Can Risperidone (atypical antipsychotic) be given to patients with Parkinson's disease?

Risperidone Should Not Be Given to Patients with Parkinson's Disease

Risperidone is contraindicated in patients with Parkinson's disease due to the high risk of worsening motor symptoms and should be avoided in this population. 1

Evidence Against Using Risperidone in Parkinson's Disease

• The FDA drug label for risperidone explicitly warns that "Patients with Parkinson's Disease or Dementia with Lewy Bodies can experience increased sensitivity to RISPERIDONE. Manifestations can include confusion, obtundation, postural instability with frequent falls, extrapyramidal symptoms, and clinical features consistent with neuroleptic malignant syndrome." 1

• Clinical studies have demonstrated that risperidone frequently causes intolerable exacerbation of parkinsonian symptoms in patients with Parkinson's disease, with 5 out of 6 patients in one study experiencing significant motor worsening 2

• Some patients treated with risperidone developed encephalopathy in addition to motor worsening, which resolved when switched to alternative medications 2

Alternative Antipsychotics for Parkinson's Disease

If an antipsychotic is needed for a patient with Parkinson's disease, the following options are recommended:

• First-line options:

  • Quetiapine - Well-tolerated with minimal impact on motor function based on cumulative reports involving >200 Parkinson's disease patients 3
  • Clozapine - Effective without deterioration of motor function, but requires blood monitoring due to risk of agranulocytosis 3, 4
  • Pimavanserin - A selective 5-HT2A inverse agonist specifically approved for Parkinson's disease psychosis 5, 6

• Dosing considerations:

  • Start with low doses and titrate slowly 5
  • For quetiapine: Initial dose of 12.5 mg twice daily; maximum 200 mg twice daily 5
  • For clozapine: Start at very low doses (6.25-12.5 mg daily) 3

Mechanism of Harm

• Risperidone has a higher affinity for D2 dopamine receptors compared to quetiapine and clozapine, which explains its greater propensity to worsen parkinsonian symptoms 3

• Among atypical antipsychotics, risperidone appears to be the most likely to produce extrapyramidal side effects 5

• In a comparative study, risperidone worsened motor UPDRS scores while clozapine actually improved them 4

Clinical Outcomes and Consequences

• Patients treated with risperidone may require nursing home placement due to severe worsening of parkinsonism 2

• One patient required a feeding gastrostomy due to worsening parkinsonism during risperidone treatment, but was able to return home and have the gastrostomy removed after switching to clozapine 2

• Psychosis in Parkinson's disease is the strongest known risk factor for nursing home placement, making effective and safe treatment crucial 3

Conclusion

Risperidone should be avoided in patients with Parkinson's disease. If antipsychotic treatment is necessary, quetiapine, clozapine, or pimavanserin should be used instead, with careful monitoring for side effects and at the lowest effective dose. 5, 3, 6