Antipsychotic side effects

Question 1

What are EPSEs caused by?

Answer 1

A blockade of DA receptors in the basal ganglia –> hyper stimulation

Question 2

What is acute dystonia and when does it occur?

Answer 2

= uncontrolled muscles spasm
- Patient may be unable to swallow, can be painful and frightening
- Oculogyric crisis = spasmodic movement of the eyeballs, often fixing upwards
- Torticollis = ‘wry neck’
- More common in young males and the AP naive
- Can occur within HOURS
- Anticholinergic drugs given as antidote eg procyclidine

Question 3

What is akathisia and when does it occur?

Answer 3

= unpleasant state of inner restlessness where there is a strong desire / compulsion to move eg pacing, stamping feet, moving legs
- Can be mistaken for agitation
- Occurs within hours / WEEKS
- Reduce dose and switch AP to treat

Question 4

What is pseudo-parkinsonism and when does it occur?

Answer 4

= tremor, rigidity, bradykinesia
- Can be mistaken for depression / negative symptoms
- More common in elderly females
- Can occur within DAYS / WEEKS
- Treat by reducing dose, switching AP and prescribing anticholinergic

Question 5

What is tardive dyskinesia?

Answer 5

= lip smacking, chewing, tongue protrusion, choreiform hand movements (pill-rolling, piano playing), pelvic thrusting
- Worse under stress
- More common in elderly women and those who have had EPSEs
- Most commonly caused by clozapine and quetiapine

Question 6

What is the acronym for EPSEs?

Answer 6

ADAPT
Acute Dystonia
Akathisa
Pseudo-parkinsonism
Tardive Dyskinesia

Question 7

What is Neuroleptic Malignant Syndrome?

Answer 7

Muscular rigidity, fever, mental state change evolving rapidly over 24-72h
Rare but can be fatal
More common with high potency typical drugs / AP polypharmacy and rapid dose changes
Can be treated with dopamine agonists

Question 8

What is a prolonged QTc?

Answer 8

> 440ms for men
470ms for women
Blockage of K+ channels increases risk of ventricular arrhythmias and torsades to pointes

Question 9

What are the key side effects of clozapine?

Answer 9

Neutropenia –> agranulocytosis (monitor weekly for 1st 18 weeks, then bi-weekly for 1 year, then 4 weeks)
–If neutrophils <1.5x10^9L clozapine must be stopped)
Myocarditis and cardiomyopathy
GI hypomotility –> constipation
Hypersalivation –> aspiration pneumonia
Smoking reduces plasma levels