What is the relationship between antipsychotics and gastric dysmotility?

From the Guidelines

Antipsychotic medications, particularly first-generation antipsychotics like prochlorperazine and chlorpromazine, can exacerbate gastric dysmotility due to their dopamine-blocking properties. The relationship between antipsychotics and gastric dysmotility is complex, and managing patients on these medications requires careful consideration of their potential effects on gastric motility. According to a recent study 1, phenothiazine antipsychotics, such as prochlorperazine and chlorpromazine, can reduce nausea and vomiting by inhibiting dopamine receptors in the brain, but their use in gastroparesis has not been extensively studied.

Key Considerations

• First-generation antipsychotics like haloperidol and chlorpromazine typically have stronger effects on gastric motility than second-generation agents 1.
• Clozapine is particularly associated with severe constipation, which can progress to potentially fatal complications like ileus or bowel obstruction.
• When managing patients on antipsychotics who develop gastric dysmotility, consider switching to an antipsychotic with lower anticholinergic burden such as aripiprazole, lurasidone, or ziprasidone.

Treatment Options

• Prokinetic agents like metoclopramide (10mg three times daily before meals) can help, though use should be limited to 12 weeks due to risk of tardive dyskinesia 1.
• Prucalopride (2mg daily) offers another option without dopamine antagonism.
• For constipation, recommend increased fluid intake, dietary fiber, regular exercise, and osmotic laxatives like polyethylene glycol (17g daily).

Monitoring and Education

• Patients should be educated about warning signs requiring urgent attention, including severe abdominal pain, distension, vomiting, or absence of bowel movements for several days.
• Regular monitoring of bowel habits is essential, especially when initiating or changing antipsychotic therapy, with particular vigilance for patients on clozapine or multiple anticholinergic medications.

From the FDA Drug Label

Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Esophageal dysmotility and aspiration have been associated with antipsychotic drug use, including aripiprazole.

The relationship between antipsychotics and gastric dysmotility is that esophageal dysmotility has been associated with antipsychotic drug use. This suggests a potential link between the use of antipsychotics and the development of gastric dysmotility, particularly esophageal dysmotility. Patients at risk for aspiration pneumonia should be treated with caution when prescribed antipsychotic drugs, such as quetiapine and aripiprazole 2 3. Key points include:

• Esophageal dysmotility and aspiration have been associated with antipsychotic drug use
• Antipsychotic drugs, including quetiapine and aripiprazole, should be used cautiously in patients at risk for aspiration pneumonia
• Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, particularly those with advanced Alzheimer's dementia

From the Research

Relationship Between Antipsychotics and Gastric Dysmotility

• The relationship between antipsychotics and gastric dysmotility is complex, with various studies suggesting that antipsychotics can cause gastrointestinal side effects, including dysphagia, esophageal dysmotility, and gastric hypomotility 4, 5.
• A case report and review of the literature found that all antipsychotics are associated with extrapyramidal symptoms (EPS), which can present as dysphagia, esophageal dysmotility, or aspiration 4.
• A retrospective cohort study found that the use of antipsychotics, particularly clozapine and quetiapine, was associated with an increased risk of gastrointestinal hypomotility, including constipation, ileus, and ischemic bowel disease 5.
• Another study found that quetiapine, an atypical antipsychotic, may be beneficial in managing severe refractory functional gastrointestinal disorders, including mitigating associated anxiety and sleep disturbances, augmenting the effect of antidepressants, and providing an independent analgesic effect 6.

Mechanisms and Management

• The mechanisms of antipsychotic-induced dysphagia and gastric dysmotility are not fully understood, but may be related to extrapyramidal adverse reactions or anticholinergic effects of antipsychotics 4.
• Management of dysphagia and gastric dysmotility in patients taking antipsychotics includes discontinuing the antipsychotic, reducing the dose, dividing the dose, or switching to another antipsychotic 4.
• A review of the literature found that low to modest dosages of tricyclic antidepressants and serotonin noradrenergic reuptake inhibitors may be effective in treating chronic gastrointestinal pain and painful functional gastrointestinal disorders, and that augmentation with antipsychotics such as quetiapine or aripiprazole may be beneficial in some cases 7.

Specific Antipsychotics and Gastric Dysmotility

• Clozapine and quetiapine have been associated with an increased risk of gastrointestinal hypomotility, including constipation, ileus, and ischemic bowel disease 5.
• Aripiprazole has been found to be well-tolerated and not associated with significant extrapyramidal side effects, hyperprolactinaemia, or cardiac rhythm disturbance, but its effects on gastric dysmotility are not well-studied 8.
• Quetiapine has been found to be beneficial in managing severe refractory functional gastrointestinal disorders, but may cause somnolence and lack of gastrointestinal benefits in some patients 6.