Antipsychotic Pharmacotherapy Flashcards
1
Q
The 5 major receptor targets of AP’s are…
A
Dopamine (D2)
5HT2a
Muscarinic
Alpha-1
Histaminic-1
2
Q
Majority of 1st generation AP’s primarily target these receptors:
A
Strong D2 receptor antagonism
“dirty” - mixed receptor affinity at alpha, muscarinic, and histamine receptors
3
Q
Majority of 2nd generation AP’s primarily target these receptors:
A
D2 receptor antagonism
5HT2A/2C antagonism
“dirty” - mixed receptor affinity at alpha, muscarinic, histamine receptors
4
Q
Majority of 3rd generation AP’s primarily target these receptors:
A
D2 receptor partial agonism
5HT2A antagonism
5HT1A/2C partial agonism
And additional receptor effects
5
Q
1st generation AP’s are associated with higher rates of this AE…
A
Movement adverse effects
6
Q
2nd generation AP’s are associated with higher rates of this AE…
A
Metabolic adverse effects
7
Q
3rd generation AP’s are associated with higher rates of this AE…
A
Akathisia
8
Q
Despite grouping of AP’s, they are…
A
Very different from each other; receptor profiles relate to tolerability and differences in metabolic pathways are important for drug interactions
9
Q
Overall efficacy of AP’s is…
EXCEPT FOR??
A
Similar - except for clozapine
10
Q
D2 antagonism’s therapeutic effect is…
A
The antipsychotic effect - improvement in positive symptoms
Blocking dopamine in the mesolimbic pathway
11
Q
AE’s that may result from D2 antagonism includes…
A
EPS
Elevated prolactin: gynecomastia, amenorrhea, impotence, osteoporosis - sexual dysfunction
Worsening of negative symptoms
Nigrostriatal and tuberoinfundibular dopamine blockade
12
Q
5HT therapeutic effect is…
Some are antagonistic, and some are agonistic…
A
2A/2C antagonism: antipsychotic effect (theoretically improve negative symptoms via increased dopamine release in mesocortical pathway)
1A agonism: anxiolytic
13
Q
AE’s that may result from 5HT receptor interaction includes…
A
Sedation
Hypotension
Sexual dysfunction
14
Q
Alpha1/2 antagonism therapeutic effects include…
A
None
15
Q
AE’s associated with alpha1/2 receptors include…
A
Alpha1 - Sedation, hypotension, dizziness, reflex tachycardia, incontinence, drooling
Alpha2 - sexual dysfunction
16
Q
Muscarinic antagonism therapeutic effects include…
A
None - perhaps potentiation of drugs that have anticholinergic properties
17
Q
AE’s that result from muscarinic antagonism include…
Anticholinergic !
A
Dry mouth
Blurred vision
Constipation
Urinary retention
Confusion/memory disturbance
18
Q
Histamine antagonism therapeutic effects include…
A
None - May potentiate effect of other CNS depressant drugs
19
Q
AE’s that result from histamine antagonism include…
A
Sedation, drowsiness
Postural hypotension
Weight gain
20
Q
High potency 1st generation AP’s have higher risk of ____ but weaker ____
A
Higher risk of movement disorders, but weaker anticholinergic effects
21
Q
Common high potency 1st generation AP’s include…
A
Haloperidol
Flupenthixol
Fluphenazine
Perphenazine
22
Q
Low potency 1st generation AP’s have lower risk of ____ but stronger ____
A
Lower risk of movement disorders, but stronger anticholinergic effects (highly sedating)
Metabolic effects are stronger due to stronger anticholinergic
23
Q
Common low potency 1st generation AP’s include…
A
Chlorpromazine
Methotrimeprazine
24
Q
2nd generation AP’s have lower risk of ____ but higher risk of ____
A
Lower risk of movement disorders, but higher risk of metabolic AE’s
25
Metabolic AE's may include...
Lipid dysfunction
Development of diabetes or HTN
Obesity
26
Risperidone has high affinity for the following receptors:
Dopamine, serotonin, and alpha-adrenergic receptors
27
Initial dosing of risperidone is...
1-2mg/day, once daily or BID
| May start at 0.5mg for elderly or those with co-morbidities
28
Regular doses of risperidone are...
4-6mg/day
| No higher; 1st generation features at over 8mg/day
29
Different formulations of risperidone include...
Oral solution
Oral tablets
Orally disintegrating tablets
Long acting injectable
## Footnote
Switching to injectable would require overlap with oral risperidone for 3 weeks
30
When considering 2nd generation AE's, we can consider the AE's related to receptors, such as...
| Consider the 5 receptors and AE's caused when affected
Alpha-blockade: Dizziness, sedation, orthostatic hypotension
Dopamine-blockade: Worsening of negative symptoms, EPS, prolactin
Muscarinic-blockade: Anticholinergic + metabolic effects
Histaminic-blockade: Anticholinergic + metabolic effects
Serotonin tries to help improve negative symptoms, but clinically has not seen much benefit - adds to sedation, hypotension, sexual dysfunction
31
Risperidone is unique in that it has low/no affinity for...
Low: alpha2, histamine
No affinity for muscarinic
No anticholinergic, lower rate of sedation
32
Aside from typical AP AE's, unique AE's with risperidone include...
Weight gain risk is lower vs. other 2nd gen AP's
Increased risk of prolactin/sexual dysfunction and EPS vs. other 2nd gen AP's
Headache, rhinitis, anxiety
QT Prolongation
| NO anticholinergic, but may still be sedating from histamine action
33
Important drug interactions for risperidone include...
Pharmacodynamic interactions with other CNS depressants + QTc prolonging agents
3A4/2D6 interactions
34
Paliperidone is the primary active metabolite of...
Risperidone
35
Dosing forms of paliperidone includes...
Tablets
Long-acting injectable
36
Paliperidone AE's and DI's are quite similar to risperidone, but some are more pronounced than others, such as...
Less risk of orthostatic hypotension, weight gain
More risk of insomnia
Similar risk of prolactin/sexual dysfunction
| Minimal risk of DI's compared to risperidone
37
Olanzapine is often not initially used due to...
Metabolic AE's - A LOT of histamine/muscarinic blockade
38
Initial dosing of olanzapine is usually...
5-10mg at bedtime
39
Usual dosing of olanzapine is...
10-20mg once daily
40
Dosing formulations of olanzapine includes...
Tablets
Orally disintegrating tablets
Short or long-acting injectable
41
Aside from typical AP AE's, unique AE's with olanzapine includes...
**Weight gain** - increased risk of T2DM and/or dyslipidemia compared to other 2nd gen AP's
Dose-dependent risk of EPS, especially akathisia
QT Prolongation
42
Important DI's with olanzapine includes...
Smoking - will lower olanzapine levels
1A2 inhibitors/inducers
Pharmacodynamic interactions with drugs of similar actions
43
2nd generation AP's include the following drugs...
Risperidone, paliperidone
Olanzapine
Ziprasidone
Asenapine
Lurasidone
Clozapine
44
The 2 quetiapine formulations include...
XR (once daily)
IR (BID)
45
XR quetiapine for psychosis is dosed as follows...
1st day: 300mg HS
2nd day: 600mg HS
After day 2: up to 800mg HS
46
IR quetiapine for psychosis is dosed as follows...
25mg BID, increasing q4-7 days up to 400mg po BID
47
Lower doses of quetiapine are used for ____, because...
Insomnia, bipolar, depression, anxiety... Different doses have different affinities for different receptors
## Footnote
~50mg primarily histamine blockade
~300mg includes serotonin receptors
48
Aside from typical AP AE's, unique AE's with quetiapine at high doses include...
Increased risk of T2DM and dyslipidemia vs. other 2nd gen AP's
May reduce thyroid hormone levels
QT Prolongation
49
Important DI's with quetiapine include...
Pharmacodynamic interactions; CNS depressants, QTc prolonging agents
3A4 interactions
50
Ziprasidone is not often used due to...
The need for high food intake with it
51
Ziprasidone needs to be administered with ____, because...
WITH FOOD: >500 kcal to maximize absorption and therapeutic effect
52
Initial dosing of ziprasidone is...
40mg BID; 20mg BID for antipsychotic naive first episode psychosis patients
53
Ziprasidone-induced "activation" syndrome includes symptoms such as...
Anxiety, restlessness, insomnia, hypomanic-like symptoms
54
Ziprasidone-induced activation syndrome usually develops...
After treatment initiation and occur at the lower end of the dosage range
55
Ziprasidone-induced activation syndrome can be avoided by...
Rapidly titrating in the first week, up to 120-160 mg/day especially in bipolar disorder or agitated/irritable patients
56
Aside from typical AP AE's, unique AE's with ziprasidone include...
Less hyperglycemia/dyslipidema risk vs. other 2nd gen AP's
Higher risk of QT prolongation
Dyspepsia, nausea, constipation
57
Important DI's with ziprasidone include...
Pharmacodynamic interactions; CNS depressants, QTc prolongation
3A4 Inducers/inhibitors
58
Asenapine is EDS for bipolar but is not covered for us in schizophrenia because...
Superiority vs. placebo was not clearly demonstrated, therefore is not clinically used for schizophrenia
59
Dosing of asenapine is...
Initial 5mg BID, up to 10mg BID
60
Dosing formulation of asenapine is...
Sublingual tablets
61
Aside from typical AP AE's, unique AE's with asenapine includes...
**Mouth numbness x 1hr post dose**
Minimal effect on weight, glucose, lipids
Headache, dizziness
QT prolongation
62
Important DI's with asenapine includes...
PD with CNS depressants, QTc prolonging agents
63
Luraisdone is not used often for schizophrenia in clinical practice, since...
Efficacy has only been established in studies up to 6 weeks
64
Lurasidone has a better AE profile than most 2nd gen AP's, since...
Little to no metabolic concerns
Still some EPS, prolactin, sedation, QTc, -typical AP AE's, but likely less concerning
65
Important DI's with lurasidone includes...
PD interactions with CNS depressants and QTc prolonging agents
3A4 inhibitors + inducers
66
Dosing of lurasidone is...
40mg daily, titrated up to 120-160 mg daily
67
Lurasidone administration is unique like zipraidone in that...
Food is needed to increase bioavailability (350 kcal)
68
3rd generation AP's include these three drugs...
Aripiprazole
Brexpiprazole
Cariprazine
69
3rd generation AP's are unique in that they are dopamine ____
Partial agonists
70
Dopamine partial agonists are unique in that they partially...
| AKA Dopamine system stabilizer
Activate dopamine receptor output, and cause stabilizing balance between stimulation and blockade of dopamine receptors
## Footnote
High levels of dopamine = antagonist
Low levels of dopamine = agonist
71
3rd generation AP's have a lower risk of ____, but higher rates of ____
Lower risk of metabolic + movement AE's, but higher rates of akathisia
## Footnote
Aripiprazole >> Brexpiprazole
72
Dosing of oral aripiprazole is...
10-15mg po once daily; max of 30mg/day
73
Key factor for aripiprazole titration is that the half-life is ____, so we cannot increase dose faster than ______
Half-life is 75 hours; cannot increase dose faster than 2 weeks
74
Dosing of long-acting aripiprazole is...
Long-acting injectable 400mg IM q4weeks
## Footnote
May reduce down to 300mg IM q4weeks when stable, or adverse effects
75
When choosing to initiate depot aripiprazole, we need to continue oral dosing for..
2 weeks
76
Aside from typical AP AE's, unique AE's with aripiprazole includes...
**Akathisia**
Some anxiety
Headache, GI complaints, insomnia
Minimal weight gain :)
Suicidal behaviour
QT prolongation
77
DI's with aripiprazole revolve around...
CYP 2D6 and 3A4
78
Brexpiprazole is similar to aripiprazole in AE's except for...
Less risk of akathisia
79
Half-life of brexpiprazole is around...
~91 hours
80
Target dosing of brexpiprazole for schizophrenia is...
2-4mg/day
| If MDD add-on: 0.5-2mg daily
81
Dosing of brexpiprazole for schizophrenia should be initiated at...
1mg daily
82
Cariprazine is unique in that it targets...
D2 + **D3** - partial agonist
5HT1A - partial agonist
5HT2A + 2B - antagonist
83
D3 receptors are associated with...
Mood, cognition, addictive behaviours, and reward behaviours
84
Partial agonism of the D3 receptor may help...
Improve negative symptoms + cognitive impairment of schizophrenia
85
Important PK parameters with cariprazine involve...
Highly protein bound
Extensively metabolized by CYP3A4 - affected by inducers/inhibitors
Has active metabolites that extend half-life
86
The downside with cariprazine is that trials did not...
Detect clinically meaningful responses for efficacy in improving negative symptoms compared to placebo
No direct comparative evidence vs. other antipsychotics
87
To summarize evidence of cariprazine so far, it may be effective in schizophrenia for treatment of...
Acute exacerbations, and prevention of relapse after acute exacberations
Implications for negative symptoms of schizophrenia
## Footnote
MORE direct comparative evidence and research is needed
88
1st generation AP's have shown higher discontinuation rates due to...
Adverse effects (EPS)
Lack of treatment effect
89
____ are the prefered agents for treatment of patients with early psychosis, due to ______
2nd generation AP's, due to significant increased risk of EPS with 1st generation AP's
90
When selecting an AP, we should individualize to the patient based on factors such as...
Symptomatology
AE's
DI's
Cost
Convenience
91
If oral AP's are effective and tolerated, we could...
1. Continue with oral therapy
2. Switch to long-acting injectable depot
92
Benefit of LAIA's is...
Improved adherence; given q2-4 weeks
93
LAIA's can be considered if a patient...
Relapses due to non-adherence
Or if they simply prefer the injection
94
Proven benefits of LAIA's include...
Lower risk of relapse
Decreased hospitalization rates
Decreased patient/caregiver burden
Improved adherence
95
Before starting a patient on LAIA, we need to...
Ensure tolerability, with oral formulation first
Double check how long to overlap with oral formulation
96
The only 3rd generation AP that can be given depot is...
Aripiprazole
97
Does aripiprazole require overlap from oral to depot formulation?
Yes, 2 weeks
98
2nd gen AP's that can be given as depot include...
Paliperidone
Risperidone
99
Paliperidone is unique in that it has two depot formulations that differ by...
Time of administration. One is every 1 month, and another is every 3 months.
100
Do 2nd gen AP require overlap from oral to depot?
Paliperidone does not. Risperidone does, for 3 weeks
101
1st gen AP in depot formulations include ____, however...
Flupenthixol, haloperidol, and zuclopenthixol. These should not be used unless all other options are exhausted
102
General monitoring guidelines for all AP's include...
Vitals
Behaviours
AE's - CNS changes, anticholinergic, EPS, hyperprolactin
CBC, LFT's, ECG if cardiac risk factors or QT prolonging drugs
| Will depend on the agent chosen
103
Cloazpine has most distincitve activity for these receptors...
D4
5-HT2A
Alpha-1
Muscarinic
104
Common AE's with clozapine include...
| THINK OF THE RECEPTORS
**Anticholinergic** (Constipation, blurred vision, drowsiness, dizziness)
**Metabolic** (weight gain, increased cholesterol, BG)
**Alpha-1** (tachycardia, orthostatic hypotension, dizziness, drooling)
105
Serious AE's with clozapine include...
Agranulocytosis
Myocarditis/cardiomyopathy
Severe constipation
Seizures
Neuroleptic malignant syndrome
106
Clozapine-induced agranulocytosis is...
A dangerously low neutrophil count - highly increases infection risk
107
Clozapine-induced myocarditis is...
Inflammation of the heart muscle - allergic reaction
| High mortality rate
108
Severe constipation caused by clozapine can lead to...
Adynamic ileus
| High mortality rate; monitor bowel functioning
## Footnote
Peristalsis stops in the GI tract, can rupture
109
Agranulocyotis with clozapine is most likely to occur in...
| Timeframe
The first 6 months of treatment
110
Myocarditis with clozapine is most likely to occur in...
| Timeframe
The first 4-8 weeks of treatment
111
Cardiomyopathy with clozapine is most likely to occur in...
Months to years of treatment
112
The difference between myocarditis and cardiomyopathy is...
Myocarditis = allergic-like reaction causing inflammation
Cardiomyopathy = Disease of heart muscle, making it harder to pump blood
113
Clinical presentation of myocarditis and cardiomyopathy are similar when beginning, and this may include...
Orthostatic blood pressure changes
Fatigue, decreased exercise tolerance
Chest pain, discomfort, palpitations with increased heart rate
SOB
Peripheral edema
Fever
114
Lab markers that can indicate cardiomyopathy or myocarditis include...
CRP - non-specific for inflammation
Troponin - protein in heart muscle (that typically should not be in the blood)
115
Monitoring for agranulocytosis with clozapine requires specific blood tests, which is...
The absolute neutrophil count - need to order CBC with differential, vs. just a CBC
116
Clozapine can ONLY be used and dispensed if...
Patient is actively registered with a clozapine registry, and hematological monitoring can be guaranteed
## Footnote
Remember CBC with diff - neutrophils
117
How often does blood work need to be done for clozapine monitoring?
Weekly for first 6 months
Then once every 2 weeks if green light maintained and clinically stable
Then once every 4 weeks if green light for another 6 months
118
If a patient stops clozapine, do they still need to monitor their neutrophil counts?
Yes, for 4 weeks after stopping
119
Clozapine dosing needs to be re-titrated if missed for longer than...
48 hours
120
If clozapine therapy is disrupted for more than ____, blood testing needs to be done...
| How frequently?
3+ days; blood testing resumed weekly for an additional 6 weeks
121
"Green" neutrophil count with clozapine monitoring is above...
2.0 x 10^9/L
122
"Yellow" neutrophil count with clozapine monitoring is...
| How often do we test if yellow?
In range of 1.5-2.0 x 10^9/L
| Test at least twice weekly until ANC stabilizes or increases
## Footnote
Can continue to dispense in meantime
123
"Red" neutrophil count with clozapine monitoring is...
| What do we do next?
Below 1.5 x 10^9/L
## Footnote
Immedaitely withhold and discontinue if confirmed. Monitor for signs of infection
124
Clozapine is non-rechallengable in regards to agranulocytosis, whihch means...
Patient must stop and cannot ever restart therapy if they were in "red" neutrophil count
| Still requires the weekly CBC x 4 weeks when stopped
125
The amount of clozapine dispensed must align with...
The frequency of clozapine bloodwork
## Footnote
q2weekly blood work can only have 2 weeks of clozapine dispensed from the pharmacy
126
Initial dosing and titration of clozapine is usually...
12.5-25mg/day PO; increase by 12.5-25mg on 2nd day, then 25-50mg daily PO depending on tolerance
## Footnote
Minimize risk of orthostatic hypotension and sedation
127
Usual dosing of clozapine is ____, and can go up to...
300-600mg PO/day after 2 weeks - max of 900mg PO/day
## Footnote
OD, BID, or TID
128
An important drug interaction with clozapine is...
SMOKING - induces 1A2, reducing levels
Also consider anything that may affect CYP 1A2
129
Clozapine in relation to suicide risk has shown...
A reduction in risk of suicide in schizophrenia/schizoaffective patients
| NNT = 13
130
Extrapyramidal system differs from pyramidal system mainly by...
Pyramidal = Voluntary movement
Extrapyramidal = Involuntary movement
131
Acute extrapyramidal effects usually onset within ____ days, and are mostly due to...
Within 30 days; mostly due to dopamine (D2) blockade
132
Treatment of acute EPS is usually with...
Antiparkinsonian drugs - centrally acting anticholinergics (cross BBB, block excitatory muscarinic pathways, restore dopamine/ACh balance disrupted by AP's)
133
Treating acute EPS symptoms is important to prevent...
Tardive symptoms
134
Tardive symptoms onset is usually after...
Months/years of treatment, especially if drug dose is decreased or discontinued; and tend to persist for years or decades
## Footnote
Can may become permanent even with removal of AP; precise pathophysiology remains unclear
135
FDA-approved drugs for treating tardive dyskinesia includes...
Valbenazine
Deutetrabenazine
## Footnote
DOESN'T actually treat TD, just lowers AE's. Also isn't available in Canada yet; therefore PREVENTION IS KEY
136
Important factors to consider with TD prevention include...
| All related to AP's, and dose
Early recognition + discontinuation of offending AP (not always an option)
Dose reduction/use of lowest effective dose (weigh against risk of relapse)
SLOW tapers with AP to avoid withdrawal emergent symptoms
Switch to atypical AP's
137
Acute EPS effects may include...
Dystonia
Akathisia
Pseudoparkinsonism
Pisa syndrome, rabbit syndrome
138
Physical symptoms of acute dystonia includes...
Torsions and spasms of muscle groups - mostly affecting the muscles of the head and neck
Painful and spasmodic
139
Psychological symptoms that can occur with acute dystonias include...
Anxiety, fear, panic
Dysphoria
Repetitive meaningless thoughts
140
Time of onset for acute dystonia in relation to AP treatment is usually...
Within 24-48 hours of the 1st dose; 90% occur within 1st week of treatment
141
Acute dystonia can be life-threatening because...
Dystonia relating to laryngeal/pharyngeal pathways may stop swallowing/breathing reflexes
142
With acute dystonia, oculogyria may be present, which is...
Sustained upward and lateral deviation of the eyes
143
Treatment options for acute dystonia includes...
1st line: IM benztropine
IM diphenhydramine, sublingual lorazepam
144
Physical symptoms of akathisia include...
**Motor restlessness** (fidgeting, pacing, rocking, inability to be still)
Respiratory - dyspnea or breathing discomfort
145
Psychological symptoms of akathisia include...
Restlessness, intense urges to move
Irritability, agitation, violent outbursts
Feeling uncomfrotable, "antsy"
**Can contribute to suicide and violence**
146
Proposed risk factors for developing acute akathisia include...
High potency 1st gen AP's, and 3rd gen AP's
Anxiety, mood disorders
Stimulant usage; caffeine
147
Time of onset of acute akathisia in relation to AP treatment is...
Hours-days; 90% occur within first 6 weeks of treatment and may continue throughout entire treatment
148
Treatment options for acute akathisia include...
Reduce dose (slow taper) or change AP
Trial of benzodiazepines, non-selective beta-blocker, or mirtazapine
149
Physical symptoms of acute pseudoparkinsonism include...
Tremor
Cogwheel rigidity
Bradykinesia
150
Presentation of bradykinesia may include...
Mask-like facial expression
Diminished/absent arm swing
Shuffling gait; slowness of movement
Stooped posture
151
Psychological symptoms of pseudoparkinsonism include...
Slowed thinking
Fatigue
Cognitive impairment, drowsiness
152
Time of onset of pseudoparkinsonism in relation to AP treatment is...
Acute - 90% occur within first 6 weeks of treatment and may continue through entire treatment
153
Treatment options for pseudoparkinsonism include...
Dose reduction, or changing AP
Antiparkinsonian drugs - anticholinergics (benztropine, diqphenhydramine, procyclidine, trihexyphenidyl)
154
Pisa syndrome is when the patient is...
Leaning to one side
155
Onset of pisa syndrome can be...
Either acute or tardive; usually ignored by patients
156
Rabbit syndrome is defined by...
Fine tremor of the lower lip
157
Onset of rabbit syndrome is usually...
After months of therapy; often ignored by patients
158
Treatment of pisa and rabbit syndrome is with...
Antiparkinsonian drugs - benztropine, procyclidine, trihexyphenidyl
159
Physical symptoms of tardive dyskinesia may include...
Involuntary, abnormal movement of the face, lips, jaw, tongue, eyelids, limbs, trunk, neck, or respiratory system
## Footnote
Can co-exist with parkinsonism and akathesia
160
Psychological symptoms of tardive dyskinesia may include...
Cognitive impairment
Distress (talking, eating, swallowing)
Embarassment/anxiety
161
Onset of tardive dyskinesia is usually...
After 3 or more months of therapy in adults; earlier in elderly
162
Some proposed risk factors for tardive dyskinesia include...
40+, female
History of severe EPS early in treatment
Chronic usage of AP's (1st gen > others), or high doses of dopamine agonists
Presence of mood component or cognitive impairment
Diabetes
Alcohol/drug abuse
163
Tardive dyskinesia symptoms may be persistent + permanent, but discontinuation of AP early ____
Increases chance of remission
## Footnote
Spontaneous remission in 14-24% after 5 years
164
Are there any approved options for treating tardive dyskinesia?
No - valbenazine and deutetrabenazine are not available in Canada
May possibly switch to 2nd gen or 3rd gen AP, or try options such as clonzaepam, tetrabenazine, levetiracetam...
165
A good way to measure severity of tardive dyskinesia is using this scale...
AIMS - Abnormal Involuntary Movement Scale
166
A good way to measure severity of akathisia is using this scale...
BARS - Barnes Akathisia Rating Scale
167
Proposed risk factors for acute dystonia may include...
| Contains both modifable risk factors and uncontrollable risk factors
Young male, AP naive, high potency FGA
Rapid dose increases
Prior dystonic reaction
Dehydration
Recent cocaine usage
Hypocalcemia, hyperthyroidism
168
Tardive dystonia and akathisia are similar to acute presentations, except...
THey are persistent and may be permanent even with removal of the AP
169
Neuroleptic Malignant Syndrome (NMS) is a type of ____ that is...
EPS that is acute and life-threatening, which can occur with any AP at any dose
## Footnote
VERY rare, idiosyncratic
170
Physical manifestations of NMS include...
Severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC and creatine kinase
171
When can NMS occur with AP usage?
Anytime - often early in treatment
172
Treatment for NMS mainly revolves around...
Stopping AP immediately, and providing supportive care
Bromocriptine may be used (D2 receptor agonist), dantrolene for malignant hyperthermia
