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antipsychotics history, managment of psychosis,side effect of antipsychotics, mechanism of antipsychotics, atypical antipsychotics,2nd generation antipsychotics.
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M = Mask-like Face
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The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Introduction
Dopamine receptors
Dopaminergic pathways
Pathologies associated with dopamine system
Drugs modulating dopaminergic system
Dopamine and Reward Signaling ,Addiction, ADHD &
Schizophrenia
Dopamine and CVS
Dopamine and Emesis
Summary
2
3. Synthesized by George Barger and James Ewens in 1910
Henry Dale characterized the biological properties of DA
in the periphery, and described it as a weak, adrenaline-
like substance
Was considered as just a precursor to Epinephrine and
Norepinephrine
Function as neurotransmitter discovered
by Arvid Carlsson in 1958
3
4. Synthesis
• DOPA is converted so
rapidly into Dopamine that
DOPA levels are negligible
in the brain
• Rate of synthesis is
regulated by
– Catecholamine acting as
inhibitor of TH
– Availability of BH4
– Presynaptic DA receptors
– Amount of activity in
nigrostriatal pathway
4
Rate Limiting Step
5. Metabolism
• In rats – DOPAC major
metabolite
• In primates and human –
HVA major metabolite
• Accumulation of HVA in
brain or CSF used as index of
function of dopaminergic
neurons
5
7. Metabotropic G-protein coupled receptors
D1 – like family:
◦ Includes subtypes D1 and D5
◦ Activation is coupled to Gαs ; activates adenylyl cylcase
which leads to increase in concentration of cAMP
D2 – like family:
◦ Includes D2, D3 and D4
◦ Activation is coupled to Gαi ; inhibits adenylyl cyclase
leading to decrease in concentration of cAMP
7
15. Mesolimbic Pathway
◦ Associated with pleasure, reward and goal directed
behavior
Mesocortical Pathway
◦ Associated with motivational and emotional responses
Nigrostriatal Pathway
◦ Involved in coordination of movement (part of basal
ganglia motor loop)
Tuberoinfundibular Pathway
◦ Regulates secretion of prolactin by pituitary gland and
involved in maternal behavior
20
22. Drug Pharmacokinetic and
interaction
effect Adverse effects
Levodopa Oral
T ½ - 1-2 h
Dose: 250- 1200
mg
>95% is
decarboxylated in
the peripheral
tissues (mainly gut
and liver)
Use with COMT or
MAO-B inhibitors
prolongs duration
of effect
Ameliorates all
symptoms of PD
Hypokinesia and
rigidity resolve first,
later tremor as well
significant peripheral
dopaminergic effects
Postural hypotension
Nausea & vomiting
inhibit prolactin
release
Arrhythmias
Dyskinesias
Behavioral effects
Motor fluctuation
wearing-off
phenomena/end of
dose
On off phenomena
23. Drug Pharmacokinetic
and interaction
effect Adverse effects
Levodopa • Oral
• T ½ - 1-2 h
• Dose: 250- 1200 mg
• >95% is
decarboxylated in
the peripheral
tissues (mainly gut
and liver)
• Use with COMT or
MAO-B inhibitors
prolongs duration of
effect
• Ameliorates all symptoms of
PD
• Hypokinesia and rigidity
resolve first, later tremor as
well
• Nausea & vomiting
• inhibit prolactin release
• significant peripheral
dopaminergic effects
Postural hypotension
Nausea & vomiting
Arrhythmias
Dyskinesias
Behavioral effcts
on-off and wearing-off phenomena
Levodopa
+
Carbidopa
200 mg/ 100mg
+
50mg / 25 mg
2-3 times a day
• T ½ of levodopa is
prolonged & dosage
is reduced to ¼ th
• Systemic
complications of DA
are reduced
• 'On-off' effect is
minimized as cerebral
DA levels are more
sustained.
• Involuntary
movements
• Behavioral abnormalities
• Excess day time
sleepiness
• Postural hypotension
24. agonists features interaction
Bromocriptine Oral
T ½ -6-10 hrs
Dose: 1.25-5 mg
O.D
If used alone,
doses needed are
high
used only in late cases
Reduces symptoms
Smooths out fluctuations
in levodopa response
Nausea and vomiting
postural hypotension,
dyskinesias
Pramipexole Oral
T ½- 8 h
Starting dose-0.125
mg TDS
1-1.5 mg TDS
Reduces symptoms,
Smooths out fluctuations
in levodopa response
dose titration for
maximum improvement
can be achieved in 1-2
weeks
Fewer GI effects
Nausea and vomiting
Postural hypotension
Day time sleepiness
Hallucinations
Ropinirole Starting dose-0.25mg
TDS
4-8 mg TDS
Slower rates of neuronal
degeneration ??
FDA approved for Restless
Leg Syndrome
Sudden attack of
irresistible sleepiness
25. Drug Pharmac
okinetics
Features and effect Adverse effects
Apomorphine S.C
2 mg test
dose
↓
6 mg
Inj 3
times
daily
High affinity - D4
Mod affinity - D2,3,5
low affinity - D1
FDA approved as a "rescue therapy"
Lessens motor fluctuations
Reduced frequency of on-off effect
Restless leg syndrome
Nausea and vomiting
postural hypotension
QT prolongation
Injection-site reactions,
Hallucinations
Dyskinesia
Abnormal behavior
26.
27. MAO- B
inhibitors
Pk Features Adverse effects
Selegiline
Oral
5- 10
mg/ day
BD
dosing
Oral
disintegr
ating tab
Transder
mal
patch
selective and irreversible MAO-B inhibitor
Increases dopamine stores in neurons
Adjuvant to levodopa
20-30% reduction in levodopa dose
May accentuate the adverse motor and
cognitive effects of levodopa
Metabolites of include amphetamine and
methamphetamine, which may cause
anxiety, insomnia, and other adverse
symptoms
Do not exhibit cheese reaction
Postural hypotension
Dyskinesias,
Mental confusion
Hallucination
C/I in patients with
siezures
Interactions: rarely
serotonin syndrome
with meperidine, also
with SSRIs, TCA
28. MAO- B
inhibitors
Pk Features Adverse effects
Selegiline
Oral
5- 10
mg/ day
Oral
disintegr
ating tab
Transder
mal
patch
selective and irreversible MAO-B inhibitor
Increases dopamine stores in neurons
Adjuvant to levodopa
20-30% reduction in levodopa dose
May accentuate the adverse motor and cognitive
effects of levodopa
Metabolites of include amphetamine and
methamphetamine, which may cause anxiety,
insomnia, and agitation
Do not exhibit cheese reaction
Postural hypotension
Dyskinesias,
Mental confusion or
hallucination
C/I in patients with
siezures
Interactions: serotonin
syndrome with
meperidine, also with
SSRIs, TCA
Rasagiline 5x
potent
0.5-1.0
mg tab
OD
dosing
No undesirable amphetamine metabolites
Effective in early PD??
Adjunctive therapy significantly reduced
levodopa-related "wearing off" symptoms
Neuroprotective (Parkinson Study Group, 1993;
Yacoubian and Standaert, 2008, Olanow, 2008, ).
Stupor, rigidity,
agitation, and
hyperthermia when
administered with
Meperidine
29. COMT
inhibitors
Pk Features Adverse effects
Entacapone Oral
600-
2000
mg
BD or
TDS
Adjuvants to levodopa-carbidopa
Advanced cases
Reduces metabolism of levodopa
and prolongs its action
Increased levodopa
conc
Nausea
Dyskinesias
confusion
Postural
hypotension
Tolcapone Oral
100-
300 mg
BD or
TDS
Longer acting
Enters CNS
Hepatotoxic??
30. Drugs Pk Features Adverse effects
Glutamate
(NMDA
receptor)
antagonist
Amantadine
Oral
T ½ 8
to 12
hrs
100 mg
BD
Promotes presynaptic synthesis &
release of DA in brain
Suppresses motor fluctuations &
abnormal movements
Smoothen wearing off
Anticholinergic property
Insomnia
Restlessness
Confusion
Nightmares
Hallucination
Livedo reticularis
Ankle edema
31.
32.
33.
34. Occasional substance use is an impulse choice driven by
positive reinforcement of the drug’s expected effect
This teaches the brain to anticipate reward on subsequent
exposure to the drug
When the substance is taken, pleasure will be
experienced again, usually followed by regret
35. With repeated exposure to the drug neurobiological
changes occur in the brain
leads to craving,
reduced reward on drug exposure
withdrawal during abstinence
(negative reinforcement)
This leads to craving which is
released by drug ingestion
36. Nucleus Accumbens
Occurs due to increased release of dopamine
caused by the psychotropic substances like
morphine
heroin
Cannabis
cocaine
nicotine
37.
38.
39. Decrease In Dopamine Level in Anterior frontal cortex
◦ An area associated with cognitive function such as
Attention
Concentration
40. Defects in “dopamine transporters” in brain
Dopamine transporter density (DTD)
The transporters take up too much dopamine
before it can be passed from one brain cell to
another
Decreased dopamine activity
41. Methylphenidate and Amphetamine
Increase both dopamine and norepinephrine levels in
brain
Methylphenidate-5 mg at morning & lunch gradually
increased to 60 mg
10-30 mg/ day amphetamine
Adverse effects
Restlessness, dizziness, tremor, hyperactive reflexes,
talkativeness, irritability, insomnia & euphoria.
Confusion, aggressiveness & delirium
43. Bromocriptine
Start at a low dose (1.25 mg) at bedtime After 1 week, a
morning dose of 1.25 mg can be added.
If clinical symptoms persist or prolactin levels remain
elevated, the dose can be increased gradually, every 3-7
days
5 mg BD or TDS as tolerated
Cabergoline
Ergot derivative with a longer t1/2 (65 hours)
Higher affinity & greater selectivity for the D2 receptor (
4x potent) than bromocriptine
Induces remission
0.25 mg twice/week or 0.5 mg once/week can be ↑ to
2mg twice or thrice /week
44. Defective dopamine neurotransmission – relative excess
of central dopaminergic activity
An increase in DA function in the mesolimbic system
(postive symptom)
Decreased function in the mesocortical DA system
(negative symptoms)
Behavior similar to the behavioral effects of
psychostimulants
54
45. Came to existence from the fortuitous discovery of
chlorpromazine's therapeutic efficacy in schizophrenia
Carlsson –
Postsynaptic D2 receptor antagonism was the common
mechanism that explained antipsychotic properties
Reserpine, exhibited antipsychotic properties by
decreasing dopaminergic neurotransmission
High risk for drug-induced psychosis with drugs that
directly increase synaptic dopamine availability, including
cocaine, amphetamines & L-dopa
46. Synaptic DA availability Val{108/158}
Met polymorphism of COMT
DA neurotransmission (dysbindin)
47. Antipsychotic
Typical
Mechanism of action Toxicity
Phenothiazines:
• Chlorpromazine
• Fluphenazine
• Thioridazine
• Thioxanthenes
• Thiothixene
• flupenthixol
Blockade of
D2>>5HT2A
Also blocker of alpha
1, M, H1
Akathisia,
Dystonia,
Parkinson symptom
Tardive dyskinesia,
Hyperprolactinemia
Butyrophenones
• Haloperidol
• Droperidol
• Domperidone
Blockade of
D2>>5HT2A
Alpha 1and minimal
M 1blockade
Extrapyrimidal dysfunction
50. D1 and D2
β 1 & α1 agonist
Effect on CVS is dose dependent
Low dose
1-2 mcg/kg/min
Moderate dose
3-10mcg/kg/min
High dose
>10 mcg/kg/min
D 1
renal and mesenteric
blood vessels dilates
β 1
↑ H.R
↑ contractility
↑ AV conduction
α₁ action predominates
vasoconstriction
↑ G.f.r.
↑ Renal blood flow
Natriuresis
↑ C.O & SBP
TPR unaltered
TPR ↑
51. C.O & SBP with little effect on DBP
No effect on nonvascular α₁ receptors
Does not penetrate blood-brain barrier-no CNS effects
Management of low cardiac output states associated with
compromised renal function
IV infusion (0.2-1 mg/min) which is regulated by
monitoring BP and rate of urine formation
52. Dopamine -only IV, preferably into a large vein
calibrated infusion pump
Dosage
Initially at a rate of 2-5 mcg/kg per min; this rate may be
increased gradually up to 20-50 mcg/kg per min or more
Monitoring of arterial and venous pressures and the ECG
Adverse effects & precautions
Nausea, tachycardia, anginal pain, arrhythmias, HTN headache
Extravasation of DA during infusion may cause ischemic
necrosis and sloughing
53. Agonist for peripheral D1 receptors and antagonist to α2
receptors
No significant affinity for D2, α 1 or β receptors
Rapidly acting(4 mins) and short duration of action
(< 10 minutes) vasodilator used for control of
severe hypertension
Dilates Coronary arteries, renal afferent and efferent
arterioles and mesenteric arteries
Dosage
Calibrated infusion pump @ 01-1.6 g/kg per min
Adverse effects are related to the vasodilation and
include headache, flushing, dizziness, and tachycardia or
bradycardia
54. Synthetic analog related to DA
D1 and D2 receptors as well as at β2 receptors
Patients with severe congestive heart failure,
sepsis, and shock
Patients with low cardiac output, significantly
increases stroke volume with a decrease in SVR
Tachycardia and hypotension can occur, usually
only at high infusion rates
55.
56.
57. Blocks D2-receptors, agonist at 5HT4 and in high
doses blocks 5-HT3
Antiemetic action
Accelerate gastric emptying (prokinetic)
Raises LES pressure
Increases intestinal peristalsis
58. PK
Orally it acts in ½ to 1 hr
10 min after I.M. and 2 min after I.V. inj
Action lasts for 4-6 hours
Interactions
Hastens the absorption of many drugs, e.g. aspirin,
diazepam(facilitating gastric emptying)
It reduces absorption of digoxin
Blocks D2 in basal ganglia, abolishes the therapeutic
effect of levodopa
Adverse effects
Sedation, dizziness, loose stools, muscle dystonias
Long-term use can cause parkinsonism, galactor
rhoea and gynaecomastia.
59. Prokinetic action is not blocked by atropine and is
based only on D2 blockade in upper g.i.t.
Crosses BBB poorly
levodopa or bromocriptine, it counteracts their dose
limiting emetic action without affecting the therapeutic
effect in parkinsonism
Oral 10-40 mg TDS, BA ~15% due to FPM
EPS are rare, but hyperprolactinaemia can occur
Cardiac arrhythmias on rapid i.v. injection.
61. Phenothiazines & Butyrophenones
Phenothiazines
Prochlorperazine
Promethazine
Phenothiazines are antipsychotics with potent
antiemetic property due to D2 antagonism.
Butyrophenone
Droperidol
Droperidol used for postop. nausea & vomiting, but
cause QT prolongation.
Editor's Notes
1950s were stores of DA were found in tissues, suggesting DA had a signaling function of its own. By decade's end, Carlsson and Montagu had each identified DA stores in the brain
Hornykiewicz discovered the DA deficit in the parkinsonian brain, fueling interest in the role of DA in neurological diseases and disorders
Arvid Carlsson (born 25 January 1923) is a Swedish neuropharmacologist who is best known for his work with the neurotransmitter dopamine and its effects in Parkinson's disease. For his work on dopamine, Carlsson was awarded the Nobel Prize in Physiology or Medicine in 2000,
DA is closely related to melanin, a pigment that is formed by oxidation of DA, tyrosine, or L-DOPA.
Melanin exists in the skin and cuticle and gives the substantia nigra its namesake dark color
Two enzymes that play major roles in the degradation of dopamine are mao and (COMT).
MAO is located on the outer membrane of mitochondria.
Two MAO isozymes
MAO-A : Which preferentially deaminates serotonin and norepinephrine.
MAO-B : Which deaminates dopamine, histamine, and a broad spectrum of phenylethylamines.
COMT is located in the cytoplasm and is widely distributed throughout the brain and peripheral tissues.
It has a wide substrate specificity, catalyzing the transfer of methyl groups from S-adenosyl methionine to the m-hydroxyl group of most catechol compounds.
The predominant metabolites of dopamine is Homovanillic acid (HVA)
DA is sequestered by VMAT2 in storage granules and released by exocytosis.
Synaptic DA activates presynaptic autoreceptors and postsynaptic D1 and D2 receptors.
Synaptic DA may be taken up into the neuron via the DA and NE transporters (DAT, NET), or removed by postsynaptic uptake via OCT3
Cytosolic DA is subject to degradation by monoamine oxidase (MAO) and aldehyde dehydrogenase (ALDH) in the neuron, and by catechol-O-methyl tranferase (COMT) and MAO/ALDH in non-neuronal cells
D1 receptor is also located in the kidney, retina, and cardiovascular systemthe neostriatum expresses the highest levels of D1 D1 receptor has been shown to interact with a variety of other proteins, including A1 adenosine receptors, NMDA receptors, Na+,K+-ATPase, calnexin, and caveolin (
Auto receptors Stimulation of somatodendritic autoreceptors slows the firing rate while stimulation of those in nerve terminals inhibits dopamine release and synthesis
most common form of parkinsonism is idiopathic PD, first described by James Parkinson in 1817 as paralysis agitans, or the "shaking palsy."
The pathological hallmark of PD is the loss of the pigmented, dopaminergic neurons of the substantia nigra pars compacta, with the appearance of intracellular inclusions known as Lewy bodies
70-80% of dopaminergic neurons required to cause symptomatic PD
Without treatment, PD progresses over 5-10 years to a rigid, akinetic state
Death frequently results from complications of immobility, including aspiration pneumonia or pulmonary embolism.
impairment of postural balance leading to disturbances of gait and falling
which usually abates during voluntary movement)
DA released in the striatum tends to increase the activity of the direct pathway and reduce the activity of the indirect pathway, wherea
net effect of the reduced dopaminergic input in PD is to increase markedly the inhibitory outflow from the SNpr and GPi to the thalamus and reduce excitation of the motor cortex.
Secondary symptoms of posture,gait, handwriting, speech, facial expression, mood, self care and interest in life are gradually normalized
he effectof levodopa on behaviour has been described as a 'general alerting response'. In some patients this progresses to excitement frank psychosis may occur.
1 Gastric emptying: if slow, levodopa is exposed to degrading enzymes present in gut wall and liver for a longertime-less is availabl o penetrate blood-brain barrier.ii) Amino acids present in food compete for the same carrier for absorption: blood levels are lower when taken with meals. Levodopa undergoes high first pass metalism in g.i. mucosa and liver
Interactions----Pyridoxine: Abolishes therapeutic effec: .enhancing peripheral decarboxylation
Phenothiazines, butyrophenones, met, pramie reverse therapeutic effect of levodopa by blocking DA receptors.
Nonselective MAO inhibitors: prevent degradation of peripherally synthesized DA .' NA-hypertensive crisis can occur.
Antihypertensives: postural hypotensic·: Atropine, and other anticholinergic dr- _ have additive antiparkinsonian action with .
doses of levodopa, but retard its absorptic·:- more time is available for peripheral degrad< : -efficacy of levodopa may be reduced.
Secondary symptoms of posture,gait, handwriting, speech, facial expression,mood, self care and interest in life are gradually normalized
he effectof levodopa on behaviour has been described as a 'general alerting response'. In some patients this progresses to excitement frank psychosis may occur.
1 Gastric emptying: if slow, levodopa is exposed to degrading enzymes present in gut wall and liver for a longertime-less is availabl o penetrate blood-brain barrier.ii) Amino acids present in food compete for the same carrier for absorption: blood levels are lower when taken with meals. Levodopa undergoes high first pass metalism in g.i. mucosa and liver
Interactions----Pyridoxine: Abolishes therapeutic effec: .enhancing peripheral decarboxylation
Phenothiazines, butyrophenones, met, pramie reverse therapeutic effect of levodopa by blocking DA receptors.
Nonselective MAO inhibitors: prevent degradation of peripherally synthesized DA .' NA-hypertensive crisis can occur.
Antihypertensives: postural hypotensic·: Atropine, and other anticholinergic dr- _ have additive antiparkinsonian action with .
doses of levodopa, but retard its absorptic·:- more time is available for peripheral degrad< : -efficacy of levodopa may be reduced.
Enz conversion of these drugs arent required they dony=t depend on the functional capacity of the dopaminergic neurons
Bromo-----'first dose has occurred in some patients, especially those on antihyperten sive medication( potent agonist on D2)
startin with low doses with low doses (1 .25 mg once at night) and gradually increasing as needed upto 5-10 mg thrice daily.
smoothen 'end of dose' and 'on-off' fluctuations.
Prami- dose titration for maximum improvement can be achieved in 1-2 weeks, while the same may take several months with bromocriptine.(D3Agonist)
Adrenergic a 1D, 2B, and 2C
approved as a "rescue therapy" for the acute intermittent treatment of "off" episodes in patients with a fluctuating response to dopaminergic therapypre- and post-treatment anti-emetic therapy. Oral trimethobenzamide (d2 anta at CTZ), dose of 300 mg three times daily, should be started 3 days prior to the initial dose of apomorphine and continued at least during the first 2 months of therapy
Profound hypotension and loss of consciousness when apomorphine was administered with ondansetron; hence, the concomitant with 5-HT3 antagonist class is contraindicated
potential adverse effects, use of apomorphine is appropriate only when other measures, such as oral DA agonists or COMT inhibitors, have failed to control the "off" episodes
MAO-A and MAO-B) are present in the periphery and inactivate monoamines of intestinal origin, the isoenzyme MAO-B is predominant in striatum and platelets is responsible for most of the oxidative metabolism of DA in the brain inhibition of MAO-B in the brain is a reduction in the overall catabolism of DA, which may reduce the formation of potentially toxic free radicals
CA accumulation and hype4tensive reaction does not develop, while :cerebral degradation of DA is retarded. T:-: responsible for the therapeutic eff
delivery routes are intended to reduce hepatic first-pass metabolism and limit the formation of the amphetamine metabolites.
cheese effect," the potentially lethal potentiation of catecholamine action observed when patients on nonspecific MAO inhibitors(phenelzine, tranylcypromine, and isocarboxazid) ingest indirectly acting sympathomimetic amines such as the tyramine found in certain cheeses and wine
Adjunctive therapy significantly reduced levodopa-related "wearing off" symptoms in advanced PD
MAO-A and MAO-B) are present in the periphery and inactivate monoamines of intestinal origin, the isoenzyme
MAO-B is predominant in striatum and is responsible for most of the oxidative metabolism of DA in the brain
inhibition of MAO-B in the brain is a reduction in the overall catabolism of DA, which may reduce the formation of potentially toxic free radicals
COMT transfers a methyl group from the donor S-adenosyl-L-methionine, producing the pharmacologically inactive compounds 3-O-methyl DOPA (from levodopa) and 3-methoxytyramine
Advanced and fluctuating PD
Smoothen wearing off
Increases on time, decreases off time
Improves activity of daily living and helps to reduce the dose of levodo
Hepatotoxic ----Use only in patients not responding satisfactorily to other treatments. Requires monitoring of liver function cases of fulminant hepatic failure in patients taking tolcapone
pa
an antiviral agent used for the prophylaxis and treatment of influenza A release of infectious viral nucleic acid into the host cell by interfering with the function of the transmembrane domain of the viral M2 protein. In certain cases, Amantadine is also known to prevent virus assembly during replica
Advanced and fluctuating PD
It indirectly acts to stimulate DA availability by decreasing the glutamate mediated tonic inhibition of DA release in mesolimbic pathway
Increases on time, decreases off time
Improves activity of daily living and helps to reduce the dose of levodopa
Nucleus Accumbens is a centre for reward
cocaine binds to the dopamine, and does not allow it to be recycled. Effect ends after 30 mins, and the person is left craving to feel as he once did
Progressively a tolerance builds up dopamine is also released when something pleasurable yet unexpected occurs, after the first time, the person expects the effect, thus less dopamine is released, and the experience is less satisfying.
Drug seeking behavior of rats , negATIVE consequenses don’t affect an addicted brain as it does to a normal brain
some genetic links between dopamine receptors, the dopamine transporter and ADHD
higher concentrations of proteins called dopamine transporters.
These transporters temporarily prevent dopamine from going on to the next cell.
This lessens the effects of dopamine, in spite of high levels of dopamine in brain cells
Psychostimulants->
70% of those who use these stimulants see improvements in ADHD symptoms
Pemoline is structurally dissimilar to methylphenidate but elicits similar changes in CNS function with minimal effects on the cardiovascular system.
can be given once daily because of its long t1/2. Clinical improvement may require treatment for 3-4 weeks. Use of pemoline has been associated with severe hepatic failure
In the ant pituitary, spontaneous prolactin release from lactotrophs is tonically inhibited by activation of D2 receptors
Features : Amenorrhoea, Galactorrhoea, Anovulation, loss of libido
Infertility, decreased libido, sexual dysfunction (in both men and women), erectile dysfunction, infertility, and gynecomastia in MEN
dopamine antagonists are another cause of hyperprolactinemia.
Hyperprolactinemia inhibits the secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus (by increasing the release of dopamine from the arcuate nucleus), which in turn inhibits the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland and results in diminished gonadal sex hormoneproduction (termed hypogonadism)
Dopamine receptor blockers
Atypical antipsychotics: risperidone
Phenothiazines: chlorpromazine, perphenazine
Butyrophenones: haloperidol
Thioxanthenes
Metoclopramide
Dopamine synthesis inhibitors
α-Methyldopa
Catecholamine depletors
Reserpine
Opiates
H2 antagonists
Cimetidine, ranitidine
Imipramines
Amitriptyline, amoxapine
Serotonin reuptake inhibitors
Fluoxetine
Calcium channel blockers
Verapamil
Estrogens
TRH
Incre mesolimb pos symptomshallucination, delusion, agitated , dis organised speech
Decre mesocortical prefrontal cort neg symptoms & cognitive symptom apathy alogia(poverty of speech) avolition(severe lack of initiative or motivation)
Reserpine, derived from Rauwolfia, exhibited antipsychotic properties by decreasing dopaminergic neurotransmission(irreversibly blocks the vesicular monoamine transporter (VMAT), free momoamines are acted upon by MAO).; however, unlike D2 receptor antagonists, reserpine exerted its effects through depletion of monoamines from presynaptic nerve terminals
dopamine theory of psychosis was reinforced by the high risk for drug-induced psychosis among substances that directly increased synaptic dopamine availability, including cocaine, amphetamines, and the Parkinson's disease treatment L-dopa (Carlsson, 1978).
Met polymorphism of catechol-O-methyltransferase, which increases DA catabolism)
DA neurotransmission (dystrobrevin binding protein 1 or dysbindin,
The sedative effect is produced promptly, while antipsychotic effect takes weeks to develop. Moreover, tolerance develops to the sedative but not to the a Phenothiazines
and thioxanthenes also block Dl, D3 and D4receptors,antipsychotic effect.
Acute muscle dystonia earliest app symptom
Akathisia- most common symptom
Sedation—max—cpz & min ziprasidone and aripiprazole
Wt gain in typical –all expect haloperidol
Wt gain, hyperlipidaemia, new onset dm —all except zipra lesser risk with ari, illoperidone and asenapine
Siezures-clo, olan, cpz lesswith risperidone and quetiapine
Post hypotns & inhibn of ejaculatn- thioridazine
Anticholinergic se– max with thioridazine, cpz, clozapine
qT prolongation—asenapine, ziprasidone & paliperidone
Retinal degen– thioridazine
Cataract- quetiapine
Cholestatic jaundice—cpz
periphery, it is synthesized in epithelial cells of the proximal tubule and is thought to exert local diuretic and natriuretic effects
Activation of D1 receptors---renal tubular cells---- decreases Na+ transport by cAMP-dependent and cAMP-independent mechanisms.
Increasing cAMP production in the proximal tubular cells and the medullary part of the thick ascending limb of the loop of Henle inhibits the Na+-H+ exchanger and the Na+,K+-ATPase pump.
The renal tubular actions of DA that cause natriuresis may be augmented by the increase in renal blood flow and the small increase in the gfr
increase in hydrostatic pressure in the peritubular capillaries and reduction in oncotic pressure may contribute to diminished reabsorption of Na+ by the proximal tubular cells.
D1 in renal and mesenteric blood vessels are the most sensitive:
i.v. infusion of low dose of DA dilates these vessels(raising inracellular cAMP). This increases g.f.r. and Na+ excretion(d1 on proximal tubular cell)
excretion by inhibiting the activity of various Na+ transporters, including the apical Na+-H+ exchanger and the basolateral Na+,K+-ATPase
Tpr usually is unchanged when low or intermediate doses of DA are given, probably because of the ability of DA to reduce regional arterial resistance in some vascular beds, such as mesenteric and renal,
Positive inotropic (direct l3 and Dl action + that due to NA release),
Cardiogenic or septic shock and severe CHF wherein it increases BP and urine outflow
sloughingRarely, gangrene of the fingers or toes has followed prolonged infusion of the drug.
DA should be avoided or used at a much reduced dosage (one-tenth or less) if the patient has received a MAO inhibitor.
Careful adjustment of dosage also is necessary in patients who are taking tricyclic antidepressants
in shock, hypovolemia should be corrected by transfusion of whole blood, plasma, or other appropriate fluid.
Untoward effects due to overdosage generally are attributable to excessive sympathomimetic activity patients require clinical assessment of myocardial function, perfusion of vital organs such as the brain, and the production of urine.
peripheral vasoconstriction may be encountered during dopamine infusion
Reduction in urine flow, tachycardia, or the development of arrhythmias may be indications to slow or terminate the infusion
potent DA t receptor agonist that produces renal vasodilation and a reduction in systemic arterial blood pressure without compromising renal function
fenoldopam reduces cardiac afterload in the presence of maintained or increased RBF and increased sodium and water excretion, IT may also be useful in the treatment of CCF
malignant hypertension180/120 with end-organ damage) in hospitalized patients for not more than 48 hours.
Accelerated hypertension is defined as a recent significant increase over baseline blood pressure that is associated with target organ damage
It also inhibits of neuronal re-uptake of norepinephrine
0.5 - 6 microgram/kg/min
Central(ctz) and peripheral Da (D2 receptors) is an inhibitory transmitter in the g.i.t.- normally acts to delay gastric emptying
also appears to cause gastric dilatation and LES relaxation nausea and vomiting
Metoclopramide blocks D2 receptors and hastens gastric emptying and enhancing LES tone by augmenting ACh release. However,
clinically this action is secondary to that exerted through 5HT4 receptors.
Rapidly absorbed orally, enters brain, crosses placenta and is secreted in milk
CINV___A higher dose (1-2 mg i.v.) is often needed, but is effective when phenothiazines and antihistamines do not workPromethazine, diphenhydramine, diazepam lorazepam injected i.v. along with meclopramide supplement its antiemetic action and to reduce the attending dystonic reaction
Dexamethasone i.v. also augments the effect of metoclopramide.
drug is considered necessary, choice of drug may be dictated by other considerations such as a person's preference, adverse-effect profile and cost.
As CTZ is outside BBB both have antiemetic effects.
But as metoclopramide crosses BBB it has adverse effects like extrapyramidal side effects..
Domperidone is well tolerated.