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how is dopamine made
tyrosine → DOPA → DA
degrading enzymes in dopaminergic pre synaptic axon terminal
MAO and COMT
what is D2 involved in
psychosis, movement, prolactin regulation
4 main dopamine tracks in the brain
nigrostriatal
mesolimbic
mesocortical
tuberoinfundibular
what causes positive symptoms
excess DA in mesolimbic tract
what causes negative symptoms
DA deficit in mesocortical tract (dorso lateral pre frontal cortex and ventro medial pre frontal cortex)
what causes cognitive symptoms
DA deficient in mesocortical tract (dorsolateral pre frontal cortex)
what causes mood symptoms
DA deficit in mesocortical tract (ventromedial pre frontal cortex)
treatment goals of schizophrenia (what do you want to do w/ the tracts and what Sx will it help)
positive symptoms: decrease DA in mesolimbic tract
negative symptoms: increase DA in mesocortical tract (dorsolateral PFC + ventromedial PFC)
cognitive symptoms: increase DA in mesocortical tract (dorsolateral PFC)
mood symptoms: increase DA in mesocortical tract (ventromedial PFC)
**leave the other 2 pathways alone (nigrostriatal and tuberoinfundibular pathways)
1st gen antipsychotics moa (specify all the diff agonist/antagonist effects)
D2 antagonist
M1 antagonists
H1 antagonists
alpha1 antagonist
2nd gen antipsychotics moa (agonist/antagonist and what type)
5HT2>D2 antagonist
3rd gen antipsychotics moa (Agonist/antagonist and what type)
D2 partial agonist
higher potency D2 block is associated with ae
EPS/TD and increased prolactin
low potency D2 block is associated with
anticholinergic effects (M1), alpha1 antiandrenergic effects , antihistaminic effects (H1)
D2 antagonism effects on mesolimbic tract
alleviates positive symptoms
D2 antagonism effects mesocortical tract
may exacerbates negative symptoms
D2 antagonist effects nigrostriatal tract
EPS/TD
D2 antagonist effects in tuberoinfundibular tract
hyperprolactinemia
M1 antagonism causes….
dry eyes, urinary retention, confusion, delirium
alpha 1 antagonism causes
anti adrenergic ae (orthostatic hypotension + reflex tachycardia)
H1 antagonism causes
antihistimic side effects (weight gain, drowsiness)
what type of 5HT receptors are on dopamine neurons
presynaptic heteroreceptors (aka brakes)
what happens when endogenous 5-HT binds to presynaptic heteroreceptors
DA release is inhibited (negative feedback mechanism)
second gen antipsychotics are in love with which receptor
5HT2A
do 5HT2a antagonists stimulate or inhibit DA release
stimulate
Effects of SGA on mesocortical tract
blocks presynaptic 5HT2a receptor therefore endogenous 5HT cannot inhibit dopamine release. So now we have increased dopamine in the mesocortical tract to help with affective, cognitive, negative symptoms (usually not enough for a meaningful increase unless they are a super responder)
Effects of SGA on nigrostriatal and tuberinfundibular tracts
Block the 5HT2A receptor and therefore reduce the D2 blockade that endogenous 5HT would cause (net slight increase in DA). When D2 blockade is reversed it does not cause EPS/hyperprolactinemia
which ae do SGAs not cause that FGAs cause
EPS/TD + hyperprolactinemia
Effect of SGA on mesolimbic tract
There are no presynaptic 5HT2a receptors here therefore acts as an antagonist on D2 receptors. This helps positive symptoms (reduced delusions, hallucinations etc)
Common ae of SGAs and the receptors which causee
5HT2c + H1 antagonism= weight gain + dyslipidemia
M3 antagonism= IGT, T2DM
**remember less likely to cause hyperprolactinemia and EPS/TD than FGA
what causes hyperprolactinemia and EPS/TD
D2 antagonism in nigrostriatal tract tubulofundibulad tract
metabolic liability scale of SGA
olanzapine, clozapine > quetiapine > others
what types of affinities for which receptors are likely to have problems with weight gain and dyslipidemia
at least moderate affinity for one of these receptors plus mod-high affinity for one : H1 and 5HT2C
why do SGAs have less D2 side effects
they have lower affinity for D2 receptor, they prefer 5HT2A receptor
What is unique about risperidone
Can change it’s mind and flip affinity + turn into a first gen and cause EPS/hyperprolactinemia
TGA effects on 4 dopamine tracts
mesolimbic: partial agonist behaves kind of like antagonist since there is too much dopamine here
mesocortical: partial agonist behaves like agonist because there is too little dopamine here
nigrostriatal: less chance of EPS/TD
tuberofundibular: less chance of hypeprolactinemia