Management of common adverse effects of antipsychotic medications

Abstract

The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.

Safety of 80 antidepressants, antipsychotics, anti‐attention‐deficit/hyperactivity medications and mood stabilizers in children and adolescents with psychiatric disorders: a large scale systematic meta‐review of 78 adverse effects

“…Finally, this meta‐review does not include data on strategies to prevent or mitigate adverse events of psychotropic medications in youth. While this is clearly an important area, this topic is beyond the scope of the present review and needs to be considered on the basis of targeted reviews and studies focusing on specific adverse events of individual medications 195‐201 .…”

The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness

“…Beyond causes seen in the general population, postural hypotension may be related to psychotropic medication, notably clozapine and quetiapine 200 . If increased fluid intake and salt consumption are ineffective, dose adjustment of switch of the responsible psychiatric medication should first be considered, followed by non-pharmacological therapy (appendix page 22: Table 3.6) with regular blood pressure monitoring.…”

Olanzapine Versus Haloperidol for Treatment of Delirium in Patients with Advanced Cancer: A Phase III Randomized Clinical Trial

“…All TRAEs resolved without sequelae when the study drug was discontinued. The use of antipsychotics is associated with QTc prolongation, which can lead to life‐threatening arrhythmia . In this study with routine ECG assessment, only one atrioventricular block episode was reported in the haloperidol arm.…”