Side effects of Anti-Psychotic agents

Edited by: Prithwiraj Maiti, MBBS

House physicianDepartment of Internal Medicine, R.G.Kar Medical College

Author: “An Ultimate Guide to Community Medicine”Author: “A Practical Handbook of Pathology Specimens and Slides”

[Both published by Jaypee Brothers Medical Publishers, India]

Side effects of Anti-psychotic agentsPart 1: Autonomic side effects

Side effects Mechanism Maximum with ManagementDry mouth

Muscarinic cholinergic blockade

Chlorpromazine

NoneConstipation LaxativesCycloplegia None, occasionally Pilocarpine

(2%)Urinary retention Occasionally catheterization

Delirium Physostigmine, occasionally Diazepam

Mydriasis Thioridazine None, occasionally Pilocarpine (2%)

Orthostatic hypotension α1 Adrenergicblockade Chlorpromazine

Change in posture, raise legs; plasma expanders (in severe

cases only)Impotence Decrease dose/ change

medicationImpaired ejaculation Thioridazine

Side effects of Anti-psychotic agentsPart 2: Extrapyramidal side effects (EPSE)

Side effects Mechanism Maximum with ManagementParkinsonian side effects

(Ex: Tremor)

D2 receptor blockade in brain

Haloperidol

Anti-Parkinsonian medicationAcute dystonia

Rabbit syndrome (Peri-oral tremor)

Akathisia (motor restlessness) Beta blockers (Propranolol)/ BZDs

Neuroleptic Malignant Syndrome

(Fever, EPS, High CPK, catatonic symptoms and autonomic dysfunction)

Sudden reduction in dopamine activity due

to blockade of Dopamine receptors

HaloperidolChlorpromazine

Bromocriptine, Dantrolene,

Baclofen, Adequate rehydration, Add-on

LorazepamTardive Dyskinesia (Late

onset oro-facial dyskinesia)D2 receptor

super-sensitivityChlorpromazine

AripiprazoleClonazepam

Side effects of Anti-psychotic agentsPart 3: CNS side effects

Side effects Mechanism Maximum with ManagementSeizures Decreased seizure

threshold ClozapineChlorpromazine

Decrease dose/ Change to a safer drug

Sedation Histaminergic blockade

May be beneficial, if chief complaint: Decrease dose

Side effects of Anti-psychotic agentsPart 4: Metabolic and Endocrine side effects

Side effects Mechanism Maximum with ManagementWeight gain H1 blockade

ClozapineOlanzapine

Change drugDietary restrictionDiabetes

Weight gain + Inhibition of glucose transport into muscle

GalactorrheaIncreased Prolactin

released due toDopaminergic

blockade in hypothalamus

HaloperidolRisperidone

Change drug

Side effects of Anti-psychotic agentsPart 5: Allergic side effects

Side effects Mechanism Maximum with ManagementCholestatic jaundice

Hypersensitivity reaction

Chlorpromazine Change drugSupportive care

Agranulocytosis ClozapineStop drug urgently

Treat infectionG-CSF (Filgastrim) may be

used

Side effects of Anti-psychotic agentsPart 5: Cardiac side effects

Side effects Mechanism Maximum with ManagementECG changes

(especially QT prolongation)Anticholinergic effectCalcium channel block

ThioridazinePimozide

Change the drug in severe cases

Side effects of Anti-psychotic agentsPart 6: Ocular side effects

Side effects Mechanism Maximum with ManagementGranular deposits in cornea

and lens PhotosensitivityChlorpromazine (Dose-related)

Change drug

Pigmentary retinopathy Thioridazine(Dose-related)

Preventive: Never give more than 800 mg/day

Side effects of Anti-psychotic agentsPart 7: Dermatological side effects

Side effects Mechanism Maximum with ManagementPhotosensitive reaction

Photosensitivity Chlorpromazine (High dose)

Avoid sunlightUse sunscreen

Blue-grey metallic discoloration

Change drug