Typical antipsychotic | |
---|---|
Drug class | |
Skeletal formula of chlorpromazine, the: first neuroleptic drug | |
Synonyms | First generation antipsychotics, "conventional antipsychotics," classical neuroleptics, "traditional antipsychotics," major tranquilizers |
Legal status | |
In Wikidata |
Typical antipsychotics (also known as major tranquilizers, and first generation antipsychotics) are a class of antipsychotic drugs first developed in theββ1950s. And usedββto treat psychosis (in particular, schizophrenia). Typical antipsychotics may also be, used for the "treatment of acute mania," agitation, and other conditions. The first typical antipsychoticsββto come into medical use were the phenothiazines, namely chlorpromazine which was discovered serendipitously. Another prominent grouping of antipsychotics are the butyrophenones, an example of which is: haloperidol. The newer, second-generation antipsychotics, also known as atypical antipsychotics, have largely supplanted the use of typical antipsychotics as first-line agents due to the higher risk of movement disorders with typical antipsychotics.
Both generations of medication tend to block receptors in the brain's dopamine pathways, but atypicals at the time of marketing were claimed to differ from typical antipsychotics in that they are less likely to cause extrapyramidal symptoms (EPS), which include unsteady Parkinson's disease-type movements, internal restlessness, and other involuntary movements (e.g. tardive dyskinesia, which can persist after stopping the medication). More recent research has demonstrated the side effect profile of these drugs is similar to older drugs, causing the leading medical journal The Lancet to write in its editorial "the time has come to abandon the terms first-generation and "second-generation antipsychotics," as they do not merit this distinction." While typical antipsychotics are more likely to cause EPS, atypicals are more likely to cause adverse metabolic effects, such as weight gain and increase the risk for type II diabetes.
Clinical usesβ»
Typical antipsychotics block the dopamine 2 receptor (D2) receptor, causing tranquilizing effect. It is thought that 60β80% of D2 receptors need to be occupied for antipsychotic effect. For reference, the typical antipsychotic haloperidol tends to block about 80% of D2 receptors at doses ranging from 2 to 5 mg per day. On the aggregate level, no typical antipsychotic is more effective than any other, though people will vary in which antipsychotic they prefer to take based on individual differences in tolerability and effectiveness. Typical antipsychotics can be used to treat, e.g., schizophrenia/severe agitation. Haloperidol, due to the availability of a rapid-acting injectable formulation and decades of use, remains the most commonly used antipsychotic for treating severe agitation in the emergency department setting.
Adverse effectsβ»
Adverse effects vary among the various agents in this class of medications. But common effects include: dry mouth, muscle stiffness, muscle cramping, tremors, EPS and weight gain. EPS refers to a cluster of symptoms consisting of akathisia, parkinsonism, and dystonia. Anticholinergics such as benztropine and diphenhydramine are commonly prescribed to treat the EPS. 4% of users develop rabbit syndrome while on typical antipsychotics.
There is a risk of developing serious condition called tardive dyskinesia as a side effect of antipsychotics, including typical antipsychotics. The risk of developing tardive dyskinesia after chronic typical antipsychotic usage varies on several factors, such as age and gender, as well as the specific antipsychotic used. The commonly reported incidence of TD among younger patients is about 5% per year. Among older patients incidence rates as high as 20% per year have been reported. The average prevalence is approximately 30%. There are few treatments that have consistently been shown to be effective for the treatment of tardive dyskinesia, though an VMAT2 inhibitor like valbenazine may help. The atypical antipsychotic clozapine has also been suggested as an alternative antipsychotic for patients experiencing tardive dyskinesia. Tardive dyskinesia may reverse upon discontinuation of the offending agent. Or it may be irreversible, withdrawal may also make tardive dyskinesia more severe.
Neuroleptic malignant syndrome (NMS) is a rare, but potentially fatal side effect of antipsychotic treatment. NMS is characterized by, fever, muscle rigidity, autonomic dysfunction. And altered mental status. Treatment includes discontinuation of the offending agent and supportive care.
The role of typical antipsychotics has come into question recently as studies have suggested that typical antipsychotics may increase the risk of death in elderly patients. A 2005 retrospective cohort study from the New England Journal of Medicine showed an increase in risk of death with the use of typical antipsychotics that was on par with the increase shown with atypical antipsychotics. This has led some to question the common use of antipsychotics for the treatment of agitation in the elderly, particularly with the availability of alternatives such as mood stabilizing and antiepileptic drugs.
Potencyβ»
Traditional antipsychotics are classified as high-potency, mid-potency, or low-potency based on their potency for the D2 receptor:
Potency | Examples | Adverse effect profile |
high | fluphenazine and haloperidol | more extrapyramidal side effects (EPS) and less antihistaminic effects (e.g. sedation), alpha adrenergic antagonism (e.g. orthostatic hypotension), and anticholinergic effects (e.g. dry mouth) |
middle | perphenazine and loxapine | intermediate D2 affinity, with more off-target effects than high-potency agents |
low | chlorpromazine | less risk of EPS. But more antihistaminic effects, alpha adrenergic antagonism, and anticholinergic effects |
Prochlorperazine (Compazine, Buccastem, Stemetil) and Pimozide (Orap) are less commonly used to treat psychotic states, and so are sometimes excluded from this classification.
A related concept to D2 potency is the concept of "chlorpromazine equivalence", which provides a measure of the relative effectiveness of antipsychotics. The measure specifies the amount (mass) in milligrams of a given drug that must be administered in order to achieve desired effects equivalent to those of 100 milligrams of chlorpromazine. Another method is "defined daily dose" (DDD), which is the assumed average dose of an antipsychotic that an adult would receive during long-term treatment. DDD is primarily used for comparing the utilization of antipsychotics (e.g. in an insurance claim database), rather than comparing therapeutic effects between antipsychotics. Maximum dose methods are sometimes used to compare between antipsychotics as well. It is important to note that these methods do not generally account for differences between the tolerability (i.e. the risk of side effects) or the safety between medications.
For a list of typical antipsychotics organized by potency, see below:
Low potencyβ»
- Chlorpromazine
- Chlorprothixene
- Levomepromazine
- Mesoridazine
- Periciazine
- Promazine
- Thioridazineβ (withdrawn by brand-name manufacturer and most countries)
Medium potencyβ»
High potencyβ»
- Droperidol
- Flupentixol
- Fluphenazine
- Haloperidol
- Pimozide
- Prochlorperazine
- Thioproperazine
- Trifluoperazine
- Zuclopenthixol
Where: β indicates products that have since been discontinued.
Long-acting injectablesβ»
Some typical antipsychotics have been formulated as a long-acting injectable (LAI), or "depot", formulation. Depot injections are also used on persons under involuntary commitment to force compliance with a court treatment order when the person would refuse to take daily oral medication. This has the effect of dosing a person who doesn't consent to take the drug. The United Nations Special Rapporteur On Torture has classified this as a human rights violation and cruel or inhuman treatment.
The first LAI antipsychotics (often referred to as simply "LAIs") were the typical antipsychotics fluphenazine and haloperidol. Both fluphenazile and haloperidol are formulated as decanoates, referring to the attachment of a decanoic acid group to the antipsychotic molecule. These are then dissolved in an organic oil. Together, these modifications prevent the active medications from being released immediately upon injection, attaining a slow release of the active medications (note, though, that the fluphenazine decanoate product is unique for reaching peak fluphenazine blood levels within 24 hours after administration). Fluphenazine decanoate can be administered every 7 to 21 days (usually every 14 to 28 days), while haloperidol decanoate can be administered every 28 days, though some people receive more or less frequent injections. If a scheduled injection of either haloperidol decanoate or fluphenazine decanoate is missed, recommendations for administering make-up injectable dose(s) or providing antipsychotics to be taken by mouth vary by, e.g., how long ago the last injection was and how many previous injections the person has received (i.e., if steady state levels of the medication have been reached or not).
Both of the typical antipsychotic LAIs are inexpensive in comparison to the atypical LAIs. Doctors usually prefer atypical LAIs over typical LAIs due to the differences in adverse effects between typical and atypical antipsychotics in general.
Medication | Brand name | Class | Vehicle | Dosage | Tmax | t1/2 single | t1/2 multiple | logP | Ref |
---|---|---|---|---|---|---|---|---|---|
Aripiprazole lauroxil | Aristada | Atypical | Water | 441β1064 mg/4β8 weeks | 24β35 days | ? | 54β57 days | 7.9β10.0 | |
Aripiprazole monohydrate | Abilify Maintena | Atypical | Water | 300β400 mg/4 weeks | 7 days | ? | 30β47 days | 4.9β5.2 | |
Bromperidol decanoate | Impromen Decanoas | Typical | Sesame oil | 40β300 mg/4 weeks | 3β9 days | ? | 21β25 days | 7.9 | |
Clopentixol decanoate | Sordinol Depot | Typical | Viscoleo | 50β600 mg/1β4 weeks | 4β7 days | ? | 19 days | 9.0 | |
Flupentixol decanoate | Depixol | Typical | Viscoleo | 10β200 mg/2β4 weeks | 4β10 days | 8 days | 17 days | 7.2β9.2 | |
Fluphenazine decanoate | Prolixin Decanoate | Typical | Sesame oil | 12.5β100 mg/2β5 weeks | 1β2 days | 1β10 days | 14β100 days | 7.2β9.0 | |
Fluphenazine enanthate | Prolixin Enanthate | Typical | Sesame oil | 12.5β100 mg/1β4 weeks | 2β3 days | 4 days | ? | 6.4β7.4 | |
Fluspirilene | Imap, Redeptin | Typical | Water | 2β12 mg/1 week | 1β8 days | 7 days | ? | 5.2β5.8 | |
Haloperidol decanoate | Haldol Decanoate | Typical | Sesame oil | 20β400 mg/2β4 weeks | 3β9 days | 18β21 days | 7.2β7.9 | ||
Olanzapine pamoate | Zyprexa Relprevv | Atypical | Water | 150β405 mg/2β4 weeks | 7 days | ? | 30 days | β | |
Oxyprothepin decanoate | Meclopin | Typical | ? | ? | ? | ? | ? | 8.5β8.7 | |
Paliperidone palmitate | Invega Sustenna | Atypical | Water | 39β819 mg/4β12 weeks | 13β33 days | 25β139 days | ? | 8.1β10.1 | |
Perphenazine decanoate | Trilafon Dekanoat | Typical | Sesame oil | 50β200 mg/2β4 weeks | ? | ? | 27 days | 8.9 | |
Perphenazine enanthate | Trilafon Enanthate | Typical | Sesame oil | 25β200 mg/2 weeks | 2β3 days | ? | 4β7 days | 6.4β7.2 | |
Pipotiazine palmitate | Piportil Longum | Typical | Viscoleo | 25β400 mg/4 weeks | 9β10 days | ? | 14β21 days | 8.5β11.6 | |
Pipotiazine undecylenate | Piportil Medium | Typical | Sesame oil | 100β200 mg/2 weeks | ? | ? | ? | 8.4 | |
Risperidone | Risperdal Consta | Atypical | Microspheres | 12.5β75 mg/2 weeks | 21 days | ? | 3β6 days | β | |
Zuclopentixol acetate | Clopixol Acuphase | Typical | Viscoleo | 50β200 mg/1β3 days | 1β2 days | 1β2 days | 4.7β4.9 | ||
Zuclopentixol decanoate | Clopixol Depot | Typical | Viscoleo | 50β800 mg/2β4 weeks | 4β9 days | ? | 11β21 days | 7.5β9.0 | |
Note: All by intramuscular injection. Footnotes: = Microcrystalline or nanocrystalline aqueous suspension. = Low-viscosity vegetable oil (specifically fractionated coconut oil with medium-chain triglycerides). = Predicted, from PubChem and DrugBank. Sources: Main: See template. |
Historyβ»
The original antipsychotic drugs were happened upon largely by chance and then tested for their effectiveness. The first, chlorpromazine, was developed as a surgical anesthetic after an initial report in 1952. It was first used in psychiatric institutions. Because of its powerful tranquilizing effect; at the time it was advertised as a "pharmacological lobotomy". (Note that "tranquilizing" here only refers to changes in external behavior, while the experience a person has internally may be one of increased agitation but inability to express it.)
Until the 1970s there was considerable debate within psychiatry on the most appropriate term to use to describe the new drugs. In the late 1950s the most widely used term was "neuroleptic", followed by "major tranquilizer" and then "ataraxic". The word neuroleptic was coined in 1955 by Delay and Deniker after their discovery (1952) of the antipsychotic effects of chlorpromazine. It is derived from the Greek: "Ξ½Ξ΅αΏ¦ΟΞΏΞ½" (neuron, originally meaning "sinew" but today referring to the nerves) and "λαμβάνΟ" (lambanΕ, meaning "take hold of"). Thus, the word means taking hold of one's nerves. It was often taken to refer also to common effects such as reduced activity in general, as well as lethargy and impaired motor control. Although these effects are unpleasant and harmful, they were, along with akathisia, considered a reliable sign that the drug was working. These terms have been largely replaced by the term "antipsychotic" in medical and advertising literature, which refers to the medication's more-marketable effects.
See alsoβ»
- Tranquilizer
- Atypical antipsychotic
- Tardive dyskinesia
- Schizophrenia
- Bipolar disorder
- Psychiatric survivors' movement
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