From Chlorpromazine to Clozapine—Antipsychotic Adverse Effects and the Clinician's Dilemma

Abstract

The pharmacotherapy of schizophrenia remains an ongoing challenge for researchers and clinicians alike. Current medications remain suboptimal to effectively treat this illness despite the recent surge of what are considered to be better antipsychotics: the atypicals. The atypicals cause fewer extrapyramidal symptoms and tardive dyskinesia, but there is growing concern regarding the significant long-term metabolic and cardiac adverse effects of these novel antipsychotics. There are differences among the atypicals in their propensity to produce these adverse effects, and clinicians should weigh the risk-benefit ratio for each drug with each individual patient. Diabetes, heart disease, obesity, and unhealthy lifestyle choices are on the rise in the general population, and individuals with chronic schizophrenia are even more at risk. The dilemma clinicians face in trying to avoid the neurological morbidity of the typicals (extrapyramidal side effects and tardive dyskinesia) is the risk of consequently exposing patients to both the morbidity and potential mortality of the atypicals (cardiovascular, endocrine, and metabolic adverse effects). The importance of baseline investigations and monitoring at regular intervals as well as identification of patients at risk for obesity, diabetes, and cardiovascular morbidity has become crucial. Informed decision making is essential for successful antipsychotic pharmacotherapy. For a condition, which often necessitates long-term pharmacotherapy, the importance of prevention and (or) minimization of morbidity and mortality related to adverse effects of such pharmacotherapy cannot be understated.

Sudden cardiac death and antipsychotics Part 2: Monitoring and prevention

“…Unfortunately, these are particularly common in people with schizophrenia. In addition, obesity, hyperlipidaemia and glucose intolerance may be exacerbated by antipsychotic drug therapy (Abidi & Bhaskara, 2003). This suggests that cardiac safety should be a routine part of clinical care.…”

Metabolic Risk with Second-Generation Antipsychotic Treatment: A Double-Blind Randomized 8-Week Trial of Risperidone and Olanzapine

“…The first-generation antipsychotics were widely used for treatment of psychotic symptoms in the past several decades, however their routine use has been hindered due to extrapyramidal effects and tardive dyskinesia (1). Second-generation antipsychotics (SGA) effectively counter the movement side effects, and produce superior results with respect to affect flattening, alogia, and avolition in many people, albeit from secondary negative symptoms (2).…”

Why and how antipsychotic drugs are used in 40 Sydney nursing homes

“…These drugs have been found to possess efficacy at least equal to haloperidol, but with a lower potential for producing extrapyramidal symptoms than 'conventional' antipsychotics (Edell and Tunis, 2001;Wirshing WC, 2001). However, the dilemma clinicians face in trying to avoid drug-induced neurological morbidity by using atypical antipsychotic medication is the risk of cardiovascular, endocrine and metabolic adverse effects (Abidi and Bhaskara, 2003).…”