Identify Potential Side Effects Associated With Antipsychotic Medications (Both First and Second Generation Antipsychotics)
The fourth exception, pimavanserin, is a serotonin 5HT2A inverse agonist and antagonist with no dopamine D2 affinity.
Some antipsychotics are also approved for treatment of bipolar disorder, treatment‐resistant depression, autism, or Tourette's disorder. In addition, these medications are prescribed off‐label for individuals with other conditions, such as borderline personality disorder, obsessive‐compulsive disorder, anorexia nervosa, insomnia, delirium, and various dementia syndromes including Alzheimer's disease. The utility of these drugs is hampered by their adverse effects, which must be weighed against their variable benefits for these conditions. The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life‐threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first‐ and second‐generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life‐threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta‐blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.
Antipsychotic medications are sometimes used to calm older adults with psychosis related to dementia. However, use of antipsychotics by older adults has been associated with an increased risk of stroke. Other ways of calming the person should always be tried first, and when antipsychotics are needed, they should only be used until symptoms are relieved.
Allison DB, Casey DE. Antipsychotic-induced weight gain: a review of the literature. J Clin Psychiatry. 2001;62(Suppl. 7):22–31.
Wirshing DA, Wirshing WC, Kysar L. Novel antipsychotics: comparison of weight gain liabilities. J Clin Psychiatry. 1999;60:358–363.
Arvanitis LA, Miller BG. (Seroquel Trial 13 Study Group). Multiple fixed doses of “Seroquel” (quetiapine) in patients with acute exacerbation of schizophrenia: a comparison with haloperidol and placebo. Biol Psychiatry. 1997;42:233–246
Nemeroff CB. Dosing the antipsychotic medication olanzapine. J Clin Psychiatry. 1997;
Rondanelli M, Sarra S, Antoniello N. No effect of atypical antipsychotic drugs on weight gain and risk of developing type II diabetes or lipid abnormalities among nursing home elderly patients with Alzheimer’s disease. Minerva Med. 2006