3 Antipsychotics

Antipsychotic groups and typical risks

Antipsychotics are used to treat psychotic disorders; some agents are also used for conditions such as bipolar disorder. First-generation antipsychotics (FGAs), including haloperidol, and second-generation antipsychotics (SGAs), including risperidone, olanzapine, and aripiprazole, differ in their average adverse-effect profiles.

These are general patterns, not rules that apply to every medication. Individual risks vary by drug and patient, so treatment selection should account for goals, prior response, health conditions, and patient preference.

Movement, metabolic, and prolactin effects

High-potency FGAs generally carry greater risk of extrapyramidal symptoms (EPS). Many SGAs carry greater metabolic risk, including weight gain, dyslipidemia, or hyperglycemia, but risks vary across agents. Risperidone and paliperidone, for example, can increase prolactin.

Olanzapine is associated with weight gain and adverse changes in glucose and lipids. These effects should be monitored rather than assumed to occur or not occur in an individual patient. Neither medication group is free of all movement or metabolic risks, and individual drugs can differ.

Recognizing movement-related adverse effects

Sudden, sustained muscle contractions, sometimes involving the neck, jaw, or eyes, are characteristic of acute dystonia. Painful neck spasms with upward deviation of the eyes in a person taking haloperidol are an example.

Akathisia is inner restlessness with difficulty sitting still. Tardive dyskinesia usually involves later-onset involuntary movements, often of the face or tongue; it differs from the sudden contractions of acute dystonia.

Recognizing neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening emergency associated with antipsychotics. Fever, severe muscle rigidity, altered mental status or confusion, and autonomic instability such as unstable blood pressure are warning signs.

Suspected NMS requires urgent medical evaluation. It should not be treated as an expected early side effect or left for a routine appointment.

Baseline and follow-up monitoring

Assess relevant risks before treatment and repeat appropriate monitoring during treatment. Baseline assessment includes weight, waist circumference, blood pressure, glucose or HbA1c, lipids, prolactin, and movement symptoms. Monitoring metabolic measures only when a patient reports symptoms is not sufficient.

ECG assessment may also be appropriate depending on the medication, cardiovascular risks, and clinical setting. The monitoring plan should account for the medication and the patient's circumstances.

Clozapine and treatment-resistant schizophrenia

Clozapine should be considered when schizophrenia symptoms persist despite adequate trials of two antipsychotics. Because clozapine can cause severe neutropenia, absolute neutrophil count (ANC) monitoring is required before treatment and during treatment according to prescribing information.

Clozapine's ANC monitoring does not replace monitoring for metabolic effects when those are relevant.

Individualized treatment and review

Choose treatment collaboratively, considering expected benefits, adverse-effect risks, treatment goals, prior response, health conditions, and patient preferences. Start cautiously, then monitor response and adverse effects and review treatment regularly.

Avoid routine long-term use of multiple antipsychotics; combination treatment should be used only when clinically justified. Individualized decisions help balance potential benefits and harms.

• Metabolic monitoring