The routine use of Intramuscular anticholinergics and depot antipsychotics BY DR. CHANTELLE MAGRI FOUNDATION YEAR 1

The routine use of Intramuscular anticholinergics and depot antipsychotics BY DR. CHANTELLE MAGRI FOUNDATION YEAR 1

Contributors Dr. Francesca Falzon Aquilina; BST psychiatry Dr Claire Axiaq; Resident Specialist psychiatry Nurses at POP Denhia and Carmen

Understanding psychosis MISPERCEPTION ARISING FROM PATIENT S OWN IMAGINATION AS REALITY Including delusions and hallucinations About 3% of the general population

Schizophrenia POSITIVE SYMPTOMS NEGATIVE SYMPTOMS Hallucinations - wakeful distortions of perception (especially auditory) of content that is not actually present. They can include: auditory hallucinations Spoken commands or running commentary on the patient's actions) visual hallucinations olfactory hallucinations (e.g. unpleasant odors) tactile hallucinations (e.g., feeling that someone is touching you when no one is near by) Delusions - fixed false beliefs & misinterpretation of perceptions that can include: Thought insertion/ broadcast (e.g., believing one's thoughts and movements are controlled by someone else) delusions of reference (e.g., believing someone on TV is talking specifically to you) Thought disorders - illogical thought & speech that can include: poverty of speech thought blocking - a sudden losing train of thought, abrupt interruption in speech word salad - words strung together nonsensically loosening of associations Flat affect - decrease in the intensity of emotional expression, apathy Poor motivation - decrease in initiation of goal-directed behavior Poor attention and memory Social withdrawal grandiose delusions (e.g., believing one is a billionaire who owns all hotels in the city) persecutory delusions (e.g., believing ones is being followed &/or harrassed by the CIA) somatic delusions (e.g., believing ones nose is infested by worms)

Understanding antipsychotics How do antipsychotics work? We do not know exactly

Dopamine Hypothesis Bind to dopamine receptors D2 and D3 Decrease the transmission of dopamine Can be of two classes: First or Second generation Second generation drugs bind with less affinity to receptors thus exhibit less side effects mainly involving Parkinsonism

Dopamine Hypothesis

Antipsychotics TYPICAL 1 st generation (conventional) ATYPICAL 2 nd generation Phenothiazines: chlorpromazine (Stemetil ), was the 1st antipsychotic introduced. It has additional indications, including treatment of nausea & vomiting and to relieve prolonged hiccups. Butyrophenones: haloperidol (Haldol ) is a butyrophenone. It can produce severe side effects including an Extra Pyramidal Syndrome, Tardive Diskinesia (potentially permanent) and Neuroleptic Malignant Syndrome. Thioxanthines: flupentixol has a relatively lower incidence of side effects compared to chlorpromazine & haloperidol. Sulpiride clozapine (Clozaril ) olanzapine (Zyprexa ) quetiapine (Seroquel ) risperidone (Risperdal ) aripiprazole (Abilify )

Long acting injections vs oral medication ADVANTAGES DISADVANTAGES Higher percentage of adherence Takes longer to reach steady state More stable plasma concentration levels Regular interaction with staff Slower titration of dose Side effects persist for longer after Rx is stopped Decreased incidence of side effects

Antipsychotic long acting injections Up to one third of patients are on antipsychotic depots Shortening the dosing interval does not improve efficacy Take long to reach maximum plasma levels; approximately 6-8 weeks Thus doses should not be increased before 1 month

Side effects of antipsychotics METABOLIC- weight gain, insulin resistance, diabetes mellitus ANTIHISTAMINERGIC- sedation ANTIDOPAMINERGIC- extrapyramidal movement disorders (acute dystonia, Parkinsonism, akathisia, tardive dyskinesia), hyperprolactinaemia, sexual dysfunction ANTICHOLINERGIC- dry mouth, urinary retention, constipation, confusion ANTIADRENERGIC- postural hypotension CARDIAC- prolonged QT interval arrhythmias NEUROLEPTIC MALIGNANT SYNDROME- hyperpyrexia, confusion, increased muscle tone, elevated creatine kinase blood test Metabolic side effects are more common in second generation antipsychotics

What is the use of anticholinergic drugs such as Procyclidine (Kemadrin)?

Anticholinergic drugs Mainly work on dystonia and Parkinsonism Acute dystonic reactions include; 1. Torcicollis 2. Oculogyric crisis: a prolonged involuntary upward deviation of the eyes 3. Hypertonia Reversible on stopping drug treatment Parkinsonian features: 1. tremor (involuntary rhythmic muscle contractions) commonly affecting the hands, arms, eyes, face & head. 2. hypokinesia (decreased body movement) 3. rigidity (increased muscle tone causing resistance to externally imposed joint movements) 4. postural instability (balance impairment, associated with an increased risk of falls & resulting hospitalization)

Anticholinergic drugs Have little effect on akathisia and tardive dyskinesia Akathisia from the Greek term meaning inability to sit means motor restlessness. Beta blockers and benzodiazepenes may help more in akathisia if decreasing the dose of the antipsychotic is unfeasible Tardive dyskinesia is a late-occuring syndrome and includes grimacing, tongue movements, lip puckering & smacking, pursing of the lips, frequent eye blinking, movements of the limbs, torso & fingers. Unfortunately this is often irreversible on stopping drug treatment

Our study Introduction: Depot antipsychotics do not induce dystonic side effects upon administration. In fact acute movement disorders may take hours to several days to develop after administration of depot. According to The Maudsley Prescribing Guidelines in Psychiatry the administration of intramuscular procyclidine with each dose is illogical, as the effects of the anticholinergic drug will have worn off before plasma levels peak. Aim: To check whether procyclidine IM is routinely given or not with depot antipsychotics Method: Data was collected from all the depot charts of all patients who routinely received the depot antipsychotic at the depot clinic at psychiatric outpatients in 2015.

Generic name Flupentixol Decanoate Trade name Fluanxol Typical Zuclopenthixol Decanoate Fluphenazine Decanoate Clopixol Modicate Haloperidol decanoate Haldol Atypical Risperidone microspheres Risperdal Consta Depot Antipyschotics used in our study

Results : Out of a total of 13 consultants ; 287 were found to receive antipsychotic depot injections. Out of these 114 receive intramuscular procyclidine injections. Therefore, 39.72% of patients receive procyclidine along with their antipsychotic treatment. Long acting antipsychotic injections Without procyclidine With procyclidine

Conclusions Awareness regarding the misuse of intramuscular procyclidine needs to be created. We aim to achieve by presenting these results in this conference and by circulating emails to all firms at Mount Carmel Hospital. Finally, we intend to re-audit this practice in order to complete the audit cycle.

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