Antipsychotic Pharmacotherapy and Orthostatic Hypotension

Abstract

Orthostatic hypotension is a common adverse effect of antipsychotics that may delay or prevent titration to a dose necessary to control psychotic symptoms. Complications of orthostatic hypotension include syncope, transient ischaemic attack, stroke, myocardial infarction and death. The risk of orthostatic hypotension associated with antipsychotic therapy is increased in patients with disorders of the autonomic nervous system, fluid imbalance and those taking concomitant drug therapy that affects haemodynamic tone. Prospective monitoring for changes in postural blood pressure is important because patients with psychotic disorders often do not articulate symptoms of orthostasis and the subjective report of dizziness does not correlate well with orthostatic blood pressure changes. Nonpharmacological strategies and patient education, most notably, slowly rising from the supine position, are crucial first steps in the prevention and treatment of both symptomatic and asymptomatic orthostatic hypotension. Pharmacological treatment is only recommended when symptomatic orthostatic hypotension persists despite proper nonpharmacological therapy and there is a compelling indication for antipsychotic treatment. Fludrocortisone is a reasonable first choice for symptomatic orthostatic hypotension. Other agents including desmopressin and midodrine may be considered in patients who do not respond favourably to a trial of fludrocortisone, but safety concerns and lack of evidence limit the utility of these agents.

Blood pressure monitoring in psychiatric inpatients with bipolar affective disorder

“…These medicines have a variety of effects on blood pressure. Antipsychotics most often lower blood pressure, in particular causing orthostatic hypotension, 51,52 although some, most notably clozapine, also have a propensity to elevate blood pressure, probably through an affinity for alpha2-adrenergic receptors. 53,54 Of the antidepressant medicines, the tricyclics (TCAs) and serotonin-noradrenergic reuptake inhibitors (SNRIs) are associated with hypertension, through noradrenergic potentiation.…”

Quetiapine and Refractory Hypotension During General Anesthesia in the Operating Room

“…7 Several reports have described hypotensive episodes with overdoses of quetiapine that have been effectively treated with intralipids. 4,[8][9][10] Quetiapine's antagonism of adrenergic α 1 receptors may explain the postural hypotension observed with this drug (Table 1, Ref. 1).…”

“…Postural hypotension is a more common adverse effect with second-generation antipsychotics than first-generation antipsychotics. 4 Among the second-generation class, clozapine and quetiapine have the highest incidence of postural hypotension, followed by iloperidone, lurasidone, and asenapine. 4 The patient was also taking venlafaxine and lamotrigine.…”

“…4 Among the second-generation class, clozapine and quetiapine have the highest incidence of postural hypotension, followed by iloperidone, lurasidone, and asenapine. 4 The patient was also taking venlafaxine and lamotrigine. There have been no case reports of these drugs precipitating adverse reactions during anesthesia.…”

Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism

“…The DIP patients were subgrouped according to their underlying diseases (psychiatric diseases vs. functional dyspepsia or gastrointestinal prophylaxis) since patients with a psychiatric disease may experience some degree of autonomic dysfunction and most neuroleptics have the side effect of OH and act on dopaminergic, noradrenergic, cholinergic, and serotonergic pathways,1112131415161718 whereas most prokinetics mainly inhibit the dopamine D2 receptor in the central nervous system. 192021 Twenty-five age-matched healthy subjects free from neur,logical disease were enrolled as controls.…”