1. Pharmacology of Antipsychotic drugs

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

3. Schizophrenia

4. There is some evidence for involvement of 5-HT
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

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)

6. Schizophrenia: Symptoms
Positive Symptoms
Hallucinations
Delusions
Thought disturbances
Negative Symptoms
Blunted emotions
Social withdrawal
Loss of motivation
impaired personal hygiene

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…..

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)

9. Antipsychotic Drugs

10. Atypical drugs are preferred as a first line treatment because they:
Antipsychotics are broadly divided into two groups: The typical = 1st generation and the atypical = 2nd 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 symptoms”of schizophrenia

11. Mechanism of Action

12. All antipsychotic drugs block D2 receptors in the brain & periphery
Atypical antipsychotics exert part of their action through blocking of 5-HT2A 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.

13. Many antipsychotics block other receptors e. g
Many antipsychotics block other receptors e.g. acetylcholine (M), noradrenaline (α ) and histamine (H1) receptors

14. Typical antipsychotic Drugs
1- Phenothiazine derivatives:
Chlorpromazine, promethazine,
Fluphenazine
2- Butyrophenone derivatives:
Haloperidol, droperidol
Atypical antipsychotic drugs
Risperidone , Clozapine , Olanzapine
Aripiprazole

15. Pharmacological Actions

16. 1- Antipsychotic effects
Though blocking D2 receptors in the mesolimbic system, antipsychotic drugs relieve hallucination, improve thoughts. The additional blocking effects of atypical antipsychotics on 5-HT2 receptors can treat the negative symptoms of schizophrenia
2- Autonomic effects:
Anticholinergic effects , dry mouth, constipation and blurred vision
Blocking of α–adrenergic receptors hypotension

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

18. 6-Antipsychotics block H1 receptors causing sedation and confusion
5- Endocrine effects: Amenorrhea-galactorrhea, false–positive 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)

19. Therapeutic Uses

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

21. 2- Treatment of other psychotic disorders e. g
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

22. 6- To induce hypothermia in certain major operations (Chlorpromazine)
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 حازوقه

23. Adverse Effects

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

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)

26. Tardive dyskinesia
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

27. Atypical drugs have lower incidence of EPS & tardive dyskinesia as they block 5-HT2A receptors and have less D2 receptor blocking effect

28. 3-Autonomic effects:Orthostatic hypotension
3-Autonomic effects:Orthostatic hypotension !!!!, (α-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

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 individual’s seizure threshold

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).

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)

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

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

34. Typical antipsychotics

35. Chlorpromazine Phenothiazine class Increased prolactin (gynaecomastia)
Hypothermia
Anticholinergic effects
Hypersensitivity reactions
Obstructive jaundice
Ocular complications
EPS

36. Fluphenazine
Phenothiazine class but:
does not cause jaundice
causes less hypotension
causes more EPS

37. Halopirodol Butyrophenone class
As chlorpromazine but does not cause jaundice
Fewer anticholinergic side effects
Strong EPS tendency

38. Atypical Drugs

39. Differences between typical and atypical groups
receptor profile
Serotonin receptors (5-HT2A) 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

40. Clozapine Dibenzodiazepine class Potent antagonist at D4-receptors
Selectively blocks 5-HT2A receptors
Sedation
Extrapyramidal side effects are minimal
Low incidence of Tardive dyskinesia
Increased risk for seizures (2-3%)

41. Clozapine
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

42. Risperidone
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

43. Aripiprazole 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

44. Advantages & disadvantages of Clozapine
Effective in the treatment of negative and positive symptoms of schizophrenia
More effective than classical agents for resistant cases
Clozapine has the risk of inducing agranulocytosis
Clozapine tends to lower an individual seizure threshold

45. Advantages Disadvantages
Incidence of extrapyramidal symptoms is lowest
Tardive dyskinesia is extremely rare with clozapine
Atypical drugs cause weigh gain
Atypical drugs may exacerbate DM & hyperlipidemia
Are more expensive than typical antipsychotics