1. Continuing Nursing
Education
on
Antipsychotics
From: A.U.Basavaraja
Lecturer, MSRINER

2. Antipsychotics/Majortranquilizers/Neuroleptics/
Atractics/antischizophrenics/D2receptor
blockers
Antipsychotic drugs are useful in following conditions
1. Acute and chronic psychoses
2. Bipolar disorder (BD)
3. SCZ and BD (prophylactic use)
4. Agitated aggressive behaviour in dementia

3. Conti….
Off-label use of antipsychotics
a. Refractory major depression
b. Delusional depressive disorder
c. Anorexia
d. Hallucinogen-induced psychosis
e. Agitation in dementia and depression
f. Huntington’s disease
g. Impulsivity
h. Augmentation of refractory OCD
i. Porphyria
j. Refractory hiccups
k. Itching
l. Antiemetic uses
m. Personality disorders

4. Chemical classification of traditional
antipsychotics
I.Phenothiazines
Aliphatics Chlorpromazine (highly sedating, causes
orthostasis),Promazine,Triflupromazine
Piperidines Thioridazine (may cause fatal arrhythmia
Mesoridazine
Piperazines Fluphenazine
Trifluperazine
Perphenazine

5. Conti..
II. Buterophenones Haloperidol,Droperidol
III. Thioxanthene Thiothixene
IV. Dibenzoxazepine Loxapine
V. Dihydroindolone Molindone
VI.Diphenylbutylpiperidine Pimozide

6. Chemical classification of atypical
antipsychotics
I. Dibenzodiazepine Clozapine (gold standard in
the management of refractory SCZ)
II. Benzisoxazole Risperidone
III. Thienobenzodiazepine Olanzapine
IV. Dibenzothiazepine Quetiapine
V. Benzisothiazolyl Ziprasidone
VI. Quinolinone Aripiprazole
VII.Benzamide Sulpride,Amisulpride

7. Typical Vs Atypical antipsychotics:
Main features
Typical antipsychotics block dopamine D2
receptors in limbic system, anterior
pituitary(Prolactin levels increase), and
striatum(EPSEs)
Atypical antipsychotics less effective in blocking
D2 receptors. But are effective in antagonizing
other dopamine receptors and 5HT2 receptor.

8. Characteristics of atypical
antipsychotics:
1. Cause fewer EPSEs (decreased D2 antagonism in nigrostriatal
tract)
2. Are effective for negative and/or cognitive symptoms
3. Do not elevate prolactin (decreased D2 antagonism in
tuberoinfundibular tract)
4. Antagonize 5HT2a
5. Reduce risk for TD
Time line in the market: Clozapine (1990), Risperidone (1994),
Olanzapine (1996), Quetiapine(1997), Ziprasidone (2000),
Aripiprazole (2002), Amisulpride (available in India and European
markets)

9. Pharmacokinetics
- Oral absorption is variable
- Peak plasma levels is within 1-6 hours
-Tranquilizing effects occur within an hour
-Antipsychotic effects start within 1-2 weeks, with improvement
continuing in most patients for up to 6-8 weeks
- Antipsychotics are lipophilic and accumulate in fatty tissue, from which
they release slowly
- Traces of metabolites found in the urine months after
pharmacotherapy is stopped ( for several days, patients are free of
psychosis despite stopping the drug)
-Plasma protein binding: nearly 100%
-Geriatric patients have decreased protein-binding capabilities and
hence antipsychotics have increased effect in elderly patients

10. Side effects of antipsychotics
Side effects due to action of PNS
Constipation
Dry mouth
Nasal congestion
Blurred vision
Mydriasis
Photophobia
Hypotension or Orthostatic hypotension
Tachycardia
Urinary retention
Urinary hesitation
Sedation
Weight gain
Agranulocytosis
Side effects due to action on
CNS
Akathisia
Dystonias
Drug‐induced parkinsonism
Tardive dyskinesia
Neuroleptic malignant syndrome
Seizures

11. CNS adverse effects of antipsychotics:
EPSEsOrder of development Definition and explanation Incidence
1. Dystonic reaction (most
within the first days)
Spastic contraction of muscle
groups
10% of patients
2. Akathisia
(usually within first 10 days)
Restlessness, an irresistible
need to move, manifested
objectively and subjectively
20‐25% of patients
3. Akinesia
(usually by 3rd week)
Difficulty with movement Up to 33% of patients
4.Parkinsonism Tremor
rigidity(usually developing
after weeks to months)
bradykinesia Tremor, rigidity, Up to 20% of patients
5. Tardive dyskinesia (usually
developing after
months of continuous use)
Abnormal, involuntary
skeletal muscle movements of
the face,tongue, trunk, and
extremities
20‐35%of patients with
generally 5% annual
incidence

12. Acute dystonic reactions
Oculogyric crisis: Spasm of the extra orbital muscles, causing upwards and outwards
deviation of the eyes
Blephorospasm :sustained, forced, involuntary closing of the eyelids
Torticollis :Head held turned to one side
Opisthotonus :Painful forced extension of the neck. When severe the back is involved
and the patient arches off the bed
Macroglossia :The tongue does not swell, but it protrudes and feels swollen
Buccolingual crisis: May be accompanied by trismus (inability to normally open the
mouth), risus sardonicus (highly characteristic, abnormal,sustained spasm of the facial
muscles that appears to produce grinning), dysarthria and grimacing
Laryngospasm: Uncommon but frightening
Spasticity: Trunk muscles and less commonly limbs can be affected

15. PNS
SIDE EFFECTS
 CONSTIPATION
NURSING
INTERVENTIONS
• Advised the patient to
take Fiber rich content
food
• Advised the patient to
drink 2-3 liters fluids
• Encouraged the patient
to do exercise

16. SIDE EFFECTS
DRY MOUTH
NURSING
INTERVENTIONS
• Applied Vaseline on the
lips
• Advise patient to take sips
of water frequently
• Provide sugarless hard
candies, sugarless gum,
and mouth rinses
• Advised the patient to do
frequent mouthwash.

17. SIDE EFFECTS
• NASAL
CONGESTION
• BLURRED VISION
NURSING INTERVENTIONS
• Nasal decongestants SOS
a. Advise patient to avoid
potentially dangerous tasks
(e.g.,driving)
b. Reassure patient that normal
vision typically returns in a few
weeks, when tolerance to this side
effect develops
c. Pilocarpine eye drops for short
term use

18. SIDE EFFECTS
• MYDRIASIS
• PHOTOPHOBIA
NURSING
INTERVENTIONS
• Advise patient to report
eye pain immediately
• Advise patient to wear
sunglasses outdoors

19. SIDE EFFECTS
HYPOTENSION OR
ORTHOSTATIC
HYPOTENSION
NURSING
INTERVENTIONS
1. Ask patient to get out of
bed/chair slowly
2. Patient should sit on the
side of the bed for about 1
full minute
while dangling feet, then
slowly rise
3. Monitor BP closely
(preferably after each dose)
4. Consider changing the
antipsychotic drug

20. SIDE EFFECTS
TACHYCARDIA
NURSING
INTERVENTIONS
i. Ascertain that tachycardia is usually
a reflex response to hypotension
ii. Intervention for hypotension takes
care of reflex tachycardia

21. SIDE EFFECTS
URINARY
RETENTION
NURSING
INTERVENTIONS
1. Encourage frequent voiding
2. Monitor I/O chart of urine
3. Specific precaution in older men
with BPH as they are particularly
susceptible

22. SIDE EFFECTS
URINARY HESITATION
SEDATION
WEIGHT GAIN
NURSING
INTERVENTIONS
Provide privacy, run water in the
sink/bucket, run warm water
over the perineum
Help patient to get up early and
get the day started
Appropriate diet and absolute
discouragement of diet pills

23. SIDE EFFECTS
AGRANULOCYTOSIS:
Rare but
significant
adverse effect
with clozapine
NURSING
INTERVENTIONS
1. WBC count every week for first 6 months and if
no apparent problems every 2 weeks then on
2. Clozapine should not be started if baseline WBC
count is <3500cells/mm3
3. After starting clozapine, if WBC count is <3000
cells/mm3 and absolute neutrophil count (ANC) is
<1500 cells/mm3, anticipate infection and
treatment interruption
4. If no infection, continue clozapine
5. If WBC count is <2000 cells/mm3 and ANC is
<1000 cells/mm3,stop clozapine and no
rechallenging the patient with clozapine
6. If infection, consider antimicrobial drugs

24. CNS SIDE EFFECTS
AKATHISIA
NURSING
INTERVENTIONS
• Reassure the patient about jitteriness and
about help by the appropriate drug
intervention
• Akathisia may lead to noncompliance with
antipsychotic regimens
• Consider switching to a different
antipsychotic, starting an antiparkinson
drug, reducing the dosage of the current
drug, and in some cases waiting for
tolerance to develop

25. CNS SIDE EFFECTS
DYSTONIA
NURSING
INTERVENTIONS
If dystonic reaction is severe, give
antiparkinson or antihistamine drugs
immediately, as needed, and reassure
the patient
Intramuscular injections are preferable
(Benztropine 2 mg, or diphenhydramine
50 mg, or lorazepam 1 mg )

26. CNS SIDE EFFECTS
TARDIVE DYSKINESIA
NURSING
INTERVENTIONS
Abnormal Involunatry
Movement Scale (AIMS)
Keep in mind anticholinergic
drugs worsen TD

27. CNS SIDE EFFECTS
NEUROLEPTIC
MALIGNANT
SYNDROME (NMS)
NURSING
INTERVENTIONS
Anticipate fever, rigidity, and
tremor whenever antipsychotics
are prescribed
Encourage adequate water intake
for all patients taking
antipsychotics

28. CNS SIDE EFFECTS
SEIZURES
NURSING
INTERVENTIONS
1% incidence. More with
clozapine (600‐900 mg/day).
Consider alternative
antipsychotic if seizures occur
Or Add an anticonvulsant (not
CBZ) like divalproex sodium
(Dicorate)

29. Miscellaneous side effects
1. Other CNS side effects:
Wt gain (upto 40% of patients)
sedation
insomnia
anxiety
dysphagia
dose-related reduction of lowering of seizure threshold
memory impairment due to anticholinergic effects
heat dysregulation

30. Cont…
2. GI effects:
Anorexia
sialorrhea (about 30% of patients taking
clozapine)
3. Sexual dysfunction:
impaired ejaculation
decreased libido
erectile dysfunction
retrograde ejaculation

31. Cont….
4. Endocrine side effects
• Elevated prolactin levels (galactorrhoea,
decreased libido, menstrual irregularities,
gynecomastia, weight gain, hypoglycemia or
hyperglycemia,polydypsia, polyurea)
• Chronic prolactin elevation leading to sexual
dysfunction and osteoporosis

32. Cont…
5. Cutaneous side effects
Blue-gray skin rash
sun-sensitive skin (ziprasidone)
6. Hepatic side effects
Jaundice (typically during the first month
of treatment)
Elevation of liver enzymes

33. Cont..
7. Ocular side effects
Pigmentary retinopathy (with thioridazine
and CPZ)
8. Hemotologic side effects
Leukopenia (upto 10% with CPZ)
Agranulocytosis (with clozapine)

34. Any?

35. THANK U