Anti-Psychotic Drugs 2024-2025 PDF

‫كلية التمريض_ كلية معتمدة‬ Anti-psychotic Drugs Supervision By: Dr:Amged Said Dr:Hend Karem Demo:Ahmed Zaher First term 2024-2025 Prepared by:  Habiba Hedar.  Habiba Hamdy.  Habiba Ahmed  Habiba Sayed.  Hanan Ghattas.  Gehad Kamal.  Gehad Moham...

‫كلية التمريض_ كلية معتمدة‬ Anti-psychotic Drugs Supervision By: Dr:Amged Said Dr:Hend Karem Demo:Ahmed Zaher First term 2024-2025 Prepared by:  Habiba Hedar.  Habiba Hamdy.  Habiba Ahmed  Habiba Sayed.  Hanan Ghattas.  Gehad Kamal.  Gehad Mohamed.  Gaber Mohamed.  Hazem Mahmoud.  Hassan Sophy. 1|Page  Outlines of antipsychotic drugs 1. Introduction of antipsychotic drugs. 2. Mechanism of action of antipsychotic drugs. 3. Classification of antipsychotic drugs. a) Typical. b) Atypical. 4. Pharmacokinetics of antipsychotic drugs. 5. Indication of antipsychotic drugs. 6. Adverse effect of antipsychotic drugs. (Neurological & Non Neurological). 7. Contraindications of antipsychotic drugs. 8. Nursing intervention for side effect of antipsychotic drugs. 9. Health education for the patient and family for receiving antipsychotic drugs. 10. References of antipsychotic drugs. 2|Page Introduction of antipsychotic drugs: It is hard to image how psychiatric illnesses were treated before the development of psychopharmacological medications. Antipsychotic medications were among the first drugs ever used to treat psychiatric disorders. First synthesized by Paul Charpentier in 1950, chlorpromazine became the interest of Henri Lorit, a French surgeon, who was attempting to develop medications that controlled preoperative anxiety. Administered in intravenous doses of 50 to 100 mg, chlorpromazine produced drowsiness and indifference to surgical procedures. At Lori's suggestion, a number of psychiatrists began to administer chlorpromazine to agitated psychotic patients. In 1952, Jean Delay and Pierre Deniker, two French psychiatrists, published the first report of chlorpromazine's calming effects with psychiatric patients. They soon discovered it was especially effective in relieving hallucinations and delusions associated with schizophrenia. As more psychiatrists began to prescribe the medication, the use of restraints and seclusion in psychiatric hospitals dropped sharply, ushering in a revolution in psychiatric treatment. Since that time, numerous antipsychotic medications have been developed. Older, typical antipsychotic medications, available since 1954, are equally effective, inexpensive drugs that vary in the degree to which they cause certain groups of side effects. 3|Page  Mechanism of action of antipsychotic drugs. The exact mechanism of action is not known. The drugs are thought to work by blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brain stem, and medulla. As positive symptoms of schizophrenia is due to hypersecretion of dopamine in mesolimbic tract Dopaminergic tract 1. The mesocortical tract: Is involved in cognitive process. Antipsychotic drugs can intensify cognitive problems '' secondary negative symptoms ". While block by atypical agents are thought to liberate dopamine and thus improve cognitive processes. 2. The mesolimbic tract: Is involved in emotional and sensory process. Antipsychotic blockade normalize these process in individual with schizophrenia 3. Nigrostriatal tract: Is involved in movement. Antipsychotic drugs can cause Extra-pyramidal side effect. 4. The Tuberoinfundibular tract: Modulates pituitary function. Antipsychotic drugs can lead to elevation prolactin level. 4|Page Typical and Atypical Antipsychotics The term typical antipsychotic now identifies the older antipsychotic drugs with many common neurologic side effects, and atypical antipsychotic identifies the newer generation of antipsychotic drugs with fewer adverse neurologic effects. Classification of Antipsychotic Drugs into: Typical ((Classical)) Atypical Typical antipsychotic drug Atypical antipsychotic drug Block dopamine receptors Block dopamine & serotonin receptor Classical, oldest Newer, novel First generation Second generation Convential Uncongenial More side effects Less side effects High risk for EPSES Low risk for EPSES More effective Less effective Less expensive Mors expensive to 5|Page  Typical antipsychotic: GENERIC NAME Trade name Chlorpromazine Thorazine Trifluperazine Stelazine Thioridazine Mellaril Haloperidol Halodol Atypical antipsychotic drug: Generic name Trade name (Clozapine) Clozaril (Risperidone) Risperdal (Olanzapine) Zeprexa 6|Page  Pharmacokinetics of antipsychotic drugs. Absorption: Antipsychotic drugs will be absorbed when they are administered orally or parenteral. Drugs that are orally administered lead to less predictable absorption than parenteral administration. Metabolism: They are metabolized in the liver by CYP450 enzymes. Distribution: Plasma concentrations of the drugs usually reach peak levels from Ito 4 hours after oral ingestion and 30 to 60 minutes after IM administration and then reach to all body circulation Excretion: by the kidney after being metabolized in the liver. Indications of antipsychotic drugs. 1. Schizophrenia and Schizoaffective disorders 2. Acute Mania 3. Major Depressive Disorder with Psychotic features 4. Substance-induced psychotic disorder 5. Delusional Disorder 6. Severe Agitation 7. Tourette Disorder 8. Borderline Personality Disorder 9. Dementia and Delirium 7|Page  Adverse Effects of Antipsychotic Drugs. Classification into Neurological Non neulogical A. Neuroleptic malignant syndrome 1. Ant cholinergic side effects (NMS). 2. Blood disorders B. Extra pyramidal syndrome include: (a granulo cytosis). 1. Acute Dystonia (muscle spasm). 3. Eye problems. 2. Pseudo Parkinsonism. 4. Sedation. 3. Akathisia. 5. Endocrine and sexual side effects 4. Tardive dyskinesia (TD). 6. Skin problem. 7. Cardiovascular side effects 8. Metabolic syndrome. 9. Hypersalivation (with clozapine) 8|Page  A. Neuroleptic malignant syndrome (NMS) It's a complication of treatment with Neuroleptic drugs, NMS is a rare but serious neurological disorder, which means it affects Nervous system it can happen as a side effect of taking antipsychotic. The symptoms are: 1. Sweating or fever, with a high temperature. 2. Tremor (shaking) 3. Rigidity (feeling stiff and unable to move Muscles) or loss of movement. 4. Difficulty speaking and swallowing. 5. Rapid heartbeat, very rapid breathing, and changes in blood Pressure. 6. Changes in consciousness, including confusion and lethargy, Stupor, or coma. 7. Increase CPK level (Creatine phosphokinase is an enzyme a Protein that helps to elicit chemical changes) 8. 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. This condition is treated by immediately stopping the causative agent and giving supportive care as well as some pharmacological treatment 9|Page  B. Neurological side effects Extra pyramidal syndrome Extra pyramidal Side Effects, Extra pyramidal symptoms (EPS), serious neurologic symptoms, are the major side effects of antipsychotic drugs. They include 1. Acute Dystonia (muscle spasm). 2. Pseudo Parkinsonism. 3. Akathisia 4. Tardive dyskinesia (TD). 10 | P a g e Acute Dystonia (muscle spasm) Dystonia (involuntary muscular movements [spasms] of face, arms, legs, and neck) this occurs most often in men and in people. A. Oculogyric crisis: (Uncontrolled rolling back of the eyes) oculogyric crisis should be treated as an emergency situation. The physician should be contacted and intravenous or intramuscular benztropine mesylate (Cogentin) is commonly administered. Stay with the client and offer reassurance and support during this frightening time. B. Torticollis contracted positioning of the neck C. Reteocollis rolling back of the neck D. Larengeal spasm: is a spasm of the vocal cord constriction, asphexia death may occurs. E. Latero collis: contracted to the side F. Antero collis: Contracted to forward 11 | P a g e Pseudo Parkinsonism (Tremor, shuffling gait, drooling, rigidity) Symptoms may appear 1 to 5 days following initiation of antipsychotic medication; occurs most often in women, the elderly and dehydrated clients. Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and difficulty swallowing) *All clients receiving long-term (months or years) antipsychotic therapy are at risk. "The symptoms are potentially irreversible. The drug should be withdrawn at the first sign, which is usually vermiform movements of the tongue; prompt action may prevent irreversibility. 12 | P a g e Akathisia Akathisia (continuous restlessness and fidgeting) these symptoms may occur 50 to 60 days following initiation of therapy. Not respond to treatment effectively. For example Feel intensely restless and unable to sit still Rock from foot to foot, shuffle legs, cross or swing legs repeatedly, or continuously pace up and down. ➤ Feel emotionally tense and uneasy. Tardive dyskinesia Tardive dyskinesia (bizarre facial and tongue movements, stiff neck, and difficulty swallowing). All clients receiving long-term (months or years) antipsychotic therapy are at risk. The symptoms are potentially irreversible. The drug should be withdrawn at the first sign, which is usually vermiform movements of the tongue, prompt action may prevent irreversibility. 13 | P a g e  Non neurological Side Effects 1. Ant cholinergic Side Effects Ant cholinergic side effects resulting from blockade of acetylcholine are another common concern with typical and with some of the atypical antipsychotic drugs.  Dry mouth  Slowed gastric motility  Constipation  Urinary hesitancy or retention  Vaginal dryness  Blurred vision.  Dry eyes.  Nasal congestion.  Confusion or decreased memory. Elderly patients are often most susceptible to a potential toxicity that results from high blockade of acetylcholine. This toxicity is called an anticholinergic Crisis. 2. Blood Disorders 14 | P a g e Certain blood disorders can be a side effect of antipsychotics especially clozapine. Agranulocytosis (clozapine) is a blood disorder which involves the loss of one type of white blood cell (Neutrophil count (NC), causing neutropenia. It 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. This happens more with clozapine than with other antipsychotics. 3. Eye problems: Certain antipsychotics may cause various eye problems. These include:  Blurred vision  Difficulty reading  Build-up of granular deposits in the cornea and lens . This doesn’t usually affect your vision  Degeneration of the retina: which is the light-sensitive part of the eye. This can affect your vision.  Glaucoma, which is a serious eye condition.  Oculogyric crisis, which affects the muscles that control your eye movements. It can cause your eyes to turn suddenly, so you can’t control where you look. 15 | P a g e 4. 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. So if you experience this you might find it very hard to get up in the morning. Or it might feel difficult to motivate yourself to be active during the day. 5. Endocrine and sexual side effects Endocrine and sexual side effects result primarily from the blockade of dopamine in the tuber infundibular pathways of the hypothalamus. As a result, blood levels of prolactin may increase with almost all of the typical antipsychotics but less commonly with the atypical antipsychotics. In Males: gynecomastia, erectile dysfunction, "retrograde ejaculation Retrograde ejaculation: occurs when semen enters the bladder instead of emerging through the penis during orgasm In Female: Amenorrhea, and Galactorrhea 16 | P a g e 6. Skin problems Antipsychotics can cause various skin problems, for example:  Allergic rashes: These usually occur within the first two months of starting treatment. They usually disappear when you stop taking the drug. If you get a rash, you should contact your GP straight away to have it checked.  Increased sensitivity to sunlight, especially at high doses. If you're taking antipsychotics, you may need to take extra care to protect yourself from the sun.  A blue-grey discoloration in some skin types. 7. Heart problems Antipsychotics may cause certain heart problems, such as: Increased heart rate  Heart palpitations, which are heartbeats that suddenly become more noticeable in chest  Effects on heart rhythm. This has been known to cause sudden death in extreme cases. The risk of this is especially linked to being on a high dose, or taking more than one antipsychotic at the same time. 17 | P a g e 8. Metabolic syndrome 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 You don’t have to experience all of these symptoms to be diagnosed with metabolic syndrome. Taking antipsychotics can increase your risk of developing metabolic syndrome. If you experiencing metabolic syndrome, this means you are at higher risk of developing:  Diabetes  Stroke  Heart disease This risk of this is increased even more if you have an unhealthy lifestyle. Your doctors may suggest trying to eat a healthier diet and get enough physical activity can help to reduce this. 9. Hypersalivation (with clozapine) A significant number of clients receiving clozapine (clozaril) therapy experience extreme salivation. Offer support to the client because this may be an embarrassing situation. It may even be a safety issue) e.g., risk of aspiration) if the problem is very severe 18 | P a g e  Contraindications of antipsychotic drugs  Known hypersensitivity to the drug.  Bone marrow depression.  Parkinsonism.  Sever cardiovascular  Tardive dyskinesia. disease.  Previous neuroleptic malignant  CNS depression or coma. syndrome.  Alcoholism.  Glaucoma.  Hepatic disease.  Blood dyscrasias. Precautions of antipsychotic drugs: 1. Diabetes mellitus, Pregnancy, and lactation. 2. Older patient require lower doses, are prone to hypotension and sedative side effects. 3. History of seizures, renal disease, respiratory disorder, glaucoma, and prostatic hyper trophy. 19 | P a g e  Nursing intervention for side effect of antipsychotic drugs. Side effect Nursing intervention 1. Discontinue antipsychotic drugs. 2. Give anticholinergic as prescribed, as (Cogentin, Artane& Akineton) 3. Provide safe environment for patient as removing harmful and injurious objects. 4. Report doctor if there is excess tremor. Extrapyramidal 5. Assist patient in performing the activities so patient gets symptoms minimal stress out. 6. Make patient sit comfortably till motor restlessness gets relieved. 7. Reassurance. 8. Tardive dyskinesia Drug should be withdrawn at first sign, which is usually vermiform movements of the tongue; prompt action may prevent irreversibility. 1. Discontinue antipsychotic drugs immediately and identify physician. Neuroleptic 2. Physician order bromocriptine (parlodel) or dantrolene malignant (dantrium) syndrome 3. Monitor vital signs, degree of muscle rigidity, intake and output and level of consciousness. 4. Reduce fever by cold application, antipyretic, IV fluids and keep patient hydrated. 20 | P a g e  5. Give deep venous thrombosis prophylaxis. 6. After stabilization can restart low dose low potent neuroleptic in 2-3 weeks. 7. Administer skeletal muscle relaxants as prescribed. 1. Discontinue antipsychotic drugs immediately and identify physician (clozapine) 2. Observe for symptoms of sore throat, fever and malaise. 3. Complete blood count should be monitored if symptoms appear. 4. White blood cell count can drop to extremely low levels Agranulocytosis white blood cells and neutrophil count should be measured weekly for 18 week and every 28 days. 5. When treatment with clozapine is discontinued white blood cells and neutrophil count should be monitored at least for 4 weeks from the day of discontinuation or until (WBC is more than 3500/mm^3 and ANC is more than 2000/mm^3). 21 | P a g e  Dry mouth 1. Ensure that patient Take frequent liquid throughout the day, water is the best. 2. Provide patient sugarless candy or gum, Ice, and frequent sips of water. 3. Ensure that patient practices strict oral hygiene. 4. Avoid spicy or salty food. 5. Brush teeth twice a day morning and night. Blurred vision Anticholinergics Instruct patient not to drive a car until his vision is clear. side effects 2. Remove small item from the pass way to prevent falls. 3. Use artificial tears to keep eyes moist. Constipation 1. Instruct patient to increase fluid intake and increase food intake rich in fibers. 2. Encourage patient to do exercise and physical activity. 3. Explain the use of pharmacological agents as ordered. 4. The use of laxatives and enemas is indicated for short term management of constipation as ordered. 22 | P a g e  Urinary retention 1. Monitor intake and output. 2. Promote fluid if not contraindicated. 3. Encourage patient to avoid at least every 4 hours. 4. Allow patient to listen to sound of running water. 5. Offer fluid before voiding. 6. Discuss the importance of adequate fluid intake. Pour warm water over perineum. A. Decreased libido, retrograde ejaculation, Gynecomastia (men):  Provide an explanation for the effect and reassure for reversibility. B. Amenorrhea (women): Hormonal  Instruct patient to continue use of contraception because effect amenorrhea doesn't indicate cessation of ovulation. C. Weight gain:  Weigh patient every other day  Encourage healthy eating and order calorie-controlled diet.  Encourage physical exercise. 23 | P a g e  1. Administer tablets and capsules with food. 2. Concentrates may be diluted and administered with fruit Nausea juice or other liquid; they should be mixed before GIT upset. administration. 1. Report appearance of any rash on skin to physician. 2. Avoid spilling any of the liquid concentrate on skin; Skin rash contact dermatitis can occur 1. Discuss with physician possibility of administering drug at bedtime. 2. Discuss with physician possible decrease in dosage or Sedation order for 3. Less sedating drug. Instruct client not to drive or operate dangerous equipment while experiencing sedation. 1. Instruct client to rise slowly from sitting or lying position. Orthostatic 2. Measure blood pressure (lying and standing) each shift. hypotension 3. Document and report significant changes. 4. Avoiding crossing legs when sitting. 1. Ensure that patient wear protective sunglasses and full Photosensitivity sleeves while spending outdoor. 2. Ensure that patient use sunblock lotion. 24 | P a g e   Offer support to the client, as this may be an embarrassing Hypersalivation situation. It may even be a safety issue (e.g., risk of aspiration), if the problem is very severe. (with clozapine) 1. Including prolongation of the QT, this is particularly true with ziprasidone, pimozide, and thioridazine. 2. Caution is advised in prescribing these medications to ECG changes individuals with history of arrhythmias. 3. Monitor vital signs every shift. 4. Observe for symptoms of dizziness, palpitations, syncope, or weakness. 1. Starting on atypical antipsychotic drugs be monitored regularly for worsening of glucose control. 2. Patients with risk factors for diabetes should undergo Hyperglycemia fasting blood glucose. and diabetes 3. Testing at the beginning of treatment. 4. Monitoring for symptoms of hyperglycemia (polydipsia, polyuria, polyphagia, and weakness).. 25 | P a g e  Health education for the patient And family for receiving antipsychotic drugs. The client should: 1. Use caution when driving or operating dangerous machinery. Drowsiness and dizziness can occur. 2. Not stop taking the drug abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, tremulousness. 3. Use sun block lotion and wear protective clothing when spending time outdoors. Skin is more susceptible to sunburn, which can occur in as little as 30 minutes. 4. Report weekly (if receiving clozapine therapy) to have blood levels drawn and to obtain a weekly supply of the drug. 5. Report the occurrence of any of the following symptoms to the physician immediately: sore throat fever, malaise, unusual bleeding, easy bruising, persistent nausea and vomiting, severe headache, rapid heart rate, difficulty urinating, muscle twitching ,tremors, darkly colored urine, excessive urination excessive thirst, excessive hunger, weakness, pale stools, yellow skin or eyes, muscular incoordination or skin rash. 6. Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure. 7. Take frequent sips of water, chew sugarless gum, or suck on hard candy, if dry mouth is a problem. Good oral care (frequent brushing, flossing) is very important. 8. Consult the physician regarding smoking while on neuroleptic therapy. Smoking increases the metabolism of neuroleptics, requiring an adjustment in dosage to achieve a therapeutic effect. 26 | P a g e 9. Dress warmly in cold weather, and avoid extended exposure to very high or low temperatures. Body temperature is harder to maintain with this medication. 10.Not drink alcohol while on neuroleptic therapy. These drugs potentiate each other's effects. 11.Not consume other medications (including over-the counter products) without the physician's approval Many medications contain substances that interact with neuroleptics in a way that may be harmful. 12.Be aware of possible risks of taking neuroleptics during pregnancy. Safe use during pregnancy and lactation has not been established. 13.Neuroleptics are: Thought to readily cross the placental barrier, if so, a fetus could experience adverse effects of the drug. 14.Inform the physician immediately if pregnancy occurs is suspected, or is planned. 15.Be aware of side effects of neuroleptic drugs. Refer to written materials furnished by health care providers for safe self-administration. 16.Continue to take the medication, even if feeling well and as though it is not needed. Symptoms may return if medication is discontinued. 17.Carry a card or other identification at all times describing medications being taken. 27 | P a g e  Resources of antipsychotic drugs: Essentials of mental health and psychiatric nursing, (KP NEERAJA), VOL2, New Delhi. 2008, 372-373. Blue prints, psychiatry, MICHAEL J.MURPHY, VI ED, London, 2019, 133-136. Drummond N, McCleary L, Freiheit E, Molnar F, Dalziel W, Cohen C, Turner D, Miyagishima R, Silvius J. Antidepressant and antipsychotic prescribing in primary care for people with dementia. Can Fam Physician. 2018 Nov; 64(11):e488-e497. [PMC free article] [PubMed] Dopamine and Reward: A Review of the Evidence" - [Frontiers in Psychology] (https://www.frontiersin.org/articles/10.3389/fpsyg.2020.00123/full) "Dopamine's Role in the Regulation of Hormones" - [Endocrine Reviews](https://academic.oup.com/edrv/article/38/2/157/5863296) - Discusses how dopamine affects hormonal balance and various physiological functions. https://pubmed.ncbi.nlm.nih.gov/7911807/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6009248/ https://www.jaacap.org/article/S0890-8567(18)30541-0/abstract https://www.ncbi.nlm.nih.gov/books/NBK519503/ 28 | P a g e