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Chlorpromazine ( CPZ ), marketed under the trade names Thorazine and Largactil among others, is an antipsychotic medication.
Common side effects include movement problems, sleepiness, dry mouth, low blood pressure upon standing, and increased weight.
Chlorpromazine was discovered in 1950 and was the first antipsychotic.
Contents
1 Medical uses
1.1 Other
2 Adverse effects
2.1 Contraindications
2.2 Interactions
2.3 Tolerance and withdrawal
3 Pharmacology
3.1 Pharmacokinetics
3.2 Pharmacodynamics
3.3 Peripheral effects
4 History
5 Brand names
6 Veterinary use
7 Research
7.1 Amebocidal ability
8 References
9 External links
Medical uses
Chlorpromazine is classified as a low-potency typical antipsychotic and in the past was used in the treatment of both acute and chronic psychoses, including schizophrenia and the manic phase of bipolar disorder, as well as amphetamine-induced psychosis. Low-potency antipsychotics have more anticholinergic side effects, such as dry mouth, sedation, and constipation, and lower rates of extrapyramidal side effects, while high-potency antipsychotics (such as haloperidol ) have the reverse profile.
In a 2013 comparison of 15 antipsychotics in schizophrenia, chlorpromazine demonstrated mild-standard effectiveness. It was 13% more effective than lurasidone and iloperidone, approximately as effective as ziprasidone and asenapine, and 12-16% less effective than haloperidol, quetiapine, and aripiprazole.
Chlorpromazine has also been used in porphyria and as part of tetanus treatment. It still is recommended for short-term management of severe anxiety and psychotic aggression. Resistant and severe hiccups, severe nausea / emesis, and preanesthetic conditioning are other uses.
Other
Chlorpromazine is occasionally used off-label for treatment of severe migraine.
In Germany, chlorpromazine still carries label indications for insomnia, severe pruritus, and preanesthesia.
Comparison of chlorpromazine to placebo
Measured outcome
Findings in words
Findings in numbers
Quality of evidence
Global effects
Not any improvement (9 weeks – 6 months)
30% less risk of having no improvement in mental state, behaviour and functioning
RR 0.7 CI 0.6 to 0.9
Very low (estimate of effect uncertain)
Relapse (6 months – 2 years)
35% less risk of relapse
RR 0.7 CI 0.5 to 0.9
Adverse effects
See also: List of adverse effects for chlorpromazine
There appears to be a dose-dependent risk for seizures with chlorpromazine treatment.
Chlorpromazine may deposit in ocular tissues when taken in high dosages for long periods of time.
Comparison of chlorpromazine to placebo
Measured outcome
Findings in words
Findings in numbers
Quality of evidence
Adverse effects
Weight gain
5 times more likely to have considerable weight gain, around 40% with chlorpromazine gaining weight
RR 4.9 CI 2.3 to 10.4
Very low (estimate of effect uncertain)
Sedation
3 times more likely to cause sedation, around 30% with chlorpromazine
RR 2.8 CI 2.3 to 3.5
Acute movement disorder
3.5 times more likely to cause easily reversible but unpleasant severe stiffening of muscles, around 6% with chlorpromazine
RR 3.5 CI 1.5 to 8.0
Parkinsonism
2 times more likely to cause parkinsonism (symptoms such as tremor, hesitancy of movement, decreased facial expression), around 17% with chlorpromazine
RR 2.1 CI 1.6 to 2.8
Decreased blood pressure with dizziness
3 times more likely to cause decreased blood pressure and dizziness, around 15% with chlorpromazine
RR 2.4 CI 1.7 to 3.3
Contraindications
Absolute contraindications include:
Circulatory
CNS depression
Coma
Drug intoxication
Bone marrow suppression
Phaeochromocytoma
Hepatic failure
Active liver disease
Previous hypersensitivity (including jaundice, agranulocytosis, etc.) to phenothiazines, especially chlorpromazine, or any of the excipients in the formulation being used.
Relative contraindications include:
Epilepsy
Parkinson’s disease
Myasthenia gravis
Hypoparathyroidism
Prostatic hypertrophy
Very rarely, elongation of the QT interval may occur, increasing the risk of potentially fatal arrhythmias.
Interactions
Consuming food prior to taking chlorpromazine orally limits its absorption, likewise cotreatment with benztropine can also reduce chlorpromazine absorption.
It is also a moderate inhibitor of CYP2D6 and also a substrate for CYP2D6 and hence can inhibit its own metabolism.
Chlorpromazine may also interact with epinephrine (adrenaline) to produce a paradoxical fall in blood pressure.
Other drugs that prolong the QT interval such as quinidine, verapamil, amiodarone, sotalol and methadone may also interact with chlorpromazine to produce additive QT interval prolongation.
Tolerance and withdrawal
The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotic treatment to avoid acute withdrawal syndrome or rapid relapse.
A failure to notice withdrawal symptoms may be due to the relatively long half life of the drug resulting in the extremely slow excretion from the body. However, there are reports of muscular discomfort, exaggeration of psychotic symptoms and movement disorders, and difficulty sleeping when the antipsychotic drug is suddenly withdrawn, but after years of normal doses these effects are not normally seen.
Pharmacology
Pharmacokinetics
Pharmacokinetic parameters of chlorpromazine
Bioavailability
t max
C SS
Protein bound
V d
t 1/2
Details of metabolism
Excretion
Notes
10–80%
1–4 hours (Oral); 6–24 hours (IM)
100–300 ng/mL
90–99%
10–35 L/kg (mean: 22 L/kg)
30±7 hours
CYP2D6, CYP1A2 —mediated into over 10 major metabolites.
Urine (43–65% after 24 hours)
Its high degree of lipophilicity (fat solubility) allows it to be detected in the urine for up to 18 months.
Three common metabolites of chlorpromazine
Pharmacodynamics
Chlorpromazine is a very effective antagonist of D2 dopamine receptors and similar receptors, such as D3 and D5. Unlike most other drugs of this genre, it also has a high affinity for D1 receptors. Blocking these receptors causes diminished neurotransmitter binding in the forebrain, resulting in many different effects. Dopamine, unable to bind with a receptor, causes a feedback loop that causes dopaminergic neurons to release more dopamine. Therefore, upon first taking the drug, patients will experience an increase in dopaminergic neural activity. Eventually, dopamine production of the neurons will drop substantially and dopamine will be removed from the synaptic cleft. At this point, neural activity decreases greatly; the continual blockade of receptors only compounds this effect.
Chlorpromazine acts as an antagonist (blocking agent) on different postsynaptic and presynaptic receptors:
Dopamine receptors (subtypes D 1, D 2, D 3 and D 4 ), which account for its different antipsychotic properties on productive and unproductive symptoms, in the mesolimbic dopamine system accounts for the antipsychotic effect whereas the blockade in the nigrostriatal system produces the extrapyramidal effects
Serotonin receptors (5-HT 1 and 5-HT 2 ), with anxiolytic, and antiaggressive properties as well as an attenuation of extrapyramidal side effects, but also leading to weight gain and ejaculation difficulties.
Histamine receptors ( H 1 receptors, accounting for sedation, antiemetic effect, vertigo, and weight gain)
α 1 – and α 2 -adrenergic receptors (accounting for sympatholytic properties, lowering of blood pressure, reflex tachycardia, vertigo, sedation, hypersalivation and incontinence as well as sexual dysfunction, but may also attenuate pseudoparkinsonism—controversial. Also associated with weight gain as a result of blockage of the adrenergic alpha 1 receptor)
M 1 and M 2 muscarinic acetylcholine receptors (causing anticholinergic symptoms such as dry mouth, blurred vision, constipation, difficulty or inability to urinate, sinus tachycardia, electrocardiographic changes and loss of memory, but the anticholinergic action may attenuate extrapyramidal side effects).
The presumed effectiveness of the antipsychotic drugs relied on their ability to block dopamine receptors. This assumption arose from the dopamine hypothesis that maintains that both schizophrenia and bipolar disorder are a result of excessive dopamine activity. Furthermore, psychomotor stimulants like cocaine that increase dopamine levels can cause psychotic symptoms if taken in excess.
Chlorpromazine and other typical antipsychotics are primarily blockers of D2 receptors. In fact an almost perfect correlation exists between the therapeutic dose of a typical antipsychotic and the drug’s affinity for the D2 receptor. Therefore, a larger dose is required if the drug’s affinity for the D2 receptor is relatively weak. A correlation exists between average clinical potency and affinity of the antipsychotics for dopamine receptors.
Chlorpromazine tends to have greater effect at serotonin receptors than at D2 receptors, which is notably the opposite effect of the other typical antipsychotics. Therefore, chlorpromazine with respect to its effects on dopamine and serotonin receptors is more similar to the atypical antipsychotics than to the typical antipsychotics.
Chlorpromazine and other antipsychotics with sedative properties such as promazine and thioridazine are among the most potent agents at α-adrenergic receptors. Furthermore, they are also among the most potent antipsychotics at histamine H1 receptors. This finding is in agreement with the pharmaceutical development of chlorpromazine and other antipsychotics as anti-histamine agents. Furthermore, the brain has a higher density of histamine H1 receptors than any body organ examined which may account for why chlorpromazine and other phenothiazine antipsychotics are as potent at these sites as the most potent classical antihistamines.
In addition to influencing the neurotransmitters dopamine, serotonin, epinephrine, norepinephrine, and acetylcholine it has been reported that antipsychotic drugs could achieve glutamanergic effects. This mechanism involves direct effects on antipsychotic drugs on glutamate receptors. By using the technique of functional neurochemical assay chlorpromazine and phenothiazine derivatives have been shown to have inhibitory effects on NMDA receptors that appeared to be mediated by action at the Zn site. It was found that there is an increase of NMDA activity at low concentrations and suppression at high concentrations of the drug. No significant difference in glutamate and glycine activity from the effects of chlorpromazine were reported. Further work will be necessary to determine if the influence in NMDA receptors by antipsychotic drugs contributes to their effectiveness.
Chlorpromazine does also act as FIASMA (functional inhibitor of acid sphingomyelinase ).
Peripheral effects
Chlorpromazine is an antagonist to H 1 receptors (provoking antiallergic effects), H 2 receptors (reduction of forming of gastric juice), M 1 and M 2 receptors (dry mouth, reduction in forming of gastric juice) and some 5-HT receptors (different anti-allergic/gastrointestinal actions).
Because it acts on so many receptors, chlorpromazine is often referred to as a ” dirty drug “.
History
Advertisement for Thorazine (chlorpromazine) from the early 1960s
In 1933, the French pharmaceutical company Laboratoires Rhône-Poulenc began to search for new anti-histamines. In 1947, it synthesized promethazine, a phenothiazine derivative, which was found to have more pronounced sedative and antihistaminic effects than earlier drugs.
Following on, Laborit considered whether chlorpromazine may have a role in managing patients with severe burns, Raynaud’s phenomenon, or psychiatric disorders. At the Villejuif Mental Hospital in November 1951, he and Montassut administered an intravenous dose to psychiatrist Cornelia Quarti who was acting as a volunteer. Quarti noted the indifference, but fainted upon getting up to go to the toilet, and so further testing was discontinued ( orthostatic hypotension is a possible side effect of chlorpromazine). Despite this, Laborit continued to push for testing in psychiatric patients during early 1952. Psychiatrists were reluctant initially, but on January 19, 1952, it was administered (alongside pethidine, pentothal and ECT) to Jacques Lh. a 24-year-old manic patient, who responded dramatically, and was discharged after three weeks having received 855 mg of the drug in total.
Pierre Deniker had heard about Laborit’s work from his brother-in-law, who was a surgeon, and ordered chlorpromazine for a clinical trial at the Sainte-Anne Hospital Center in Paris where he was Men’s Service Chief.
Deniker then visited America, where the publication of their work alerted the American psychiatric community that the new treatment might represent a real breakthrough. Heinz Lehmann of the Verdun Protestant Hospital in Montreal trialled it in 70 patients and also noted its striking effects, with patients’ symptoms resolving after many years of unrelenting psychosis.
Rhône-Poulenc licensed chlorpromazine to Smith Kline & French (today’s GlaxoSmithKline ) in 1953. In 1955 it was approved in the United States for the treatment of emesis (vomiting). The effect of this drug in emptying psychiatric hospitals has been compared to that of penicillin and infectious diseases.
Chlorpromazine largely replaced electroconvulsive therapy, hydrotherapy,
Brand names
Brand names include Thorazine, Largactil, Hibernal, and Megaphen (sold by Bayer in West-Germany since July 1953 ).
Veterinary use
The veterinary use of chlorpromazine has generally been superseded by use of acepromazine.
Chlorpromazine may be used as an antiemetic in dogs and cats, or, less often, as sedative prior to anesthesia.
It is commonly used to decrease nausea in animals that are too young for other common anti-emetics.
The use of chlorpromazine in food-producing animals is not permitted in the EU, as a maximum residue limit could not be determined following assessment by the European Medicines Agency.
Research
Amebocidal ability
Chlorpromazine has tentative benefit in animals infected with Naegleria fowleri.

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