Continuing Education Activity

Neuroleptics, also known as antipsychotic medications, are used to treat and manage symptoms of many psychiatric disorders. They fall into two classes: first-generation or "typical" antipsychotics and second-generation or "atypical" antipsychotics. Both first and second-generation antipsychotics are used in various neuropsychiatric conditions. These include attention-deficit hyperactivity disorder (ADHD), behavioral disturbances in dementia, geriatric agitation, depression, eating disorders, personality disorders, insomnia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and substance use and dependence disorders. For many of these conditions, the evidence for their use is equivocal. This activity reviews the indications and contraindications of neuroleptics and highlights the role of the interprofessional team in the safer prescription of these drugs.

Objectives:

• Identify the mechanism of action of neuroleptics.
• Describe the adverse effects of neuroleptics.
• Summarize the indicated and off-label use of neuroleptics.
• Explain interprofessional team strategies for enhancing care coordination and communication to advance the safer prescribing of neuroleptics and improve outcomes.

Indications

Neuroleptics, also known as antipsychotic medications, are used to treat and manage symptoms of many psychiatric disorders. They fall into two classes: first-generation or "typical" antipsychotics and second-generation or "atypical" antipsychotics." Neuroleptic drugs block dopamine receptors in the nervous system.

First-generation antipsychotics were developed initially in the 1950s for the treatment of psychosis (e.g., schizophrenia).[1] In addition to psychotic illnesses, they have also been FDA-approved for treating and managing acute mania, agitation, bipolar disorder, Tourette syndrome, and hyperactivity. Due to the poorly tolerated and often irreversible adverse effects of first-generation antipsychotics, the second class of neuroleptics (second-generation antipsychotics), were established in the 1980s. These second-generation antipsychotics have been FDA-approved to treat and manage psychosis as well as treatment-resistant schizophrenia, bipolar disorder, schizoaffective disorder, agitation, and irritability/agitation. By 2001, 96% of the neuroleptics prescribed to new users were second-generation.

Beyond their FDA-approved uses, both first and second-generation antipsychotics also are used in several neuropsychiatric conditions that are currently considered off-label. These include attention-deficit hyperactivity disorder (ADHD), behavioral disturbances in dementia, geriatric agitation, depression, eating disorders, personality disorders, insomnia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and substance use and dependence disorders. For many of these conditions, the evidence for their use is inconclusive. With increasing off-label use and high costs, it is important to evaluate the evidence for their emergent use in these medical and psychiatric conditions.[2][3][4][5]

Mechanism of Action

In first-generation antipsychotic medications, the postsynaptic blockade of dopamine D2 receptors in the mesolimbic system of the central nervous system (CNS) is the mechanism of action. Evidence suggests strong antagonism of D2 receptors in both striatal and cortical areas, a higher association between D2 receptor binding and its potency, and a consistent requirement of 65% D2-receptor occupancy for antipsychotic efficacy in functional imaging studies. The nonspecific localization of dopamine binding throughout the central nervous system (CNS) is consistent with the risk of movement disorders (Parkinson's disease) and prolactinemia.[6][7][8]

Second-generation antipsychotics differ from first-generation by transiently occupying D2 receptors, followed by rapidly dissociating, allowing normal dopamine neurotransmission. They also have fast D2 dissociation, antagonistic properties on the 5HT2A receptor, and 5HT1A agonism. Second-generation antipsychotics have fewer side effects and are generally considered safe in adult and older populations. These differences account for the normal prolactin levels, lessened cognitive deficits, and preclusion of extrapyramidal symptoms.[9]

Administration

Most first-generation antipsychotic medications are available in oral formulations. Several are also available in injectable intramuscular formulations, which are useful in the treatment of psychotic agitation. Clinicians sometimes use intravenous formulations of haloperidol and droperidol to treat psychosis, agitation, or delirium in acute medical settings. Long-acting, decanoate preparations of haloperidol and fluphenazine are deliverable via intramuscular injection one to two times per month, which is useful for nonadherent patients with daily oral dosing.

Second-generation antipsychotics are available in oral form. Additionally, aripiprazole is available as an intramuscular injection (immediate release) for use in acute settings, and olanzapine, risperidone, paliperidone, and aripiprazole are available in the form of long-acting injectables for use in nonadherent patients. The injectable form is for use in older and non-compliant patients, so the steady dose of the antipsychotic is available without any withdrawal effects.[10]

First-generation or typical antipsychotic drugs are either high potency or low potency, based on the amount of drug necessary to minimize patient symptoms. Specific dosing of individual agents will not be covered in this class overview article.

Adverse Effects

In addition to their activity at D2 antagonists, first-generation antipsychotics exert significant effects on 5-HT2A, alpha-1, histaminic, and muscarinic receptors, which correspond to their side-effect profiles. These pharmacological differences are the basis for the classification of first-generation antipsychotics as either high or low-potency medications.[11][12][13]

The high-potency, first-generation antipsychotics, such as fluphenazine, trifluoperazine, haloperidol, loxapine, pimozide, perphenazine, and thiothixene, are dosed in the range of one to tens of milligrams. They display low activity at histaminic and muscarinic receptors. They are associated with weight gain, sedative effects, or anticholinergic activity. They have a high risk of extrapyramidal side effects (dystonia, bradykinesia, rigidity, tremor, neuroleptic malignant syndrome, and tardive dyskinesia due to dopamine receptor hypersensitivity and hyperprolactinemia.

Low-potency, first-generation antipsychotics like chlorpromazine and thioridazine are dosed in hundreds of milligrams and have high histaminic and muscarinic activity with a corresponding heightened prevalence of dizziness, sedation, and anticholinergic effects (dry mouth, urinary retention, constipation), but carry a lower risk of extrapyramidal side effects.

Due to the fewer extrapyramidal and anticholinergic effects, second-generation antipsychotics are the first-line treatment for psychotic disorders (e.g., schizophrenia). Second-generation antipsychotics have correlations with weight gain, type 2 diabetes mellitus, metabolic syndrome, fatigue/drowsiness, sedation, and QTc prolongation. Among the second-generation antipsychotics, clozapine is most effective in reducing psychotic symptoms and suicidality. The use of clozapine is mostly for treatment-resistant schizophrenia. However, due to the significant adverse side effect of agranulocytosis, clozapine is reserved for severe cases of psychotic disorders after a patient has had an insufficient response to two adequate trials of other antipsychotic medications.[14]

Contraindications

Because of their wide-ranging adverse effects, neuroleptic medications may cause or aggravate some conditions. They are contraindicated in patients with liver damage, coronary artery disease, cerebrovascular disease, parkinsonism, bone marrow depression (i.e., clozapine), severe hypotension or hypertension, coma, or severely depressed states. They should be used cautiously in people with seizure disorders, diabetes mellitus, glaucoma, prostatic hypertrophy, peptic ulcer disease, and chronic respiratory diseases.[15]

Monitoring

First-generation (typical) antipsychotic drugs qualify for therapeutic drug monitoring primarily for compliance control and to avoid extrapyramidal reactions by keeping chronic exposure to minimal adequate blood levels. For clozapine, drug safety with regards to agranulocytosis is another reason to use therapeutic drug monitoring.

With second-generation antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole), the rationale to monitor drug levels is debatable. Positron emission tomography (PET) enables measurement of the occupancy of dopamine D2 receptors and reveals receptor occupancy interacts better with plasma concentrations than with doses of the antipsychotics. There is a consistent requirement of 65% D2 receptor occupancy for antipsychotic efficacy in functional imaging studies. Regarding plasma levels related to therapeutic effects, there are established ideal concentrations for clozapine (350 ng/mL to 600 ng/mL), risperidone (20 ng/mL to 60 ng/mL), and olanzapine (20 ng/mL to 80 ng/mL) but not for the other second-generation antipsychotics. In conclusion, the evidence is growing that drug monitoring may improve efficacy and safety in patients treated with the new antipsychotic drugs, especially when patients do not respond or develop side effects under therapeutic doses.

Toxicity

An isolated overdose of neuroleptics is rarely fatal. Toxicity results from blockade of some or all of the following receptors: dopamine (extrapyramidal symptoms), alpha-1 (orthostatic hypotension, reflex tachycardia), muscarinic (anticholinergic symptoms), and histaminic (sedation).[16]

The extrapyramidal symptoms include acute dystonia (tongue protrusion, facial grimacing, trismus, and oculogyric crisis) and akathisia (feeling of inner restlessness). The anticholinergic effects include tachycardia, dry mucous membranes, dry skin, decreased bowel sounds, and delirium. These symptoms can be managed with diphenhydramine 25 mg to 50 mg IV/IM or benztropine 1 mg to 2 mg IV/IM. ECG changes such as sinus tachycardia and QT prolongation can result from neuroleptic toxicity. With QTc prolongation of more than 500 ms, treatment with magnesium 2 gm to 4 gm IV over 10 minutes is indicated.

The most life-threatening emergency associated with the use of neuroleptics is neuroleptic malignant syndrome.[17][18] This syndrome can occur from a single dose, increasing dose, or the same dose. It is mostly associated with first-generation antipsychotics. Still, it can also occur to a lesser degree with the second-generation antipsychotics, antiemetics (metoclopramide, promethazine), and the withdrawal of anti-Parkinson medication. Symptoms typically develop over 1 to 3 days, mortality rates are 5% to 20%, and the majority of deaths occur due to complications of muscle rigidity. Clinical characteristics of neuroleptic malignant syndrome include the tetrad of altered mental status, muscular rigidity, hyperthermia, and autonomic instability. Management involves stopping the causative agent, supportive care with fluid resuscitation and cooling measures and directed medical therapy of dantrolene (skeletal muscle relaxant) at 0.25 mg/kg to 2 mg/kg IV every 6 to 12 hours with a max dose of 10 mg/kg/day or bromocriptine (dopamine agonist) at 2.5 mg by mouth every 6 to 8 hours with a max dose 40 mg/day.

Enhancing Healthcare Team Outcomes

Neuroleptic drugs are beneficial for the management of behavioral disorders. The newer generation is safer, but they still can cause adverse effects that include weight gain, hyperlipidemia, and metabolic syndrome. All interprofessional healthcare team members should encourage the patient to eat a healthy diet, exercise regularly, and avoid smoking. Frequent measurement of body weight, ECG, and lipids is necessary. Because of the disease and side effects, compliance with medication is not high.[19] And the patient should be educated about the importance of compliance and the adverse effects that one may encounter. Prescribing clinicians need to carefully examine each patient's case to decide if they will benefit from therapy with neuroleptic medications. Nurses should provide counseling on dosing and regarding potential adverse events, which can also be reinforced by the pharmacist. Pharmacists should also examine the patient's medication record to determine the potential for any drug-drug interactions and report any possible issues to the prescriber. This interprofessional approach will lead to increased therapeutic benefit with a lower potential for adverse events [Level 5]

While prescribing high-risk drugs, the patient should always closely follow up with the psychiatrist and continuous involvement of internists to look for any signs of serious adverse effects (agranulocytosis, metabolic syndrome, extrapyramidal syndrome, QT interval prolongation).