NURS660/ NURS 660 Exam 1 V2 (NEW 2026/ 2027) Psychopharmacology and Advanced Mental Health Exam | 100% Accurate | Complete guide with Questions and Verified Answers - Maryville

NURS660/ NURS 660 Exam 1 V2 (NEW 2026/ 2027) Psychopharmacology and Advanced Mental Health Exam | 100% Accurate | Complete guide with Questions and Verified Answers - Maryville Q. dopamine hypothesis ANSWERS the theory that schizophrenia results from excessive activity of the neurotransmitter dopamine Q. dopamine hypothesis- nigrostriatal pathway ANSWERS The nigrostriatal dopamine pathway that projects from the substantia nigra to the basal ganglia or striatum, is part of the extrapyramidal nervous system and controls motor function and movement. Q. Mesolimbic dopamine hypothesis: Hyperactivity of dopamine neurons in the mesolimbic dopamine pathway cause what symptoms of schizophrenia ANSWERS symptoms of psychosis such as delusions and hallucinations. This pathway is also involved in pleasure, reward, and reinforcing behavior, and many drugs of abuse interact here. Q. What conditions other than schizophrenia may cause positive symptoms? ANSWERS Depression, mania, dementia, drug-induced psychosis Q. Hyperactivity of the _______________________________ pathway may also play a role in the hostility and aggression found with schizophrenia. ANSWERS mesolimbic dopamine pathway Q. If there is too much dopamine in the basal ganglia causes what type of movements? ANSWERS chorea, dyskinesia and tics Q. Deficiency iof dopamine in the basal ganglia can also causes what types of movement? ANSWERS akathisia and dystonia. Q. When antipsychotics are given and dopamine is blocked in the tuberoinfundibular pathway what abnormalities will be seen? ANSWERS Hyperprolactemia leading to galactorrhea, amenorrhea, and sexual dysfunction. Q. Cross-titration must occur over several days to weeks, otherwise the patient can develop what symptoms? ANSWERS Agitation, activation, insomnia, rebound psychosis, and withdrawal. . Q. When cross titrating and the patient starts doing well while both drugs are present what should you do? ANSWERS A. Keep both drugs at the current dose and monitor the patient B. Continue with the cross titration in spite of the patient's improvement. Q. Why should a patient not be maintained on 2 antipsychotics? ANSWERS All antipsychotics suppress dopamine and there is an increased risk of side effects Q. If switching from a pine to a done, the pine should be stopped slowly over: A. 3-7 days B. 14 days B. 3-4 wks ANSWERS B Q. Clozapine must be stopped slowly over _________ weeks, to minimize what symptoms? ANSWERS 4 weeks; rebound psychosis and anticholinergic rebound Q. When going from a done to a pine, the PINE should titrate up over ___ weeks but the DONE can titrate down over ________ week. ANSWERS When going from a done to a pine, the PINE should titrate up over TWO weeks but the DONE can titrate down over ONE week Q. When replacing ariprazole with a pine or done you should ANSWERS A. Keep ariprazole at the current dose until the done or pine has reached desired dose and then stop the ariprazole B. Stop the ariprazole immediately and titrate the oter drug over 1-2 weeks starting at the lowest dosee C. Stop ariprazole immediately and start the other drug at a middle dose titrating up over 1-2 weeks. C--The ariprazole with hang around for 3-7 days so tapering down is not necessary Q. When switching to ariprazole why should you taper up slowly? ANSWERS It will replace the other drug at the D2 reeptor site immediately causing withdrawal from the first drug. Q. Switching between similar drugs is preferred, i.e. pine to pine or done to done. When titrating between same type drugs what time period should this be done over? A. 3 days B. 7 days C. 2 weeks D. 1 month ANSWERS 7 days Q. Describe how to taper from a pine or a done onto aripazole Taper on or off dones over ____________ weeks. Taper on or off pines over ______________weeks. ANSWERS Taper off dones over ONE week Taper off pines in TWO weeks. Q. hyperprolactemia ANSWERS Higher-than-normal prolactin levels, which may result in spontaneous breastmilk production and amenorrhea. Q. Hyperprolactinemia causes ANSWERS -adenoma -drugs (SSRI, antipsychotics, cocaine) -hypothyroidism -mass effect -trauma Q. Hyperprolactinemia Tx ANSWERS dopamine agonists (cabergoline, bromocriptine) Q. D2 receptor benefit ANSWERS Improves positive symptoms Q. Postural hypotension (orthostatic hypotension) ANSWERS alpha 1 adrenergic side effect Q. Sedation ANSWERS Histamine H1 side effect Q. What receptors are involved in weight gain? ANSWERS 5HT2C weight changes + H1 sedation Q. alpha 1 adrenergic receptor side effects ANSWERS Orthostatic hypotension Reflex tachycardia Dizziness Q. alpha 2 adrenergic receptors side effect ANSWERS -Modulates alpha tone -Counter regulatory for alpha-1 stimulation -Inhibits norepinephrine Risk of drug interactions Q. muscarinic receptors side effect are normally activated by acetylcholine ANSWERS ANS response blurred vision, dry mouth, constipation, urinary retention, tachycardia, memory Q. D2 antagonism side effects receptors involved in dopamine transmission decrease limbic activity EPS, TD, endocrine effects-prolactin secretion, sexual dysfunction increase reward seeking behaviors Q. 5HT2A receptors benefit ANSWERS Decreased EPS Q. 5HT2C benefit ANSWERS unknown Q. Histamine H1 ANSWERS Sedation Q. muscarinic receptor benefit ANSWERS Decrease EPS Q. alpha 1 adrenergic receptor benefit ANSWERS unknown Q. alpha 2 adrenergic benefit ANSWERS unknown Q. What do all antipsychotics have in common? ANSWERS They reduce dopaminergic neurotransmission. Q. CYP 450 inducers ANSWERS Carbamazepine, Phenobarbital, Phenytoin, Rifampin, Griseofulvin Q. CYP450 inhibitors ANSWERS CRACK AMIGOS: Cimetidine, Ritonavir (protease inhibitor), Amiodarone, Ciprofloxacin, Ketoconazole (and other azoles), Acute alcohol use, Macrolides, Isoniazid, Grapefruit Juice, Omeprazole, Sulfonamides Q. Volume of distribution (Vd) ANSWERS A ratio used to estimate the distribution of a drug within the body relative to the total amount of fluid in the body. It is calculated as the amount of drug administered divided by the plasma concentration of the drug. Q. Bioavailability ANSWERS A measure of the extent of drug absorption for a given drug and route (from 0% to 100%). Q. Pharmacokinetics ANSWERS The method by which drugs are absorbed, distributed, metabolized, and eliminated or excreted by the body. Examples of low potency typical antipsychotics Chlorpromazine (Thorazine), Thioridazine (Mellaril). Low potency antipsychotics Have fewer extrapyramidal side effects, more anticholinergic and histamine side effects, more sedation, dry mouth. Examples of high potency antipsychotics Trifluoperazine, fluphenazine, haloperidol. Effects of high potency antipsychotics Less histamine, muscarinic effects, less sedation, weight gain, anticholinergic effects, more EPS effects, affinity for and tightly bind to D2 receptors. Drug Potency vs Efficacy Drug potency refers to the receptor's affinity, ability to bind to the drug not the efficacy. All antipsychotics have efficacy. Other possible causes of hyperprolactinemia Pregnancy, stress, exercise, high protein meals, tumors, drugs (metoclopramide (Reglan), methyl dopa), estrogen, hypothyroidism, chronic renal failure. When to check for hyperprolactinemia? Not routinely checked. Ask about symptoms - menstrual changes, sexual dysfunction. Precautions when doing lab for hyperprolactinemia? Check in the morning a few hours after waking, fasting, avoid strenuous exercise 20-30 minutes before, caution stress/anxiety can increase and alter result. Dopamine primary neurotransmitter involved in schizophrenia. Glutamate secondary neurotransmitter in schizophrenia; experimental with no drug treatment. Glutamate theory of schizophrenia Observations that PCP induces acute psychotic, schizophrenia-like symptoms. Decrease in hippocampus Associated with increased dopamine activity in the striatum. FGAs First-generation antipsychotics including Chlorpromazine, Thioridazine, Loxapine, Perphenazine, Fluphenazine, Haloperidol, Trifuoperazine, Thiothixene. FGA MOA D2 antagonists that block D2 receptors and decrease neurotransmission in all 4 pathways. Serotonin 2A blockade 5HT normally suppresses DA in mesocortical, nigostriatal and tuberoinfundibular tracts, so 5HT2A block enhances DA transmission here, mitigating side effects. Serotonin (5HT)-dopamine antagonism of SGAs Atypical antipsychotics have low EPS and high affinity for 5HT2A, allowing dopamine to bind to D2 receptors more readily. Neurotransmitters in schizophrenia Dopamine, Serotonin, Glutamate. 5HT1A drugs Brexpiprazole, Cariprazine, Lurasidone, Iloperidone. 5HT1A action Antidepressant; anxiolytic; potentiation of serotonin levels in the presence of SRI. 5HT1B/D Detects 5HT at presynapse and blocks 5HT release; has antidepressant effects. 5HT1B/D blocking drugs Iloperidone, Ziprasidone, Asenapine. 5HT2C action Regulates both dopamine and norepinephrine release; blocking increases dopamine and norepinephrine from prefrontal cortex. 5HT3 action Regulates inhibiting GABA interneuron; blocking increases serotonin, dopamine, norepinephrine, acetylcholine, histamine, and is associated with nausea/vomiting. 5HT6 Key regulator of release of acetylcholine and cognitive processes; blocking improves learning and memory in experimental animals. 5HT7 Regulates serotonin release; blocking disinhibits serotonin release and affects circadian rhythm. Proven antidepressant Clozapine, quetiapine, asenapine-strong Antagonist drugs Risperidone, paliperidone, lurasidone-antagonist High concentrations of D2 receptors Ventral Tegmental, substantia nigra, hypothalamus, olfactory bulb, retina Dopamine pathways in the brain Mesolimbic, nigrostriatal, mesocortical, tuberoinfundibular pathway Dopamine roles Movement, Reward, Memory, Lactation, Attention Effect of malfunction of mesocortical pathway Cognitive, executive functions and negative symptoms Effect of blockade of nigrostriatal pathway EPS Effect of blockade of tuberoinfundibular pathway Dopamine inhibits prolactin release; Block too much released and increase prolactin blood levels; hyperprolactinemia Drugs with D2 antagonism FGA and SGAs Drugs with partial agonism Aripiprazole Psychosis definition Inconsistent and variable thought process, disorganized behavior/speech; includes hallucinations, delusions, lack of insight; defining feature of schizophrenia - everyone who has schizophrenia has psychosis but not everyone who has psychosis has schizophrenia Treatment for dystonias 1. Anticholinergic - Benztropine; 2. Antihistamine; 3. Benzodiazepine Treatment of parkinsonism 1. Lower dose; 2. Atypical AP with lower side effect profile; 3. Concomitant use of anticholinergic - trihexyphenidyl, benztropine, amantadine, and levodopa Akathisia treatment Acute - benzodiazepine (lorazepam); Prevent by 1. Lower dose; 2. Change antipsychotics; 3. Add beta-blocker propranolol (blocks adrenergic activity) Tardive dyskinesia (TD) treatment 1. Discontinue med, add clozapine or risperidone; 2. Lower dose; 3. VMAT 2 inhibitor (Valbenazine; deutetrabenazine) Sialorrhea Excessive salivation Sialorrhea treatment 1. Conservative - sucking candy, chewing gum; 2. Anticholinergic - Benztropine; topically/sublingually - ipratropium, atropine Sedation treatment 1. Dose at night; 2. Lower dose; 3. Change to less sedating antipsychotic - low dose risperidone Prolactin elevation, sexual side effects 1. Dose reduction Prolactin-sparing drugs Olanzapine, clozapine, quetiapine, ziprasidone, and aripiprazole are classed as prolactin-sparing drugs. Orthostatic hypotension treatment 1. Adjust dose or dosing schedule 2. Behavioral changes including adequate hydration 3. Ziprasidone least 4. Olanzapine does not cause but other s.e. QT prolongation treatment First choice-Change antipsychotics. Caution Avoid other QT‐prolonging agents. Neuroleptic Malignant Syndrome Adverse reaction to antipsychotics with severe 'lead pipe' rigidity, FEVER, and mental status changes. Looks like EPS. D2 blockade in nigrostriatal pathway. Neuroleptic Malignant Syndrome Treatment First choice - Discontinue antipsychotic. Second choice-Supportive measures including IV hydration and cooling. Third choice -dantrolene, bromocriptine. Neutropenia/Agranulocytosis treatment 1. Discontinue clozapine or other causative agent 2. Colony‐stimulating factors (e.g., filgastram). Impulse control disorders treatment Change antipsychotics associated with aripiprazole, cariprazine, brexpiprazole. Myocarditis treatment Discontinue clozapine or other causative agent. Metabolic syndrome treatment 1. Behavioral modification (diet, exercise) 2. Change antipsychotics (cariprazine, aripiprazole, lurasidone, iloperidone, risperidone, ziprasidone-NO 5HT2C) 3. Add metformin. Anticholinergic effects treatment 1. Treat symptoms, e.g., constipation with osmotic agents, stimulant laxatives; tachycardia with beta‐blocker 2. Limit other anticholinergic agents 3. Switch drug (cariprazine, lurasidone, iloperidone, ziprasidone-No adrenergic activity). Baseline monitoring for antipsychotics Metabolic-BMI, FBS, lipids, Cardiac -BP, HR, EKG, EPS- TD, Parkinsonism, FBS, Sedation, Hyperprolactenemia - sexual/reproductive. Side effect monitoring for each visit Sedation. Monitoring when titrating dose Weight, TD, parkinsonism/akathisia, BP, sexual/reproductive function. Monitoring at 3 months Glucose/FBS, Lipid metabolism, BP, HR. Monitoring quarterly Weight. Monitoring every 6 months Tardive dyskinesia. Risk of antipsychotics to elderly population Not provided in the notes. orthostatic hypotension falls QTc‐prolonging drugs Ziprasidone, lithium Drugs with high anticholinergic effects Strong-Clozapine; Moderate-Olanzapine; Quetiapine Drugs with high acute parkinsonism risk Strong-Haloperidol; Moderate-perphenazine, rispiradone, paliperidone; Mild-moderate-Luprasidone Drugs with risk of akathisia Strong-Haloperidol; Moderate-aripiprazole, perphenazine; Mild-moderate-Luprasidone; Low risk-clozapine, olanzapine and quetiapine Drugs with most risk of tardive dyskinesia Moderate-chlorpromazine, Haloperidol, perphenazine Drugs with the most risk of diabetes Strong-chlorpromazine, clozapine, olanzapine; Moderate-quetiapine Drugs with most risk for weight gain Strong-chlorpromazine, clozapine, olanzapine; Moderate-paliperidone, perphenazine, quetiapine, risperidone, sertindole Drugs at increased risk for increased lipids chlorpromazine, olanzapine; Moderate-clozapine, quetiapine Increase risk for sialorrhea (excessive salvation) Moderate-clozapine Drugs with increase risk for neutropenia Clozapine Which antipsychotics have a low side effect risk profile? amisulpride (hyperprolactinemia), aripiprazole (akathisia), ziprasidone (akathisia) Which antipsychotics have the highest side effect risk profile? olanzapine, clozapine (SGA); chlorpromazine, haloperidol (FGA) When should a lower dose be tried? Dose-related side effect; Not medically urgent; Has been a positive response What situations might be dose related side effects? parkinsonism, sedation, hyperprolactinemia, orthostatic hypotension, and anticholinergic effects. When is it appropriate to switch antipsychotics because of side effect? To deal with adverse effects that cannot be addressed with dosage adjustments; Need a new AP with different side effect profile; Done gradually Cross titration completed in 2-4 weeks N/A Dyslipidemias Conditions characterized by abnormal lipid levels in the blood, often treated by weight reduction. Akathisia A movement disorder characterized by a feeling of inner restlessness and an uncontrollable need to be in constant motion. Parkinsonism A syndrome that resembles Parkinson's disease, characterized by tremors, rigidity, and bradykinesia. Hyperprolactinemia An elevated level of prolactin in the blood, which can lead to various health issues. Akathesia treatment Includes benzodiazepines (diazepam, clonazepam, and lorazepam), propranolol (for orthostatic hypotension and bradycardia), and mirtazapine (serotonergic treatment). Drugs with potent antihistamine action Clozapine, quetiapine, and iloperidone, all of which are more potent H1 antagonists. Drugs with potent alpha 1 adrenergic action Clozapine, quetiapine, risperidone, and iloperidone. Drugs with low metabolic risk Ziprasidone, aripiprazole, lurasidone, iloperidone (low dyslipidemia), and asenapine. Greatest risk of weight gain Associated with 5HT2C serotonin receptor and H1 histamine receptor, particularly with clozapine, olanzapine, and quetiapine. Parameters to monitor before starting antipsychotics Weight (BMI), fasting triglycerides, fasting glucose, and blood pressure. Clozapine side effects Clozapine has a higher affinity for various receptors than D2, leading to numerous side effects. Clozapine prescription indications Prescribed when other antipsychotics fail, for treatment-resistant schizophrenia, or schizophrenia with suicidal ideation and behaviors. Olanzapine (Zyprexa) 5HT2A + D2 antagonist used for schizophrenia, bipolar disorder, and treatment-resistant depression, with more potency than clozapine and fewer side effects. Olanzapine side effects High cardiometabolic risk, consistent weight gain, increased triglycerides, and increased insulin resistance. Quetiapine (Seroquel) receptor activity 5HT2A and D2 antagonist. Quetiapine dosing recommendation Should be taken at bedtime due to its strong sedative effect. Quetiapine XR appropriateness Quetiapine XR is appropriate as it provides longer receptor occupancy and decreases the need for twice daily dosing. Quetiapine effects at different doses 50 mg for sleep, 300 mg for antidepressant effects, and 800 mg for antipsychotic effects. Preferred antipsychotic for parkinsonism and psychosis Quetiapine, as it causes virtually no extrapyramidal symptoms (EPS). Risks with moderate to high doses of Quetiapine Increased cardiometabolic risks including weight gain, elevated triglycerides, and insulin resistance. Asenapine (Saphris) antipsychotic with antidepressant effects, used for bipolar and schizophrenia, acts on 5HT2C and H1 but does not cause weight gain, very sedating. Administration of Asenapine Sublingual; no food or drink for 10 minutes. Asenapine (Saphris) usage Rapid acting PRN antipsychotic, used to top up patients in crisis without injection. Risperidone Antipsychotic used to treat children with aggression and/or autism at low to moderate doses; has a weight gain side effect. Risperidone dosage for schizophrenia and bipolar disorders High to moderate dose is needed. Off label use for Risperidone Psychosis in elderly with dementia. Risperidone formulations Available in long term depot injectable lasting 2 weeks, orally disintegrating tablet, oral liquid. Benefit of Ziprasidone (Geodone) Little to no propensity for weight gain despite moderate 5HT2C and H1 antagonism activity; can cause weight loss and lower triglycerides when switched. Administration of Ziprasidone Twice a day; must take with 500 calories of food; less food intake lowers absorption by 50%. Iloperidone (Fanapt) High potency for alpha 1 antagonism causing orthostatic hypotension; improvement in nightmares; exhibits dose dependent QTc prolongation; up dose slowly because of BP. Lurasidone No sedation, weight gain, dyslipidemia, no QTc prolongation; used for antidepressant-depression and bipolar; switch from another AP to reverse effects; moderate EPS decreased if given at night; give with food (350 calories, 500 in book). Benefits of aripiprazole Not sedating, little weight gain, dyslipidemia; can reduce weight when switched from another AP. Lurasidone (Latuda) benefits No sedation so can have low dose; little metabolic risk; no QTc prolongation; acts on 5HT7, 5HT1A, alpha 2-antidepressant; good alternative when side effects present to reverse effects. Administration of Lurasidone At least 300 calories of food (book states 500); give at night to decrease EPS risk. Main disadvantage of aripiprazole Akathisia. Treatment for akathisia Decrease dose, use anticholinergic, or benzodiazepine. Symptoms of too fast switch of antipsychotics Not specified in the notes. Agitation A state of anxiety or nervousness. Activation The process of making something active or operational. Insomnia A condition characterized by difficulty in falling or staying asleep. Rebound Psychosis A return of psychotic symptoms after the withdrawal of medication. Anticholinergic Effects Side effects caused by drugs that block the action of acetylcholine, leading to symptoms like dry mouth and blurred vision. Third Antipsychotic Course of Action A third antipsychotic is preferred before concomitant administration of drugs. Dones A group of SGA (second-generation antipsychotics) that have more anticholinergic, antihistamine, sedation, and alpha 1 antagonism. Switching a Pine to Done Steps SLOW-2 weeks; the goal is to avoid anticholinergic rebound. Clozapine Tapering Duration Clozapine should be tapered down over 4 weeks or more when switching. Switching Done to Pine Steps Titrate up the pine over 2 weeks or more. Aripiprazole Switching Considerations Higher potency for the D2 receptor; immediate withdrawal of the first drug from D2 receptors. Switching to Aripiprazole from a Pine Start with a middle dose and build aripiprazole up rapidly over 3-7 days. Taper pine over 2 weeks. Switching to Aripiprazole from a Done Start with a middle dose and build aripiprazole up rapidly over 3-7 days. Taper done in a week. Clozapine for Treatment Resistance Clozapine is recommended for treatment resistance and violence. High Dose Standard in Treatment Resistance A high dose is considered standard when patients fail to have adequate clinical responses despite attaining 60% receptor occupancy. Affective Disturbance Contribution Affective disturbance can lead to treatment resistance and violence by attaining 60% occupancy but no response, necessitating augmentation with mood stabilizers. Low Half-Life Drug Effect on Steady State A drug with a low half-life takes longer to reach steady state. CYP4503A4 Inhibitors Ketoconazole, fluvoxamine, and fluoxetine increase aripiprazole levels. CYP4503A4 Inducers Carbamazepine decreases aripiprazole levels. Phenothiazines in FGAs Phenothiazines make up 1/2 of all FGAs (first-generation antipsychotics). Affinity of Low Potency Drugs Low potency drugs do not have affinity to bind to D2 receptors; they have more affinity to H1 and M1, leading to more sedation and dry mouth with less EPS. High Potency Drugs Droperidol, Haloperidol, Loxapine, pimozide, thiothixene, trifluperazine. Low Potency Drugs Drugs that have low potency. chloropromazine An antipsychotic medication used to treat various mental health disorders. chlorprothixene An antipsychotic medication primarily used for the treatment of schizophrenia. fluphenazine An antipsychotic used to treat schizophrenia and other psychotic disorders. hydroxyzine An antihistamine that is also used to treat anxiety and tension. mesoridazine An antipsychotic medication used to treat schizophrenia. molindone An antipsychotic medication used for the treatment of schizophrenia. perphenazine An antipsychotic used to treat schizophrenia and severe anxiety. prochlorperazine An antipsychotic used to control severe nausea and vomiting. promethazine An antihistamine used to treat allergies and motion sickness. thioridazine An antipsychotic used to treat schizophrenia. long term risk of antipsychotic treatment For every year on medication, there is a 5% increase risk of TD. medical emergencies associated with antipsychotics neuroleptic malignant syndrome and serotonin syndrome. causes of Serotonin Syndrome Serotonergic agents (5HT). Symptoms of serotonin syndrome Hyperthermia, confusion, myoclonus, cardiovascular collapse, flushing, diarrhea, seizures. Course of illness in serotonin syndrome Symptoms within 24 hours of starting or changing; resolves within a few days. distinguishing feature between serotonin syndrome and neuroleptic malignant syndrome Serotonin Syndrome: hyperreflexia, myoclonus, no lab findings; NMS: severe rigidity, lead pipe, lab findings high creatine kinase, leucocytosis, low serum Fe, slower onset 1-2 weeks, longer to resolve 9-14 days. SGAs share D2 and 5HT2A antagonism. what to do in the event of an overdose Support airway, Benzodiazepine or anticholinergic; not common. H1 antagonism effect on weight gain Via hypothalamic AMO related kinase activity, increases appetite, sedative effect decreases physical activity. M3 antagonism effect on metabolism Impairment of glucose tolerance and reduction of insulin secretion from pancreatic beta cells; not correlated with weight gain. 5HT1a partial agonist Buspirone (Buspar) may mitigate weight effects of 5HT2C antagonism by decreasing carb craving. 5HT2C antagonism Causes weight gain via distribution of hypothalamic neuropeptide Y neurons and inhibition of pro-opiomelanocortin neurons. three most common side effects with clozapine Weight gain, sedation, drooling. effect of smoking and caffeine on clozapine and alazapine Smoking can induce clozapine metabolism via CYP450-1A2; smoking cessation can increase clozapine levels; clozapine toxicity (1000) can lead to seizures. SGA most chemically similar to clozapine olanzapine. antipsychotic most associated with hyperlipidemia Risperidone. Cariprazine (Vraylor) An antipsychotic medication used for the treatment of schizophrenia and bipolar disorder. No sedation, no weight gain Characteristics of certain antipsychotics. D3 more than D2 antagonism A property of some antipsychotic medications. Long half-life Beneficial in patients with poor adherence to medication. Cut dose in half if chronic marijuana use Guideline for adjusting medication dosage. Alpha 1 adrenergic receptor G-protein coupled receptors involved in sympathetic response in the autonomic nervous system, with adverse cardiac effects. Antipsychotics with high risk of QT prolongation Ziprasidone. D2 antagonism and negative symptoms of schizophrenia Intensifies hypoactivity in mesocortical dopamine pathways, increasing negative symptoms. Mesolimbic region symptoms Positive symptoms of schizophrenia. Mesocortical/prefrontal cortex symptoms Negative symptoms of schizophrenia. Nucleus accumbens symptoms Associated with reward, addiction, and negative symptoms. Dorsolateral prefrontal cortex symptoms Hypoactive in schizophrenia, leading to cognitive symptoms, planning ahead, and controlling impulses. Amygdala function Part of the limbic system, involved in memory, emotion, fear, and aggression. Ventromedial prefrontal cortex function Involved in affective symptoms and controlling emotional responses from the amygdala in decision-making. Orbitofrontal cortex function Involved in impulse control. Positive symptoms of schizophrenia Hallucinations, delusions, disorganized thoughts, distortions and exaggerations in language and communication, disorganized speech and behavior, catatonic behavior. Negative symptoms of schizophrenia 5 A: Affective, Alogia (poverty of speech), Asociality, Apathy, Anhedonia (decreased social drive), less than normal behavior or an absence. Aripiprazole MOA Partial agonism of D2 and some antagonism for 5HT1A receptors. Aripiprazole on positive symptoms Reduces dopamine output when concentrations are high. Aripiprazole on negative symptoms Increases dopamine output when concentrations are low. Common length of time for efficacy of antipsychotic medication Symptom improvement typically occurs within 1 week. Efficacy determination time 4-6 weeks to determine efficacy, rare 16-20 weeks Best drugs to augment aripiprazole Valproic acid (valproate, divalproex), other mood stabilizing anticonvulsants (carbamazepine, oxycarbazepine, lamotrigine), lithium, benzodiazepines Best augmenting agent to reduce side effects of aripiprazole Benzodiazepines, Trihexyphenidyl - akathisia Aripiprazole metabolism CYP2D6 and CYP3A4 Risk of Carbamazepine with aripiprazole CYP3A4 inducer, decrease plasma levels Monitoring for aripiprazole Weight, Hx & Fam hx-diabetes, obesity, dyslipidemia, hypertension, cardiovascular disease, waist circumference, BP, FBS, fasting lipid profile, WBC-hx low WBC counts, BMI monthly x 3 mo, then quarterly Why less EPS risk with Aripiprazole? Partial agonist in striatum - Less EPS, N/V, akathisia, weight loss when switched to Adverse response of alpha 1 adrenergic receptors in aripiprazole Dizziness, sedation, hypotension Drug interactions with aripiprazole Ketoconazole, enhance hypertensives Aripiprazole warning Impulsivity Clozapine use Treatment-resistant schizophrenia, schizophrenia associated with suicidality Clozapine monitoring parameters ANC 1500 u/L, BEN - ANC 1000 u/L Purpose of ANC monitoring with Clozapine treatment Agranulocytosis What niche symptoms does Clozapine treat? Aggression and violence What is the first atypical antipsychotic? Clozapine What is an awakening after starting Clozapine? Response of a return to near normal along with improvement of positive symptoms, hope for cure What antipsychotic has been proven to reduce the risk of suicide? Clozapine Clozapine induced myocarditis-causes & monitoring Hypersensitivity reaction, occurs in first 4 weeks, Troponin and C-reactive protein at initiation and weekly for first 4 weeks What antipsychotic has the greatest risk of life threatening complications? Clozapine Clozapine A medication used to treat schizophrenia. Clozapine side effects Side effects: NEUROLEPTIC MALIGNANT SYNDROME, sedation, salivation, dizzy, H/A, tremors, sleep problems, akinesia, fever, seizures, confusion, insomnia, slurred speech, dystonia, tachycardia, hypo/hypertension, blurred vision, drooling, constipation, abd pain, N/V/D weight gain, dry mouth, urinary abnormalities, leukopenia, agranulocytosis, rigidity, diaphoresis, death (demented geriatrics). Agranulocytosis A potentially severe side effect of certain medications, characterized by a dangerously low level of neutrophils. Aripiprazole use Used for schizophrenia, bipolar disorder, major depressive disorder, and irritability associated with autism in children/adolescents (6-17). Clozapine MOA Dual dopamine and serotonin regulation, moderate for D2 and potent for 5HT2A. Mesocortical dopamine pathway Group of dopaminergic axons that originates in the VTA and travels to the cerebral cortex, including the prefrontal, cingulated, and entorhinal cortices. It may also be called the mesocortical tract. Characteristics of typical (FGA) antipsychotics Only works on D2 receptors, D2 antagonist, very effective on positive symptoms, EPS side effects, increase in negative symptoms if too much. Neurolepsis D2 receptors are blocked in mesolimbic pathway reduces positive symptoms of schizophrenia, block reward mechanism, leaving patients apathetic, anhedonic, lacking motivation, interest and joy from social interactions, state similar to negative symptoms of schizophrenia. Neurotransmitters involved in schizophrenia Dopamine, serotonin, GABA, glutamate. Parkinsonism treatment Amantadine or Levodopa. Parkinsonism: caused by An imbalance of neurotransmitters dopamine and acetylcholine. Parkinsonism Symptoms - TRAP 1. (Resting) tremor, 2. Rigidity, 3. Akinesia (lack of movement), 4. Postural instability. Which receptor is involved in weight and appetite changes? 5HT2C. Which receptor is involved in sexual dysfunction? 5HT2A. Affective side effects Side effects that impact emotional states and mood.