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Antipsychotics (APDs, also known as neuroleptics) are agents that relieve psychosis (hallucinations and delusions), they usually work by antagonizing the dopamine D2 receptors. They include atypical antipsychotics and typical antipsychotics. The latter, older agents produce significant movement side effects,[note 1] whereas the newer ('atypical') agents produce less movement side effects.

Available agentsEdit

Explanatory notesEdit

Superscripts: Agents that are approved by the Australian TGA are given a T superscript, colon (:) the year of TGA approval (note: this date information gets a little fuzzy before the 1990s as the TGA was formed in 1989), hence may not be given. Agents that are approved by the American FDA are given a F superscript, colon (:) the year of FDA approval. Whereas agents that are approved by the British MHRA are given M superscripts with the date of first MHRA approval. Note, however, that the MHRA was first formed in 2003, when two agencies merged, hence if the product was first marketed prior to this time figures may be inaccurate.

Discontinued agents are assigned asterisks in the superscripts, after the superscript of the respective administration that has revoked its approval.

QT interval is a part of the heart's electrical cycle, usually measured using an electrocardiogram (ECG). If it prolonged it can lead to sudden and unexpected death.

Anticholinergic side effects are related to the body's involuntary muscles.

Includes
  • ​Dry mouth
  • Constipation
  • Nausea/vomiting
  • Blurred vision
  • Reduced sweating
  • Reduced urination[note 2]
  • Metabolic changes
    [note 3]

Antihistamine side effects mean things like: drowsiness, weight gain, metabolic changes (making one more likely to develop metabolic syndrome), etc.

Adrenergic side effects include: orthostatic hypotension (dizziness upon standing up, due to drops in blood pressure), drowsiness, dizziness, etc. They usually relate to blood pressure and refer to the blocking of α1 receptors.

Prolactin, is a hormone that regulates breast growth and lactation. Prolactin secretion from the pituitary gland (near the centre of the skull) normally stimulates the breast tissue to grow, and produce milk. It does not cause them to release milk (that is caused by a hormone called oxytocin). Its release is inhibited by the neurotransmitter, dopamine. Dopamine is released by the hypothalamus, which, in order inhibits prolactin release. 

References are usually found on the agent's respective page on this Wiki which is hyperlinked.

Atypical agentsEdit

  • AmisulprideM: 1997; T: 2002 (brand names: Amipride, Solian, Sulprix), a benzamide agent that possesses minimal affinity towards the 5-HT2 receptors, or histamine/cholinergic receptors. It produces significant elevation in prolactin levels, weight gain (although less than clozapine, olanzapine, quetiapine, risperidone or zotepine; fairly unprone to cause type II diabetes mellitus), QT interval prolongation (less than sertindole or pimozide) and movement disorders (less than the typical agents, but still more than clozapine or quetiapine). It is generally not sedating, neither are adrenergic and anticholinergic side effects. It is not marketed in the U.S.A. or Canada. Lower doses are also used in some countries to treat dysthymia. It was first introduced in the 1990s.
  • AripiprazoleF: 2002; M: ?; T: 2003 (brand names: Abilify, Aripiprex) is a quinolinone derivative that serves as a potent partial agonist at the D2 receptors. Movement disorders are infrequent, although akathisia is common. It causes reduced prolactin levels and is (tied with amisulpride) one of the least prone of atypicals for causing weight gain or sedation.[1][2] It is indicated for the treatment of bipolar mania, bipolar maintenance, an adjunct in major depression (that is, as an add-on agent, taken on top of antidepressants; only indicated for this use in the U.S.A.) and schizophrenia.
  • AsenapineF: 2009; M: ?; T: 2011 (brand names: Saphris, Syncrest) is a tetracyclic atypical agent that has a lower incidence of weight gain or sedation (although it is more sedating than amisulpride, aripiprazole, sulpiride and ziprasidone). Chemically it is a tetracyclic agent. It was first FDA approved in 2009. It is administered twice daily under the tongue. 
BlonanserinACS

Blonanserin's 2D structure

  • Blonanserin (brand name: Lonasen) is an 4-phenyl-2-(1-piperazinyl)pyridine agent that is sold solely in Japan and South Korea. It is used to treat schizophrenia in two divided doses. It is tetracyclic although its chemistry is distinct from clozapine, quetiapine and olanzapine.


  • ClozapineF: 1989; M: 2008; T: 1994; W (brand name: Clozaril) is a dibenzodiazepine atypical antipsychotic that was first synthesized in 1958, introduced to certain European countries in the 1970s, it was later withdrawn from the market after fatal cases of agranulocytosis were reported. It is especially effective in treatment-resistant cases.
  • IloperidoneF: 2009 (brand name: Fanapt) is a benzisoxazole atypical antipsychotic that is used to treat schizophrenia.[3]
  • LurasidoneF: 2010; T: 2014 (brand name: Latuda) is a benzisothiazole atypical antipsychotic that antagonizes the D2, 5-HT2A and 5-HT7 receptors and partially agonizes the 5-HT1A receptors, it is purported to be particularly effective at relieving the negative and cognitive symptoms of schizophrenia.
  • Melperone (brand names: Bunil, Buronil) is a butyrophenone agent with a particularly low incidence of movement disorders, weight gain, sedation and prolactin elevation. It has been purported to possess unique efficacy in the treatment of treatment-resistant patients. It is only marketed in a few European countries.
  • Perospirone (brand name: Lullan) is an azapirone agent purported to have a higher incidence of movement disorder side effects than other atypicals and a lower efficacy in treating schizophrenia.
  • QuetiapineF: 1997; M: ?; T: 2000 (brand names: Seroquel and many others) is a tetracyclic agent that, similarly to clozapine, produces minimal movement disorder side effects due to its very low affinity towards the D2 receptors, but unlike most other atypicals its affinity towards the 5-HT2A is about five fold less than its affinity towards the D2 receptor. It is used to treat a variety of conditions, including: major depression (usually as an adjunct to standard antidepressants in cases of non-response; it is the only medicine that is TGA-approved for use as an adjunct in major depression), bipolar disorder (including in bipolar depression, mania and maintenance) and schizophrenia.
  • RisperidoneF: 1993; M: ?; T: 1993 (brand names: Risperdal and others) is a benzisoxazole atypical with a relatively high affinity (for an atypical) towards to the D2 receptors, it produces more movement disorder side effects than most other atypicals. It inverse agonizes the 5-HT2A about 20 fold more potently than it antagonizes the D2 receptors. It elevates prolactin amongst the most of all antipsychotics, and is less sedating and prone to cause weight gain than tetracyclic antipsychotics.

Typical agentsEdit

  • BenperidolM: 2006 (brand name: Anquil) is a butyrophenone antipsychotic of the typical class that is also used to treat deviant sexual behaviour, although in some countries it is used to treat schizophrenia. It is marketed in the U.K., but has never been marketed in Australia or the U.S.A.
  • Bromperidol (brand names: Bromidol, Bromodol and Impromen) is a butyrophenone antipsychotic of the typical class that is used to treat schizophrenia and other psychoses, but not in any English-speaking country.
  • Carpipramine (brand names: Defekton, Prazinil) is a pentacyclic antipsychotic, that is chemically related to the TCAs. It used solely in France and Japan, it is dosed 2-3 times daily.
  • ChlorpromazineF:1957; M: ?; T: 1991; W (brand names: Largactil, Thorazine) is a phenothiazine antipsychotic of the typical class it is used to treat schizophrenia, bipolar mania, severely disturbed, agitated or violent behaviour, anxiety, nausea and vomiting, intractable hiccups, tetanus, acute intermittent porphyria or hypothermia (low body temperature). It was the first APD to be developed, it is very sedating, prone to causing movement disorders, elevated blood prolactin levels and causes weight gain in a number of patients.
  • ChlorprothixeneW (brand names: Taractan, Tarasan) is a thioxanthene antipsychotic of the typical class, it is used to treat schizophrenia and other psychoses. It is administered 3-4 times a day.
  • ClocapramineW (brand names: Clofekton, Padrasen) is an antipsychotic related to carpipramine. It is used in the treatment of schizophrenia in Japan only.
  • ClotiapineW (brand names: Entumine, Etomine, Etumine and variants) is a tetracyclic antipsychotic chemically related to clozapine, olanzapine and quetiapine that is used to treat schizophrenia, bipolar mania and anxiety. It used in a few European countries, Argentina, Israel and South Africa. It is chemically related to clozapine, olanzapine and quetiapine.
  • Dixyrazine (brand name: Esucos) is a phenothiazine antipsychotic that was marketed in a few European countries and South Africa; now just marketed in Italy.
  • Droperidol (brand name: Droleptan, Inapsine) is a butyrophenone antipsychotic that is primarily used nowadays to treat nausea/vomiting after surgery. It was once available in many countries as a treatment for schizophrenia, nowadays, however, it is no longer marketed for this purpose due to concerns over its potential for prolonging the QT interval.[4]
  • Flupentixol (flupenthixol; brand names: Depixol and Fluanxol) is a thioxanthene antipsychotic of the typical class. It is usually given via depot injections when used to treat schizophrenia, although it may also be given orally (although this preparation is not available in Australia). Lower doses are also used to treat dysthymia.
  • FluphenazineW (brand name: Modecate) is a phenothiazine typical antipsychotic that is given via depot injections and that is notably devoid of anticholinergic, antihistamine and adrenergic activity.
  • Fluspirilene (brand name: Imap, Redeptin) is a diphenylbutylpiperidine antipsychotic usually given in depot injections that is less sedating than chlorpromazine but has properties that are generally the same.[5]
  • HaloperidolF: 1967; M: 1996; T: 1991; W (brand name: Haldol, Serenace) is a butyrophenone typical antipsychotic that is notably devoid of anticholinergic, antihistamine and adrenergic activity. Movement disorders are usually severe with it.[6]
  • LevomepromazineM: 1999 (brand names: Apo-Methoprazine, Levinan, Novo Meprazine, Nozinan) is a very sedating phenothiazine typical antipsychotic that is used in palliative care (as it has painkilling and antiemetic effects).[7]
  • LoxapineF:1975; M:?* (brand names: Adasuve, Loxipac, Loxitane) is a tetracyclic typical antipsychotic that is given via inhalation (only available in the U.S.A.), tablets or by intramuscular injection. It is metabolized to amoxapine, a tricyclic antidepressant. It is given in 2-4 divided daily doses.
  • MolindoneF: 1974 (brand name: Moban) is an indole derivative that produces weight loss instead of weight gain; it is solely available in the U.S.A.[8]
  • PericiazineM: <2009; T: 1991 (pericyazine; brand name: Neulactil) is a phenothiazine agent that is used primarily in the short-term management of severe anxiety, disturbed behaviour and the management (both short-term and long-term) schizophrenia and other psychoses.
  • PimozideF: 1984; M: <1997; T: ?* (brand name: Orap) is a high potency diphenylbutylpiperidine antipsychotic used primarily to treat Tourette's syndrome in the U.S.A., in other countries (like the U.K.) it is used to treat schizophrenia and other psychoses. It is notorious for causing QT interval prolongation; it was once marketed in Australia but it is no longer, likely due to its potential for QT interval prolongation. It is one of only two APDs that is associated with weight loss (although this has not reached statistical significance) instead of weight gain.[9]
  • ThioridazineF: 1962; M: <2005*; T: <2005* (brand name: Mellaril, Melleril) is a phenothiazine antipsychotic that has similar properties to chlorpromazine but is associated with a higher incidence of anticholinergic side effects, QT interval prolongation, drowsiness and a lower incidence of movement disorders. There has been renewed interest in its use as a treatment for totally/extensively-drug resistant cases of tuberculosis as it increases the sensitivity of the bacteria that causes the disease to anti-TB drugs that is has since evolved resistance to.[10]
  • Zuclopenthixol (brand names: Clopixol) is a high-potency thioxanthene antipsychotic typically given orally or via intramuscular injections (including as depots. 

ChemistryEdit

ButyrophenonesEdit

Butyrophenones

The generalized structure of butyrophenone antipsychotics

Butyrophenones tend to be very insoluble in water. Very fat soluble, however. Hence why some (like haloperidol) come as fatty acid esters (e.g., decanoate for haloperidol). One is on the WHO-EM. They are generally high potency.

Drug SMILES of R1[note 4] Flag of the United States
FDA-approved?
Flag of the United Kingdom
MHRA-approved?
Flag of Australia
TGA approved?
Potency
Benperidol OC1=NC2=CC=CC=C2N1C1CCNCC1 No Yes No High
Bromperidol OC1(CCNCC1)C1=CC=C(Br)C=C1 No No No High
Droperidol O=C1NC2=CC=CC=C2N1C1=CCNCC1 Yes Yes Yes High
Fluanisone COC1=CC=CC=C1N1CCNCC1 No No No  ?
Haloperidol OC1(CCNCC1)C1=CC=C(Cl)C=C1 Yes Yes Yes High
Melperone CC1CCNCC1 No No No Low
Moperone CC1=CC=C(C=C1)C1(O)CCNCC1 No No No Low
Pipamperone OC(=N)C1(CCNCC1)N1CCCCC1 No No No Low
Spiperone O=C1NCN(C2=CC=CC=C2)C11CCNCC1 No No No  ?
Timiperone S=C1NC2=CC=CC=C2N1C1CCNCC1 No No No  ?



DiphenylbutylpiperidineEdit

Diphenylbutylpiperidines

Diphenylbutylpiperidines' generalized structure

R1 is cyclical for most drugs. They are also very fat soluble and water insoluble. They are all high potency typical agents, not one is on the WHO-EM.

Drug SMILES of R1 ChemSpider Notes
Fluspirilene O=C1CN(CN1)C1=CC=CC=C1 3279 Solely marketed in a few European countries (including Belgium, Germany and the Netherlands). Once marketed in Canada, Ireland and the United Kingdom. Usually given intramuscularly and is high potency.
Penfluridol FC(F)(F)C1=CC=CC=C1Cl 31017 There is also an alcohol (OH) group attached to the piperidine ring (opposite to the amine in said ring). Only marketed in a few European/South American countries.
Pimozide O=C1NC2=CC=CC=C2N1 15520 Marketed in virtually every developed country except Australia and NZ where it has been discontinued.

PhenothiazinesEdit

Phenothiazine generalized structure

Generalized structure of phenothiazines

Phenothiazines are very soluble in organic solvents and very insoluble in water. Very fat soluble, however. Two are on the WHO-EM.


Drug R1 R2 ChemSpider Notes
Acepromazine CCCN(C)C CC=O 5852 Moderate potency agent primarily used in veterinary medicine, although it has been used in human medicine.
Aceprometazine CC=O CC(C)N(C)C 24249 Rarely used.
Chlorpromazine Cl CCCN(C)C 2625 Low potency, weight gain possible, sedating, movement disorders (moderate in frequency; dose-dependent), anticholinergic side effects are moderate, antiserotonergic effects existent (used to treat serotonin syndrome in some cases) and has antiemetic effects. On the WHO-EM.
Cyamemazine C#N CC(C)CN(C)C 56597 Low potency, available solely in France and Portugal.
Dixyrazine - CC(C)CN1CCN(CCOCCO)CC1 16265 Moderate-low potency. Only used in Italy.
Fluphenazine FC(F)F CCCN1CCN(CCO)CC1 3255 High potency, high propensity for causing movement disorders, low sedation, low weight gain potency, anticholinergic effects are less prominent, etc. On the WHO-EM.
Levomepromazine CO CC(C)CN(C)C 65239 Low potency, very sedating, low potential for movement disorders, anticholinergic effects prominent, etc. Used in palliative care for pain relief and antiemetic effects.
Mesoridazine C[S]=O CCC1CCCCN1C 3936 Low potency antipsychotic, active metabolite of thioridazine, it has been withdrawn due to dose-dependent QT interval prolongation.
Perazine - CCCN1CCN(C)CC1 4582 Available only in Germany and Poland. Low potency.
Periciazine C#N CCCN1CCC(O)CC1 4585 Low potency; primarily used to treat severe anxiety.
Perphenazine Cl CCCN1CCN(CCO)CC1 4586 High potency.
Pipotiazine CN(C)S(=O)=O CCCN1CCC(CCO)CC1 56598 Moderate-high potency. Can be given orally or intramuscularly; available in New Zealand and the U.K., but not Australia or the U.S.A.
Prochlorperazine Cl CCCN1CCN(C)CC1 4748 Moderate potency; primarily used as an antiemetic.
Promazine - CCCN(C)C 4757 Low potency, not usually used to treat schizophrenia but rather disturbed behaviour.
Thioproperazine CN(C)S(=O)=O CCCN1CCN(C)CC1 9058 High-moderate potency. Only available in Canada, Greece and Russia.
Thioridazine CS CCC1CCCCN1C 5253 Low potency, QT interval prolongation can be problematic, it has been withdrawn from numerous markets due to its cardiotoxicity and anticholinergic effects. Being resurrected as an antimicrobial.
Trifluoperazine FC(F)F CCCN1CCN(C)CC1 5365 Moderate-high potency.
Triflupromazine FC(F)F CCCN(C)C 5367 Used as an antiemetic and antipsychotic.

ThioxantheneEdit

Thioxanthenes

Generalized thioxanthene structure

Where R1 is subject to cis/trans-isomerism. Not one is on the WHO-EM.


MulticyclicsEdit

Asenapine

Asenapine's structure

Carpipramine

Carpipramine's structure

Clozapine

Clozapine's structure

Loxapine

Loxapine's structure

Olanzapine

Olanzapine's structure

Quetiapine

Quetiapine's structure

Zotepine

Zotepine's structure

For multicyclics the structure varies quite significantly; hence, some examples are shown. They are very fat soluble, water insoluble and can be used to form fatty acid esters (e.g. olanzapine embonate for IM injection). Only one is on the WHO-EM (clozapine).


External linksEdit

NotesEdit

  1. Including stiffness, involuntary movements, tremor, rigidity, etc.
  2. As some involuntary muscles are required for urination
  3. Including: blood sugar changes (usually increases), diabetic ketoacidosis (a condition caused by dangerously utilization of blood sugar that leads to brain damage and death) and type II diabetes mellitus. Depends on which cholinergic receptors it binds to and other factors too
  4. Most of these R1 groups are attached at the piperidine's amine group.

Reference listEdit

  1. Bhattacharjee, J; El-Sayeh, HG (July 2008). "Aripiprazole versus typical antipsychotic drugs for schizophrenia.". The Cochrane Database of Systematic Reviews (3): CD006617. PMID 18646161. doi:10.1002/14651858.CD006617.pub3. 
  2. Khanna, P; Suo, T; Komossa, K; Ma, H; Rummel-Kluge, C; El-Sayeh, HG; Leucht, S; Xia, J (January 2014). "Aripiprazole versus other atypical antipsychotics for schizophrenia.". The Cochrane Database of Systematic Reviews 1: CD006569. PMID 24385408. doi:10.1002/14651858.CD006569.pub5. 
  3. Brayfield, A, ed. (10 April 2014). "Iloperidone". Martindale: The Complete Drug Reference. London, UK: Pharmaceutical Press. Retrieved 18 August 2014. 
  4. Brayfield, A, ed. (13 December 2013). "Droperidol". Martindale: The Complete Drug Reference. London, UK: Pharmaceutical Press. Retrieved 23 August 2014. 
  5. Brayfield, A, ed. (13 December 2013). "Fluspirilene". Martindale: The Complete Drug Reference. London, UK: Pharmaceutical Press. Retrieved 18 August 2014. 
  6. Brayfield, A, ed. (13 December 2013). "Haloperidol". Martindale: The Complete Drug Reference. London, UK: Pharmaceutical Press. Retrieved 18 August 2014. 
  7. Brayfield, A, ed. (13 December 2013). "Levomepromazine". Martindale: The Complete Drug Reference. London, UK: Pharmaceutical Press. Retrieved 18 August 2014. 
  8. Bagnall, A; Fenton, M; Kleijnen, J; Lewis, R (January 2007). "Molindone for schizophrenia and severe mental illness.". The Cochrane Database of Systematic Reviews (1): CD002083. PMID 17253473. doi:10.1002/14651858.CD002083.pub2. 
  9. Mothi, M; Sampson, S (November 2013). "Pimozide for schizophrenia or related psychoses.". The Cochrane Database of Systematic Reviews 11: CD001949. PMID 24194433. doi:10.1002/14651858.CD001949.pub3. 
  10. Amaral, L (March-April 2012). "Thioridazine: an old neuroleptic effective against totally drug resistant tuberculosis.". Acta Medica Portuguesa 25 (2): 118–21. PMID 22985923.  Check date values in: |date= (help)

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