Management of Antipsychotic Side Effects

Question 1

Approach to treating akathisia

Answer 1

1. Try to decrease AP dose if possible (monitor for re-emergence of psychotic sx)
2. Consider switching to AP with less risk of EPS (such as Quetipine, Clozapine, Iloperidone)
3. Start medication

Question 2

1st-line medical treatment of akathisia - give doses

Answer 2

Beta-blocker (Propanolol) started at 10 mg orally 2x/day. If symptoms do not resolve and patient has not experienced side effects, can increase incrementally up to 40 mg 2x/day

Question 3

Monitor ____ in patients with akathisia treated with propranolol

Answer 3

Blood pressure

Question 4

Do not use propranolol to treat akathisia in patients with __________

Answer 4

airway diseases (bronchial asthma, COPD) and heart failure

Question 5

2nd-line medical treatment of akathisia - doses?

Answer 5

Benztropine is started at 1 mg 2x/day and increased up to 2 mg 2x/day.

Question 6

Monitor for _______ in patients with akathisia treated with benztropine

Answer 6

Anticholinergic effects (dry mouth, constipation, urinary retention, memory impairment)

Question 7

3rd-line medical treatment of akathisia

Answer 7

Benzodiazepines (Lorazepam started at 0.5 mg orally 2x/day, can be increased incrementally up to 6-10 mg/day).

Question 8

Approach to treatment of parkinsonism

Answer 8

First, try reducing dose of AP, monitoring closely for exacerbation of psychotic symptoms. If decreasing the AP dose isn’t effective or feasible, try switching the AP to one with less risk of EPS. If this doesn’t work or isn’t feasible, start medication.

Question 9

1st-line medical treatment of Parkinsonism

Answer 9

1. Benztropine, start at 0.5-1 mg 2x/day (“1-2 mg/day in divided doses”) - usually effective, but if necessary the dose can be increased gradually every 3-4 days to 6-8 mg/day if tolerated.

Question 10

Side effects of benztropine used to treat parkinsonsim

Answer 10

Anticholinergic. Give in caution in glaucoma.

Question 11

If patient with AP-induced parkinsonism is on an anticholinergic AP or does not tolerate Benztropine, use ____ (+ dose and side effects)

Answer 11

Amantadine 100 mg orally 2-3x/day. Can cause hypotension and mild agitation.

Question 12

Treatment of mild dystonias

Answer 12

Switch AP to less EPS risk + use benztropine 1-2 mg orally 1-2x/day

Question 13

Treatment of very disturbing dystonias

Answer 13

Switch AP to less EPS risk + IV or IM benztropine (1-2 mg/day) or diphenhydramine (50 mg/day)

Question 14

In patients getting IM haloperidol, treatment with ____ is recommended to prevent an acute dystonic reaction.

Answer 14

an anticholinergic agent (benztropine or diphrenhydramine)

Question 15

Dose for IM benztropine given with haloperidol 5 vs 10 mg

Answer 15

5 mg IM haloperidol with 1 mg IM benztropine; 10 mg IM haloperidol with 2 mg IM benztropine