From the Guidelines
Extrapyramidal side effects (EPSE) should be managed by using the lowest effective dose of antipsychotics, considering switching to atypical antipsychotics with lower EPSE risk, and administering anticholinergics or other medications as needed to alleviate symptoms. The management of EPSE depends on the specific type of side effect, with different approaches for acute dystonic reactions, drug-induced parkinsonism, akathisia, and tardive dyskinesia.
- For acute dystonic reactions, anticholinergics such as benztropine 1-2mg IM/IV can provide immediate relief, followed by oral benztropine 1-2mg twice daily for 2-3 days 1.
- For drug-induced parkinsonism, oral anticholinergics like benztropine 1-2mg twice daily or diphenhydramine 25-50mg three times daily can be used 1.
- Akathisia often responds to beta-blockers like propranolol 10-30mg three times daily or benzodiazepines such as lorazepam 0.5-2mg twice daily 1.
- For tardive dyskinesia, prevention is key, and valbenazine 40-80mg daily or deutetrabenazine 6-48mg daily (in divided doses) are FDA-approved treatments 1. It is essential to note that atypical antipsychotics have a lower risk of EPSE compared to typical antipsychotics, and medications like risperidone, olanzapine, and quetiapine can be used with caution, considering their potential side effects 1. Early recognition and intervention are crucial to prevent progression to more persistent forms like tardive dyskinesia.
From the Research
EPSE Overview
- Extrapyramidal symptoms (EPSEs) are a common side effect of antipsychotic medication, with a pooled prevalence of 37% (95% CI: 18-55%) among patients taking antipsychotic medications 2.
- The prevalence of antipsychotic-induced parkinsonism, akathisia, and tardive dyskinesia was 20% (95% CI: 11-28%), 11% (95% CI: 6-17%), and 7% (95% CI: 4-9%), respectively 2.
Comparison of Antipsychotics
- Clozapine has a lower propensity to cause EPSEs compared to conventional antipsychotics, with a point-prevalence of akathisia of 7.3% in the clozapine group, compared to 23.8% in the group treated with conventional antipsychotics 3.
- Risperidone produces some EPSEs, but at levels lower than those of conventional antipsychotics, with a point-prevalence of akathisia of 13% in the risperidone group 3.
- Atypical antipsychotics, such as olanzapine, quetiapine, risperidone, and sertindole, are associated with less frequent use of antiparkinson medication than haloperidol, with risperidone appearing to have a slightly less favourable EPS-profile than the other new antipsychotics 4.
Management and Prevention
- The treatment of acute EPSEs and tardive dyskinesia now includes atypical antipsychotic therapy itself, although other adjunctive strategies such as antioxidants have also shown promise in preliminary trials 5.
- Appropriate prevention and early management of EPSEs can enhance the net benefits of antipsychotics 2.
- The EPS advantages offered by the atypical antipsychotics must be balanced against other important adverse effects, such as weight gain and diabetes mellitus, now known to be associated with these drugs 5.