McGraw Hill’s NAPLEX® Review Guide, 4e >Schizophrenia

S. Scott Sutton+
TABLE 56-4Neurological Side Effects of Antipsychotic Drugs

Reaction Features Time of Onset and Risk Info Proposed Mechanism Treatment

Time: 1-5 days

Spasm of muscles of tongue, face, Anti-parkinsonian agents are
Acute dystonia Acute DA antagonism
neck, back diagnostic and curativea
Young, antipsychotic naïve patients at
highest risk

Reduce dose or change drug;

Subjective and objective restlessness; clonazepam, propranolol more
Akathisia Time: 5-60 days Unknown
not anxiety or “agitation” effective than anti-parkinsonian
agentsb

Bradykinesia, rigidity, variable tremor, Time: 5-30 days Dose reduction; change medication;
Parkinsonism DA antagonism
mask facies, shuffling gait anti-parkinsonian agentsc
Elderly at greatest risk

Stop antipsychotic immediately;

Extreme rigidity, fever, unstable BP, Time: weeks–months. Can persist for
Neurolepticmalignant syndrome DA antagonism supportive care; dantrolene and
myoglobinemia; can be fatal days after stopping antipsychotic
bromocriptined

Perioral tremor (may be a late variant

Perioral tremor (“rabbit syndrome”) Time: months or years of treatment Unknown Anti-parkinsonian agents often helpc
of parkinsonism)

Prevention crucial; treatment

Orofacial dyskinesia; rarely
Tardive dyskinesia widespread choreoathetosis or
dystonia
Time: months, years of treatment.
Postsynaptic DA receptor unsatisfactory.
supersensitivity, up-regulation
Elderly at 5-fold greater risk. Risk
May be reversible with early
potency of D2blockade
recognition and drug discontinuation

aTreatment: diphenhydramine 25-50 mg IM, or benztropine 1-2 mg IM. Due to long antipsychotic t , may need to repeat, or follow with oral medication.
1/2
bPropranolol often effective in relatively low doses (20-80 mg/d in divided doses). β -Selective adrenergic receptor antagonists are less effective. Non-lipophilic β-adrenergic antagonists have limited CNS
1
penetration and are of no benefit (eg, atenolol).
cUse of amantadine avoids anticholinergic effects of benztropine or diphenhydramine.
dDespite the response to dantrolene, there is no evidence of abnormal Ca2+ transport in skeletal muscle; with persistent antipsychotic effects (eg, long-acting injectable agents), bromocriptine may be tolerated in

large doses (10-40 mg/d). Anti-parkinsonian agents are not effective.

Reproduced with permission from Meyer JM. Pharmacotherapy of Psychosis and Mania. In: Brunton LL, Hilal-Dandan R, Knollmann BC. eds. Goodman &Gilman's: The Pharmacological Basis of Therapeutics,
13e. McGraw-Hill;2018.

Date of download: 12/26/22 from AccessPharmacy: accesspharmacy.mhmedical.com, Copyright © McGraw Hill. All rights reserved.