Question

Jimbo, a 30-year old male, has a BMI of 31 kg/m2 , hypercholesterolaemia, and glaucoma. After a series of concerning episodes of mood disturbances, his psychiatrist diagnoses him with schizophrenia. He decides to prescribe an appropriate antipsychotic. Although the treatment is ultimately effective, he initially complained of several side effects with little therapeutic improvement.

a. Suggest an appropriate antipsychotic to prescribe to him. Justify your selection by referring to pharmacodynamic and toxicodynamic responses.

b. Explain why Jimbo experienced side effects and therapeutic effects at different stages in the pharmacotherapy .

Treatment proceeds well for the next few months, though one evening Jimbo is rushed to the emergency room by his brother. The emergency room team observes severe muscle spasms, hyperpyrexia, a brown discolouration of the urine, and a blood pressure of 180/115 mmHg. His brother informs the medical team that Jimbo had taken more than the required dosage that day.

c. Discuss the underlying pathogenesis of the observed clinical manifestations, and a drug you could use to treat the condition. Explain the rationale for selecting the drug for treatment.

Answer 1

1. Second-generation (atypical) antipsychotics (SGAs)—with the exception of clozapine—are the agents of choice for first-line treatment of schizophrenia. Clozapine is not recommended because of its risk of agranulocytosis.
example:
Aripiprazole (Abilify, Abilify Maintena)
Clozapine (Clozaril, Denzapine, Zaponex)
Risperidone (Risperdal & Risperdal Consta)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Paliperidone (Invega, Xeplion)​

2. Your brain contains chemicals which help to carry messages from one part of the brain to another. One of these chemicals is called dopamine. It is thought that high levels of dopamine may cause the brain to function differently and may cause the symptoms of psychosis. Antipsychotic medications reduce the amount of dopamine in the brain or restore the balance of dopamine with other chemicals in the brain.
If imbalance occur in chemicals of brain these cause side effects like EPS ( extra pyramidal symptoms)

3. Side effects of antipsychotics can include the following:

a. Stiffness and shakiness. This can often be reduced by lowering the dose. But, if a high dose is necessary, the shakiness can be treated with anticholinergic drugs. This is the same kind of medication that is used for Parkinson’s disease.
b. Uncomfortable restlessness (akathisia).
c. Movements of the jaw, lips and tongue (tardive dyskinesia).
d. Sexual problems due to hormonal changes.
e. Sleepiness and slowness.
f. Weight gain.
g. A higher risk of getting diabetes.
h. Constipation.
i. Dry mouth.

The first step in the management of any poisoned patient is ensuring the patient has an adequate and patent airway. If the patient is not adequately protecting the airway, or if there is concern that the patient is rapidly becoming more somnolent and will lose the ability to protect the airway, endotracheal intubation should be performed. After you ensure that an adequate airway exists, breathing should be monitored and respiratory distress should be treated. Hypotension should be treated initially with crystalloids, with vasopressors being used second.

There is no specific antidote for the atypical antipsychotics. Treatment is symptomatic and supportive. Patients should be monitored for CNS depression, cardiac toxicity, including hypotension and ECG abnormalities, and the possibility of seizures. In general, patients should be observed for 4-6 hours after overdose.
Flumazmil is antidote for BZP ( benzodiazepine)