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Questions and Answers
The Glasgow Antipsychotic Side-effect Scale (GASS) is utilized for comprehensive evaluation rather than initial assessment.
The Glasgow Antipsychotic Side-effect Scale (GASS) is utilized for comprehensive evaluation rather than initial assessment.
False
Clozapine is suggested as a second-line treatment for patients who do not respond to one antipsychotic drug.
Clozapine is suggested as a second-line treatment for patients who do not respond to one antipsychotic drug.
False
Amisulpride has been found to be less effective than switching to olanzapine in recent studies.
Amisulpride has been found to be less effective than switching to olanzapine in recent studies.
False
Non-adherence to treatment with depot antipsychotic preparations is very rare due to their delivery advantages.
Non-adherence to treatment with depot antipsychotic preparations is very rare due to their delivery advantages.
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Thioridazine is classified strictly as an atypical antipsychotic.
Thioridazine is classified strictly as an atypical antipsychotic.
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All drugs introduced after 1990 are classified as second-generation antipsychotics.
All drugs introduced after 1990 are classified as second-generation antipsychotics.
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The biological basis for clozapine's superiority over other antipsychotics is fully understood and well-documented.
The biological basis for clozapine's superiority over other antipsychotics is fully understood and well-documented.
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Atypical antipsychotics are known for their universal preference for D2 receptors.
Atypical antipsychotics are known for their universal preference for D2 receptors.
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Patients should have minimal involvement in decisions about their medications according to NICE guidelines.
Patients should have minimal involvement in decisions about their medications according to NICE guidelines.
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Pimavanserin is recognized for its antipsychotic activity without causing extrapyramidal symptoms.
Pimavanserin is recognized for its antipsychotic activity without causing extrapyramidal symptoms.
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Chlorpromazine belongs to the class of thioxanthenes.
Chlorpromazine belongs to the class of thioxanthenes.
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Butyrophenones are more likely to cause movement disorders than piperidine phenothiazines.
Butyrophenones are more likely to cause movement disorders than piperidine phenothiazines.
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Clozapine is classified as a typical antipsychotic due to its high liability for inducing extrapyramidal symptoms.
Clozapine is classified as a typical antipsychotic due to its high liability for inducing extrapyramidal symptoms.
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The first antipsychotic discovered was flupentixol.
The first antipsychotic discovered was flupentixol.
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Piperazine phenothiazines are the least likely to cause extrapyramidal effects.
Piperazine phenothiazines are the least likely to cause extrapyramidal effects.
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Quetiapine has a high propensity for causing extrapyramidal symptoms.
Quetiapine has a high propensity for causing extrapyramidal symptoms.
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The classification of antipsychotics prior to the 1990s was primarily based on their pharmacological effects.
The classification of antipsychotics prior to the 1990s was primarily based on their pharmacological effects.
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Amisulpride is classified under substituted benzamides.
Amisulpride is classified under substituted benzamides.
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Clozapine is considered the drug of choice for treating refractory schizophrenia.
Clozapine is considered the drug of choice for treating refractory schizophrenia.
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Evidence supports that SGAs are significantly superior to FGAs in the treatment of psychotic disorders.
Evidence supports that SGAs are significantly superior to FGAs in the treatment of psychotic disorders.
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Extrapyramidal Symptoms (EPS) are more common with SGAs than with FGAs.
Extrapyramidal Symptoms (EPS) are more common with SGAs than with FGAs.
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Risperidone has a minor advantage over both quetiapine and ziprasidone in terms of effectiveness.
Risperidone has a minor advantage over both quetiapine and ziprasidone in terms of effectiveness.
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Amisulpride ranks second in efficacy behind clozapine and olanzapine.
Amisulpride ranks second in efficacy behind clozapine and olanzapine.
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Initial meta-analysis findings displayed significant advantages of aripiprazole and ziprasidone over olanzapine.
Initial meta-analysis findings displayed significant advantages of aripiprazole and ziprasidone over olanzapine.
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Antipsychotic medications are universally effective for all patients without variation.
Antipsychotic medications are universally effective for all patients without variation.
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Weight gain and dyslipidemia are common adverse effects of both FGAs and SGAs.
Weight gain and dyslipidemia are common adverse effects of both FGAs and SGAs.
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Study Notes
Classification of Antipsychotics
- Before the 1990s, antipsychotics were classified based on their chemical structure
- Chlorpromazine, the first antipsychotic, was a phenothiazine compound
- Other phenothiazines were later developed, followed by thioxanthenes
- New chemical structures were categorized by their pharmacological characteristics, including butyrophenones, diphenylbutylpiperidines, and substituted benzamides
Chemical Classification
- Chemical classification is less relevant due to the diverse chemical structures of newer antipsychotics
- Older drugs' chemical structures are linked to their tendency to cause movement disorders
- Piperazine phenothiazines, butyrophenones, and thioxanthenes are most likely to cause extrapyramidal effects (EPS)
- Piperidine phenothiazines and benzamides are least likely to cause EPS
- Aliphatic phenothiazines and diphenylbutylpiperidines have intermediate propensity for EPS
Liability for Extrapyramidal Symptoms (EPS)
- The main distinction between typical and atypical antipsychotics is their liability for causing EPS.
- Clozapine is considered atypical due to its low EPS liability and effectiveness despite failing animal-based screening tests
- Clozapine and quetiapine are considered completely atypical with a very low propensity for EPS
Antipsychotic Treatment and Side Effects
- Adverse effects are frequent and may lead to treatment discontinuation, especially when efficacy is low.
- Patients may not report side effects due to varying experiences among psychiatrists regarding prevalence and importance
- Systematic inquiries and biochemical tests are necessary for accurate assessment of side effects.
Assessment Tools
- The Glasgow Antipsychotic Side-effect Scale (GASS) is recommended for initial assessment
- The Antipsychotic Non-Neurological Side-Effects Rating Scale (ANNSERS) provides a detailed and comprehensive assessment.
Non-adherence to Treatment
- Non-adherence is common, particularly with depot/long-acting injectable antipsychotics, which have delivery advantages
- Depot antipsychotics are proven to reduce relapse and rehospitalization risk compared to oral antipsychotics
Treatment Recommendations
- Clozapine is recommended by NICE as the most effective treatment for patients with severe symptoms who haven't responded to two or more drugs
- Olanzapine is typically recommended as one of the two drugs tried before clozapine
- Amisulpride was found to be as effective as switching to olanzapine in a study
Key Points About Antipsychotic Drugs and EPS
- Dose-related effects: Typical drugs can achieve therapeutic activity without causing EPS, highlighting the distinction between typical and atypical drugs.
- Classification of Antipsychotics: Thioridazine, initially considered atypical, is classified as a conventional phenothiazine. Risperidone, generally considered typical, has a maximum dose of 16mg/day (10mg in the USA). Sulpiride, marketed as atypical, is often classified as typical
- Receptor Preferences: Not all atypical drugs preferentially bind to D2 receptors outside the striatum. Some atypical drugs show improved efficacy or lack hyperprolactinemia, for example, clozapine.
- Recent Agents: Pimavanserin displays antipsychotic activity without causing EPS.
FGA/SGA Classification Issues
- All drugs introduced since 1990 are classified as SGAs (atypical).
- Classification remains problematic and not well defined by pharmacological characteristics.
Guidelines for Antipsychotic Choice
- The NICE guideline for medicines adherence emphasizes the importance of patient involvement in medication decisions and considering patients' beliefs about their treatment.
- The guideline highlights the significance of patient preference in medication selection for schizophrenia.
Relative Efficacy of Antipsychotics
- Antipsychotics are effective in treating both acute and maintenance phases of schizophrenia and other psychotic disorders.
- They differ in their pharmacology, pharmacokinetics, efficacy, effectiveness, and tolerability
- Individual responses and tolerability vary among patients.
Key Points from Studies on Antipsychotic Efficacy
- The World Psychiatric Association summarized evidence from independent studies: No strong evidence favors SGAs over FGAs. SGAs may have a lower risk of EPS and TD but a higher chance of metabolic side effects.
- Initial meta-analysis suggested minor advantages of olanzapine and amisulpride.
- A later network meta-analysis revealed: Olanzapine was slightly more effective than aripiprazole, risperidone, quetiapine, and ziprasidone. Risperidone showed a minor advantage over quetiapine and ziprasidone.
- Drug efficacy ranking: Amisulpride was second to clozapine and olanzapine in terms of efficacy. Small differences were considered clinically significant.
- Adverse effects: Both FGAs and SGAs have several adverse effects, such as weight gain, dyslipidemia, increased plasma glucose/diabetes, hyperprolactinemia, sexual dysfunction, EPS (including neuroleptic malignant syndrome), venous thromboembolism (VTE), sedation, and postural hypotension.
- Clozapine: Recognized as the drug of choice for refractory schizophrenia. Variations in findings likely stem from study nature and quality in different активный-comparator trials.
Conclusion
- Response to antipsychotics varies, and there is no universally best first-line treatment
- Individualized patient care is necessary for effective management of psychotic disorders.
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Description
Test your knowledge on the classification of antipsychotic medications, focusing on both chemical and pharmacological characteristics. This quiz will cover historical classifications and discuss the liability of various drugs for extrapyramidal symptoms (EPS). Enhance your understanding of antipsychotic safety and efficacy.
