Sadocks, Kaplan, 2007. Schizophrenia. Synopsis of Psychiatry.

10
th
edition, New York :
Lippincott Williams & Wilkins, Page : 490-491

Managing Side Effects
Patients will frequently experience side effects of an antipsychotic before they experience
clinical improvement. Whereas a clinical response may be delayed for days or weeks after drugs
are started, side effects may begin almost immediately. For low-potency drugs, these side effects
are likely to include sedation, postural hypotension, and anticholinergic effects, whereas high-
potency drugs are likely to cause extrapyramidal side effects.

Extrapyramidal Side Effects
Clinicians have a number of alternatives for treating extrapyramidal side effects. These
include reducing the dose of the antipsychotic (which is most commonly a DRA), adding an anti-
Parkinson medication, and changing the patient to an SDA that is less likely to cause
extrapyramidal side effects. The most effective anti-Parkinson medications are the
anticholinergic anti-Parkinson drugs. However, these medications have their own side effects,
including dry mouth, constipation, blurred vision, and, often, memory loss. Also, these
medications are often only partially effective, leaving patients with substantial amounts of
lingering extrapyramidal side effects. Centrally acting -blockers, such as propranolol, are also
often effective for treating akathisia. Most patients respond to dosages between 30 and 90 mg per
day. If conventional antipsychotics are being prescribed, clinicians may consider prescribing
prophylactic anti-Parkinson medications for patients who are likely to experience disturbing
extrapyramidal side effects. These include patients who have a history of extrapyramidal side
effect sensitivity and those who are being treated with relatively high doses of high-potency
drugs. Prophylactic anti-Parkinson medications may also be indicated when high-potency drugs
are prescribed for young men who tend to have an increased vulnerability for developing
dystonias. Again, these patients should be candidates for newer drugs.
Some individuals are highly sensitive to extrapyramidal side effects at the dose that is
necessary to control their psychosis. For many of these patients, medication side effects may
seem worse than the illness itself. These patients should be treated routinely with an SDA
because these agents result in substantially fewer extrapyramidal side effects than the DRAs.
However, these highly sensitive individuals may even experience extrapyramidal side effects on
an SDA. Risperidone may cause extrapyramidal side effects even at low dosesfor example,
0.5 mgbut the severity and risk are increased at higher dosesfor example, more than 6 mg.
Olanzapine and ziprasidone are also associated with dose-related Parkinsonism and akathisia.

Tardive Dyskinesia
About 20 to 30 percent of patients on long-term treatment with a conventional DRA will exhibit
symptoms of tardive dyskinesia. Three to five percent of young patients receiving a DRA
develop tardive dyskinesia each year. The risk in elderly patients is much higher. Although
seriously disabling dyskinesia is uncommon, it can affect walking, breathing, eating, and talking
when it occurs. Individuals who are more sensitive to acute extrapyramidal side effects appear to
be more vulnerable to developing tardive dyskinesia. Patients with comorbid cognitive or mood
disorders may also be more vulnerable to tardive dyskinesia than those with only schizophrenia.
The onset of the abnormal movements usually occurs either while the patient is receiving an
antipsychotic or within 4 weeks of discontinuing an oral antipsychotic or 8 weeks after the
withdrawal of a depot antipsychotic. There is a slightly lower risk of tardive dyskinesia with
new-generation drugs. However, the risk of tardive dyskinesia is not absent with SDAs.
Recommendations for preventing and managing tardive dyskinesia include (1) using the lowest
effective dose of antipsychotic; (2) prescribing cautiously with children, elderly patients, and
patients with mood disorders; (3) examining patients on a regular basis for evidence of tardive
dyskinesia; (4) considering alternatives to the antipsychotic being used and considering dosage
reduction when tardive dyskinesia is diagnosed; and (5) considering a number of options if the
tardive dyskinesia worsens, including discontinuing the antipsychotic or switching to a different
drug. Clozapine has been shown to be effective in reducing severe tardive dyskinesia or tardive
dystonia. The reader is referred to Section 36.2 for an extensive discussion of medication-
induced movement disorders.