Basic Knowledge of Antipsychotics: The How and The Next Five

“Haldol and Prolixin.  A few of the patients and clients are on Thorazine. How is it different from Haldol and Prolixin?”

Cindy was more curious than ever with these questions for Dawn, who has been working with her, Lily and the rest of the team on the basic fund of knowledge on psychopharmacology.

In the previous article entitled: Basic Knowledge of Antipsychotics: The How and The First Two, I gave an overview of pharmacology, psychopharmacology, and two of the most commonly used typical antipsychotics – Haloperidol (Haldol) and Fluphenazine (Prolixin).  There are over a dozen additional typical antipsychotics, however, some of them have never been used in the US, and others have been removed from the market. Nonetheless, other than Haloperidol and Fluphenazine, a few more typical antipsychotics are still commonly used.  You will find the basics of five additional typical antipsychotics below.

Chlorpromazine

The third of the five antipsychotics found on the World Health Organization’s (WHO) List of Essential Medicines; the brand or trade name for Chlorpromazine is Thorazine. It has essentially the same indications (reasons for use) as for Haloperidol and Fluphenazine, and the side effects are also generally the same.  One thing that sets Chlorpromazine apart, it was the first antipsychotic ever developed, and has gained the fame as one of the greatest advances in Psychiatry.

In the previous article entitled: Basic Knowledge of Antipsychotics: The How and The First Two, I mentioned that Haloperidol was classified as a high potency, typical antipsychotic.  And the same is true for Fluphenazine.  Chlorpromazine, on the other hand, is a low potency, typical antipsychotic, meaning that it is more likely to induce sleep or generate a “calming or antipsychotic effect;” this is important and relevant to your knowledge.  Several patients or clients do ask their doctors for Thorazine to, “help me sleep,” or to “help me calm down.”  On this note, there is a culture of using (or misusing) antipsychotics for sleep.  You can educate your patients and clients on some available alternatives to help with their insomnia.

In addition to sedation (sleepiness), the other issue relevant to Chlorpromazine’s low potency, as a typical antipsychotic, the extrapyramidal side effects (motor and abnormal movement) that occur with Haloperidol and Fluphenazine are less likely to happen, especially when starting with a low dose and slowly increasing it.

Perphenazine

The brand or trade name for Thioridazine is Mellaril.  In 2005, it was removed from the world market because of cardiac related side effects (effects to the heart). However, because this medication can still be found in the US, it is worth a brief discussion here.  Once again, similar to the other typical antipsychotics, its primary use was in the treatment of schizophrenia, and extrapyramidal symptoms are the commonly associated side effects, though much less, in comparison to the other “typicals” mentioned.  The main issue with Thioridazine, it was found to be cardiotoxic (harmful to the heart), causing the normal rhythm of the heart to become irregular (cardiac arrhythmia).  As mentioned above, this led to its removal from the world market.

Molindone

Also known as Moban, this medication is another example of a typical antipsychotic, whose indications and side effects are not significantly different from the others in this class.  Of note, however, something particular to Molindone, it tends to cause weight loss instead of weight gain, when compared to the other typical antipsychotics.  The mechanism for weight changes induced by antipsychotics, including some typical antipsychotics, is not fully understood for all of them.  However, one intermediary factor is through an increase in appetite.  This is very important information, as you can use it to educate your patients and clients about management of their hunger.  If patients and clients do not necessarily eat each time they are hungry, or if when they do eat, they eat vegetables, fruits, fibers, and less refined sugar, this will have a significant influence on the net effect of these medications on their weight.  This rule of thumb does have its exceptions, but this, along with regular exercise, remains by far the most important step our patients and clients can take to minimize the likelihood of weight gain associated with medication use.

Pimozide

Also known as Orap, this typical antipsychotic has high potency effect.  It can be even more potent than Haloperidol, and it has been indicated for the treatment of Tourette’s syndrome.  Other indications and side effect profile are overall similar to those mentioned of the other typical antipsychotics.

“Haldol and Prolixin. A few of the patients and clients are on Thorazine. How is it different from Haldol and Prolixin,” Cindy asked Dawn, who discussed five additional typical antipsychotics with both Cindy, Lily and their co-workers.  Dawn, indeed, had a love for teaching and a desire to empower clinicians.

Here you go.  Five more typical antipsychotics added to your toolkit for basic knowledge of antipsychotics.  Please share your stories and experiences. Share this article with your colleagues and help empower them.  Continue to empower yourself, stay curious, continue to wonder and keep learning.  With this, you will increase your career gratification and prevent burnout, while you continue to make a difference in the lives of others.

Thank you for choosing this challenging but noble path.  And until later.

Your friend and colleague,

Mardoche

With this series of 5 articles, you now have a foundational knowledge of antipsychotics.

References:

1. López-Muñoz, F; Alamo, C; Cuenca, E; Shen, WW; Clervoy, P; Rubio, G (2005). “History of the discovery and clinical introduction of chlorpromazine”. Annals of Clinical Psychiatry. 17 (3): 113–35.

2. Chlorpromazine. Martindale: The Complete Drug Reference. London: Pharmaceutical Press. 30 January 2013. Retrieved 8 December 2013.

3. King DJ (February 1998). “Drug treatment of the negative symptoms of schizophrenia”. European Neuropsychopharmacology. 8 (1): 33–42.

4. Lieberman JA (October 2006). “Comparative effectiveness of antipsychotic drugs. A commentary on: Cost Utility Of The Latest Antipsychotic Drugs In Schizophrenia Study (CUtLASS 1) and Clinical Antipsychotic Trials Of Intervention Effectiveness (CATIE)”. Archives of General Psychiatry. 63 (10): 1069–72.

5. Shvartsburd, A; Sajadi, C; Morton, V; Mirabi, M; Gordon, J; Smith, RC (August 1984). “Blood levels of haloperidol and thioridazine during maintenance neuroleptic treatment of schizophrenic outpatients”. Journal of Clinical Psychopharmacology. 4 (4): 194–198.

6. Bagnall A, Fenton M, Kleijnen J, Lewis R (2007). Bagnall, Anne-Marie, ed. “Molindone for schizophrenia and severe mental illness”. Cochrane Database Syst Rev (1): CD002083.