symptoms are potentially irreversible.

4 – Muscle spasms (Dystonia)
• Painful muscle contraction as a result of intake antipsychotic. They can
be painful and may have serious effects. For example:
• Laryngeal spasm:
• If a spasm affects the muscles of larynx (voice box), may have
problems with voice. This is called dysphonia. That affect the ability to
speak normally, and people may find it hard to understand and may
cause asphyxia or death

Occulogeric crisis:
If a spasm affects the muscles that control eye movements, it can makes eyes turn
suddenly. It may mean can’t control where look. This can feel very unpleasant. It
could also be dangerous, for example if it happens while are crossing the road or
pouring boiling water from a kettle. The physician should be contacted and IV OR
IM cognation is commonly administrated. Stay with patient and offer to him the
reassurance and support during this frightening time.

• Opisthotonus: contracted waist muscles or back.
• Torticallis: contracted position of the neck.
• Retrocalitis: rolling back of neck.
• laterocollis: contracted to the side
• Anterocollis: contracted to forward

3. Seizures.

B-Non-neurological side effects:
-
1 Anticholinergic effects:
• Anticholinergic effects are side effects caused by changes to the level
of the chemical acetylcholine in the body.

2.Bed-wetting
3.Blood disorders.
• Certain blood disorders can be a side effect of antipsychotics
especially clozapine. These include:
• Agranulocytosis.
• Blood clotting disorders.
• Reduced white blood cells

Agranulocytosis: Agranulocytosis is a blood disorder which involves the
loss of one type of white blood cell (Neutrophil count (NC), causing
neutropenia. It 14 means that they are more likely to catch infections and
less able to fight them. It may be a sign that the immune system is not
working as well as it should:
• Sore throats.
• Mouth ulcers.
• A fever or chills.

• Blood clotting disorders (venous thromboembolism):
• These include deep vein thrombosis (DVT) and pulmonary
thrombosis (blood clot in the lung), which can be life-
threatening.
• Reduced white blood cells:
• Taking antipsychotics may cause a reduction in white blood
cells.

4. Body temperature problems
• It may become hyper temperature or hypo temperature, both of which
can make feeling unwell.

5.Eye problems
• Certain antipsychotics may cause various eye problems. These
include:
• Blurred vision and difficulty reading.
• Glaucoma, which is a serious eye condition.
• Oculogyric crisis, which affects the muscles that control eye
movements. It can cause eyes to turn suddenly, so can’t control.

6.Cardiovascular effects
Antipsychotics may cause certain heart problems, such as:
Increased heart rate
Effects on heart rhythm
Orthostatic hypotension.
ECG changes.
Heart palpitations

7.Liver disorders:
Certain antipsychotics may cause liver disorders and jaundice (yellow
skin).
Metabolic syndrome 18 metabolic syndrome is the medical name for
a combination of the following symptoms:
• Weight gain and obesity
• High blood sugar
• Diabetes
• High blood pressure
• High cholesterol.

8. Sedation (sleepiness)
• Sedation, or sleepiness, is a common side effect of many
antipsychotics. It is more common with certain antipsychotics
than others, such as chlorpromazine and olanzapine. Sedation can
happen during the day as well as at night

9. Sexuall and hormonal problems:
• These side effects from blockage of dopamine in tuber infundibular
tracts leading to increased prolactin level with almost all of the typical
antipsychotics but less commonly with a typical antipsychotics. In
males: gynecomastia, erectile dysfunction, retrograde ejaculation
"back ward flow of semen that is very painful." Breast enlargement
and increased production and flow of breast milk “agalactorrhea".

10. Skin problems:
• Antipsychotics can cause various skin problems, for example:
Allergic rashes
Increased sensitivity to sunlight, especially at high doses.
A blue-grey discoloration in some skin types.

11. Weight gain
Weight gain is a very common side effect of many
antipsychotics, particularly some of the second generation
(newer) drugs “olanzapine and clozapine ". This may be
because antipsychotics increase appetite, so increase want to
eat more than usual.

Contraindications:
• Previous history of acute stroke or coma
• Severe intoxication with alcohol or any other drug that acts as a central
nervous system depressant
• Allergy to haloperidol or other drugs of the butyrophene class
• Heart disease
• Patients at risk of QT prolongation, a rare heart condition that
increases the risk of arrhythmia originating in the ventricles

• Impaired liver function (the metabolism of haloperidol is mainly hepatic)
• In epileptic patients, haloperidol can reduce the threshold at which a
convulsion may occur
• The effects of haloperidol are stronger in patients with hyperthyroidism and
there is an increased risk of side effects in this patient group
• The intravenous administration of haloperidol injection can lead to postural
hypotension and collapse

Nursing Care Plan

1. For Extrapyramidal symptoms:
 Provide safe environment for patient such as Removing harmful
objects, raising side rails and adequate lighting.
 Assist the patient in performing the activities, to minimize patient
stress.
 Provide comfort measures to the patient like positioning of legs and
arms.
 Report to the doctor if there is excess tremor.
 Reassurance to get the restlessness relieved.
 Give anticholinergic as prescribed.

 Apply safety measures as adequate and continuous monitoring of the
patient after the drug is consumed.
 Educate the patient and his family members regarding the side effects
of the drug for better understanding, cooperation and coping.

2. Neuroleptic Malignant syndrome:
 Discontinue antipsychotic agent.
 Assess vital signs especially Temperature and BP.
 Administer skeletal muscle relaxants as prescribed.?
 Reduce fever by cold application, antipyretic and IV fluids to keep the
patient hydrated.
 Give deep vein thrombosis prophylaxis.
 After stabilization, doctor may restart low dose low-potent neuroleptic
in 2-3 weeks.

3. Weight gain:
• Provide good food and exercise daily.
• Provide graph weight weekly to stimulate control
• Give a plan of food intake for each day.
• Ask the patient to limit food intake to one site in the home.
• Ask the patient to sit down at the table to eat.
• Rearrange schedule to avoid inappropriate eating.
• Save or reschedule everyday activities.

4. postural hypotension:
• Asking patient to drink enough water.
• Instruct client to avoid overheating.
• avoiding crossing legs when sitting.
• Instruct client to rise slowly from sitting or lying Position.
• Measure BP regularly.

5.Photosensitivity:
Make sure that the patient wears protective sunglasses
and full sleeves while being outdoors.

6.Blurred vision:
• Ask the patient not to drive a car until his vision is clear.
• Instruct the patient to remove small items from the pass way to
prevent falls.
• Explain that symptoms will most likely subsided After few weeks.

7. Hormonal effects:
• Amenorrhea in (women): Instruct patient to continue use of
contraception because amenorrhea doesn't indicate cessation of
ovulation.

• Gynecomastia in (men): Provide an explanation of the effect and
reassuring of reversibility.

• Mention 2 Interventions For Extrapyramidal symptoms?
• What is the highest priority intervention for Neuroleptic Malignant
syndrome?
• What to do to avoid weight gain?

8.Dry mouth:
• Instruct the patient to avoid spicy or salty foods.
• increase fluid intake.
• Ensure that patient Brushes his teeth twice a day.

9.Nausea and GIT upset:
• Assess nausea characteristics: (Duration, Frequency, Severity,
Precipitating factors).
• Provide an emesis basin within easy reach of the patient.

10.Constipation:
• Instruct patient to increase fluid intake.
• Increase intake of food rich in fiber.
• Advise patient to do exercises that strengthen abdominal muscles and
stimulate peristalsis.
• Privacy allows the patient to relax, which can help promote peristalsis
• Explain the use of pharmacological agent as ordered
• The use of laxatives or enemas is indicated for short term
management of constipation.

11.Urinary retention:
Instruct patient to ascertain the frequency of current urination using an
alarm system.
Advise patient to do pelvic floor muscle exercise.
Physical therapy can help gaining control over urinary retention
symptoms.

12.Agranulocytosis:
• Observe for symptoms of sore throat, fever and malaise.
• Complete blood count should be monitored if Symptoms appear.
• White blood cell count can drop to extremely low levels.
• White blood cell (WBC) and Neutrophil count (ANC) are measured
weekly for 18 weeks and every 28 days.
• When treatment with clozapine is discontinued, WBC and ANC must
be monitored for at least 4weeks from the day of discontinuation or
until: (WBC is more than 3500/mm3 and ANC is more than
2000/mm3).

patient/family education :
• Use caution when driving or operating dangerous machinery "Drowsiness and
dizziness can occur".
• Not stop the drug abruptly after long term use, to do so might produce withdrawal
symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia
and insomnia.
• Use sunblock lotion and wear protective clothing when spending time outdoors.
Skin is more susceptible to sunburn.

• Report weekly if receiving clozapine therapy to have blood levels
especially WBC.
• Report the occurrence of any of the following symptoms to the doctor
immediately" sore throat, fever, malaise, unusual bleeding, easy
bruising, persistent nausea and vomiting, sever headache, ........".
• Rise slowly from a sitting or lying position to prevent a sudden
drop in blood pressure.

• Take frequent sips of water, chew sugarless gum, or suck on hard candy, if dry
mouth is problem, good oral care (frequent brushing fussing) is very important.
• Consult the doctor regarding smoking while on neuroleptic therapy.
Smoking increase the metabolism of neuroleptic drugs, requiring an
adjustment in dosage to achieve a therapeutic effect.
• Dress warmly in cold weather and avoid extended exposure to very high
or low temperature, body temperature is harder to maintain with this
medication.

• Not drink alcohol while on neuroleptic therapy. These drugs
potentiate each other's effects.
• Not consume other medications without the doctor approval, many
medications contain substances that interact neuroleptics in a way that
may be harmful.
• Instruct the patient to take medications in the time.
• Be aware of contraindications.

• Be aware of possible risks of taking neuroleptics during pregnancy.
• Be aware of side effects of neuroleptic drugs.
• continue to take the medications, even if feeling well and as through it is not
needed. Symptoms may return if medication is discontinued.
• carry a card or other identification at all times describing medications being
taken.
• Patient awareness of the importance of antipsychotic.

References
1. Gould, I. M., & Lawes, T. (2016). Antibiotic stewardship:
prescribing social norms. The Lancet, 387(10029), 1699-1701.
2. Pellicano, O. A., Tong, E., Yip, G., Monk, L., Loh, X.,
3. Ananda‐Rajah, M., & Dooley, M. (2018). Geriatric Psychotropic
Stewardship Team to deescalate inappropriate psychotropic
medications in general medicine inpatients: An evaluation.
Australasian journal on ageing.
4. Finkel R, Clark MA, Cubeddu LX (2009).
5. Pharmacology. Lippincott Williams & Wilkins. p. 151. ISBN
9780781771559. Archived from the original on 1 April 2017.
6. https://www.cancer.gov/publications/dictionaries/ca ncer-terms
7. Meltzer HY, Matsubara S, Lee JC. Classification of typical and
atypical antipsychotic drugs on the basis of dopamine D-1, D-2
and serotonin2 pKi values. Journal of Pharmacology and

6
. Psychosis and schizophrenia in adults (CG178)". Archived from the
original on 4 March 2014.
7
. Finkel R, Clark MA, Cubeddu LX (2009). Pharmacology. Lippincott
Williams & Wilkins. p. 151. ISBN 9780781771559. Archived from the
original on 1 April 2017.
8
. Ventimiglia J, Kalali AH, Vahia IV, Jeste DV (November 2010). "An
analysis of the intended use of atypical antipsychotics in dementia"
9
. https://books.google.com.eg/books?id=ddcYMIJw6
GoC&printsec=frontcover&dq=drug+interactions+o
f+antipsychotics+drugs&hl=ar&sa=X&redir_esc=y
#v=onepage&q=drug%20interactions%20of%20anti
psychotics%20drugs&f=false
10
. https://www.rethink.org/adviceandinformation/living-
withmentalillness/medications/antipsychotics.
11
. https://rarediseases.org/rarediseases/tardivedyskinesia.
12
. https://www.aafp.org/pubs/afp/issues/2010/030 1/p617.htm.

Thank you