USMLE Step 2 Review 19 11 Drugs of Choice Antipsychotics 2

USMLE Step 2 Review 19 11 Drugs of Choice Antipsychotics 2

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Begin 19 11 Drugs of Choice Antipsychotics 2 Transcription

The side effect profiles are different, between low and high potency neuroleptics.

Student doctor, what is the time of onset of side effects with low-potency antipsychotics?

  • Immediate, they come on right away.

And what are the 3 main classes of immediate side effects with the low-potency antipsychotics?

  • Anticholinergic, antihistaminergic, antiadrenergic.

We’re going to take a minute to learn the profiles of these 3 classes of side effects. Keep in mind that with proper dosing of the low-potency neuroleptics, these side effects are usually not a big problem. They become a big problem when there is overdosing, for whatever reason.

Let’s start with the anticholinergic side effects.

What is the memory image we’re using for anticholinergic side effects?

  • It’s a little different from the classical one.

The classical one goes “hot as Hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter”. I like mine better, obviously.

What is it?

  • Anticholinergic is anti-cool.

Think of being lost in the desert, without water, without a hat, without sunscreen, and without sunglasses.

What happens to you?

  • You become hot and dry, red, blind, crazy.

Again, what are the 5 qualities of anticholinergic side effects of the low-potency neuroleptics?

  • Hot and dry, red, blind, crazy.

Which 4 are primarily due to peripheral effect of anticholinergic action?

  • Hot and dry, red, blind.

Which, then, is primarily due to central anticholinergic action?

  • Crazy.

Let’s take these one at a time, and understand them. I know we’re spending a lot of time here, but you’ll see it again and again on the boards and especially in rotations.

What are the first 2 of the 5?

  • Hot and dry.

What causes the hyperthermia?

  • Suppression of the cholinergic sweat glands.

And what 6 problems are referred to by the word “dry”?

  • Dry skin, dry mouth, dry nose, dry eyes, retention of urine, and finally, little or no intestinal secretions or motion.

Again, the 6 problems referred to by the word “dry”?

  • Dry skin, mouth, nose, eyes; retention of urine, little or no intestinal secretions or motions.

What causes the dry skin, mouth, nose, eyes, in that order?

  • Suppression of the cholinergic sweat glands, salivary glands, mucus glands, and lacrimary glands.

What causes the retention of urine in the bladder?

  • Suppression of the cholinergic urination reflex. The detrusor muscle is not as irritable.

What causes the intestinal stasis and suppression of intestinal secretions?

  • Inhibition of the cholinergic smooth muscle and intestinal glands.

Let’s move on. What is the 3rd of the 5 in anticholinergic, anti-cool side effects?

  • Red.

And what causes the flushing of the skin?

  • Cutaneous blood vessels may dilate, both due to local response to the hyperthermia and to central response to the anticholinergic effects of the drug.

And what is the 4th of the 5 in anticholinergic, anti-cool side effects?

  • Blind.

What happens to the eyes with anticholinergic action?

  • In this case, the overall effect is that the pupils dilate. Acetylcholine is involved differently in both pupillary dilation and constriction. In this case, dilation wins.

And what happens to visual acuity when the pupils are excessively dilated?

  • The vision becomes blurry.

What is the 5th of the 5 in anticholinergic, anti-cool side effects?

  • Crazy.

And what are 4 examples of ways that anticholinergic toxicity can affect the central nervous system?

  • Disorientation, hallucinations, seizure, coma.

Ok, let’s back up for just a second. What, again, are the 3 main classes of immediate side effects with the low-potency antipsychotics?

  • Anticholinergic, antihistaminergic, antiadrenergic.

What are the 2 main characteristics of the antihistaminergic side effects of the low-potency antipsychotics?

  • Sedation and weight gain.

Again, the 2 main characteristics of antihistaminergic side effects?

  • Sedation and weight gain.

Finally, what are the 2 main characteristics of the antiadrenergic side effects of the low-potency antipsychotics? Hypotension and reflex tachycardia.

Again, the 2 main characteristics of the antiadrenergic side effects?

  • Hypotension and reflex tachycardia.

Ok, let’s put them all together. Please list the 9 characteristics we’ve just learned of the anticholinergic, antihistaminergic, and antiadrenergic side effects of the low-potency neuroleptics. Hot and dry, red, blind, crazy, sedation, weight gain, hypotension, reflex tachycardia.

Those 9 again, for low potency neuroleptics?

  • Hot and dry, red, blind, crazy, sedation, weight gain, hypotension, reflex tachycardia.

With all these side effects, why would one wish to consider using a low-potency antipsychotic?

  • Because the high-potency antipsychotics, while they don’t have these side effects, have the potential for other, far more serious side effects. We’ll get to those in a minute.

****END OF TRANSCRIPTION****

 

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