From the Guidelines
Atypical antipsychotics can cause tremors as a side effect, though they generally have a lower risk compared to typical antipsychotics, and management strategies include dose reduction, switching to a different atypical antipsychotic, or using symptomatic treatments like beta-blockers or anticholinergics. If a patient develops tremors while on an atypical antipsychotic, several approaches can be considered. First, dose reduction of the current medication should be attempted if clinically appropriate, as seen in the guidelines for managing schizophrenia in children and adolescents 1. If tremors persist, switching to a different atypical antipsychotic with lower extrapyramidal symptom risk (such as quetiapine or clozapine) may help, considering the efficacy and safety profiles of these medications in various patient populations 1. For symptomatic management, beta-blockers like propranolol (starting at 10-20mg twice daily) are often effective first-line treatments, given their established use in managing tremors and other movement disorders 1. Anticholinergic medications such as benztropine (1-2mg twice daily) or trihexyphenidyl (2-5mg three times daily) can also be used, particularly for parkinsonian-type tremors, though they carry risks of cognitive side effects, especially in elderly patients, as noted in guidelines for delirium management in adult cancer patients 1. Amantadine (100mg twice daily) is another option with a different mechanism of action. These tremors occur because antipsychotics block dopamine receptors in the nigrostriatal pathway, disrupting the balance between dopamine and acetylcholine in the basal ganglia. Regular monitoring for tremors and other movement disorders is essential during antipsychotic treatment, as early intervention can prevent worsening of symptoms, emphasizing the importance of careful management and follow-up in clinical practice 1.
Some key considerations in managing tremors associated with atypical antipsychotics include:
- Dose reduction or switching to an alternative medication with a lower risk of extrapyramidal symptoms
- Use of beta-blockers or anticholinergics for symptomatic management
- Regular monitoring for tremors and other movement disorders to allow for early intervention
- Awareness of the potential for cognitive side effects with certain medications, particularly in elderly patients
- Consideration of the patient's overall clinical context, including the presence of other medical conditions or the use of concurrent medications that may influence the risk of tremors or other side effects.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Atypical Antipsychotics and Tremors
- Atypical antipsychotics are commonly prescribed medications that can cause various adverse effects, including extrapyramidal symptoms such as tremors 2.
- Tremors associated with atypical antipsychotics can be a result of drug-induced parkinsonism (DIP), which often presents as bradykinesia and rigidity, as well as rhythmic tremor 3.
- The prevalence of DIP and tardive dyskinesia (TD) among antipsychotic users can range from approximately 20 to 35% 3.
- Management strategies for atypical antipsychotic-induced tremors can include switching to a different antipsychotic medication with a lower propensity for DIP, or using anticholinergic agents such as benztropine, although these can worsen TD 3.
- Amantadine, a non-anticholinergic agent, may be preferred in patients with comorbid DIP and TD 3.
Comparison of Atypical Antipsychotics
- Quetiapine, an atypical antipsychotic, has been compared to other atypical antipsychotics in terms of its effects on schizophrenia and schizophrenia-like psychoses 4, 5.
- Efficacy data tend to favor olanzapine and risperidone over quetiapine, but the clinical meaning of these data is unclear 4, 5.
- Quetiapine may produce fewer movement disorders, such as tremors, compared to olanzapine and risperidone 4, 5.
- However, quetiapine may also lead to greater weight gain and cholesterol increase compared to some other atypical antipsychotics, such as ziprasidone 4, 5.