What is the best antipsychotic to use in patients with psychosis and esophageal dysmotility?

From the Guidelines

For patients with psychosis and esophageal dysmotility, aripiprazole is the best antipsychotic choice due to its minimal anticholinergic effects and lower risk of worsening gastrointestinal motility issues. When considering the treatment of patients with schizophrenia, the American Psychiatric Association practice guideline recommends a comprehensive and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments 1. In the context of esophageal dysmotility, it is crucial to select an antipsychotic with a low anticholinergic burden to avoid exacerbating gastrointestinal symptoms. Aripiprazole, with its unique partial agonist activity at dopamine receptors, provides antipsychotic efficacy while causing fewer extrapyramidal and metabolic side effects, making it an ideal choice for patients with psychosis and esophageal dysmotility.

Key Considerations

• A typical starting dose of aripiprazole is 5-10 mg daily, which can be titrated up to 15-30 mg daily based on response and tolerability.
• Other reasonable options include quetiapine and lurasidone, which also have relatively low anticholinergic burden.
• High anticholinergic antipsychotics like clozapine, olanzapine, and chlorpromazine should be avoided as they can significantly worsen esophageal dysmotility by reducing smooth muscle contractions in the GI tract.
• Regular monitoring of both psychiatric symptoms and esophageal function is recommended, and consultation with both psychiatry and gastroenterology may be beneficial for optimal management of these co-occurring conditions.

Treatment Approach

• The treatment plan should be comprehensive and person-centered, including evidence-based nonpharmacological and pharmacological treatments 1.
• Patients with schizophrenia should be treated with an antipsychotic medication and monitored for effectiveness and side effects, as recommended by the APA 1.
• The selection of antipsychotic medication should be based on the individual patient's needs and medical history, taking into account the potential risks and benefits of each medication.

From the FDA Drug Label

5.13 Dysphagia Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, in particular those with advanced Alzheimer's dementia. Ziprasidone and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia [see Boxed Warning] . 5.18 Dysphagia Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, in particular those with advanced Alzheimer's dementia. Quetiapine and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia.

There is no best antipsychotic to use in patients with psychosis and esophageal dysmotility, as both ziprasidone and quetiapine should be used cautiously in these patients due to the risk of aspiration pneumonia.

• Key considerations:
  • Esophageal dysmotility and aspiration have been associated with antipsychotic drug use.
  • Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients.
  • Cautious use is recommended for patients at risk for aspiration pneumonia. 2 3

From the Research

Antipsychotic Options for Patients with Psychosis and Esophageal Dysmotility

• The choice of antipsychotic for patients with psychosis and esophageal dysmotility should be based on the individual patient's needs and medical history, as there is no single best option 4.
• A case report suggests that switching from olanzapine to aripiprazole may improve symptoms of dysphagia and esophageal dysmotility in some patients 4.
• Quetiapine has been shown to be effective in the treatment of schizophrenia, with a lower risk of extrapyramidal symptoms compared to some other antipsychotics 5, 6.
• However, quetiapine may not be the best option for all patients, as it has been associated with weight gain, sedation, and increased risk of QTc prolongation 7, 6.
• Risperidone and olanzapine have been shown to be effective in the treatment of psychosis, but may have a higher risk of extrapyramidal symptoms and weight gain compared to quetiapine 8, 7, 6.
• Aripiprazole may be a good option for patients with esophageal dysmotility, as it has been shown to have a lower risk of extrapyramidal symptoms and weight gain compared to some other antipsychotics 4, 6.

Key Considerations

• The risk of extrapyramidal symptoms, including dysphagia and esophageal dysmotility, should be carefully considered when choosing an antipsychotic 4, 5, 6.
• Patients with a history of esophageal dysmotility or dysphagia may require closer monitoring and dose adjustments when taking antipsychotics 4.
• The potential benefits and risks of each antipsychotic should be carefully weighed, taking into account the individual patient's needs and medical history 8, 7, 6.