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Introducing Th E First Step-By-Step Rehabilitation Program Introducing the first step-by-step rehabilitation program for the PVD patient Major Side Effects of Antipsychotic Drugs K. D. Charalampous, MD and G. A. Keepers, MD Houston, Texas Since the introduction of phenothiazines into clinical practice in 1952, over 250 million people have received these drugs for the treatment of psychotic states. In addition to the phenothiazines, five other classes of neuroleptic medications are now in use: butyrophenones, thioxanthenes, dihydroin- dolones, diphenylbutylpiperidines, and dibenzoxazepines. Besides their use in the treatment of psychosis, these drugs have been used in the treatment of anxiety, depression, nausea, alcoholic withdrawal, and pain, and are often adminis­ tered in combination with other medications. Through the use of these drugs, many psychotic patients have been able to move back into the community, and the family physician is coming into contact with more patients on maintenance dos­ ages of neuroleptics. He/she may wish to prescribe these drugs or may, in the treatment of a medical problem, need to pre­ scribe other medication to an individual already receiving neuroleptics. It is important, therefore, for the family physi­ cian to be aware of the side effects of these drugs and of complications which can arise when neuroleptics are given in combination with other families of drugs. The actions of neuroleptic agents are amazingly system and the autonomic nervous system. There ubiquitous and involve every organ system. Cen­ are a host of other actions including antiemetic, trally, they are dopamine-blocking agents, affect­ antihistaminic, and antipyretic. The antipsychot- ing neural transmission from the cortex to the ics, nevertheless, have a high therapeutic index brain stem and even hypothalamic control of and are remarkably safe agents. Death from pituitary function. Peripherally, they are both po­ an overdose is a rare event. Most known side ef­ tent alpha adrenergic-blocking agents and an­ fects are extensions of the pharmacological ac­ ticholinergic agents affecting the cardiovascular tions of these drugs, the most important being those on the central nervous system, endocrine system, and cardiovascular system. In addition, there are a few toxic and idiosyncratic effects un­ related to the antipsychotic actions or to the in­ teractions resulting from their concomitant pre­ From the Department of Psychiatry, Baylor College of Medicine, Houston, Texas. Requests for reprints should be scription with other medications. This article ex­ addressed to Dr. K. D. Charalampous, Department of Psy­ plores the major side effects of these drugs (Table chiatry, Texas Tech University School of Medicine, P.O. Box 4569, Lubbock, TX 79409. 1) and their interactions with other medications 993 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 5, 1978 ANTIPSYCHOTIC DRUGS (Table 2) beginning with the central nervous sys­ are acute, and one—tardive dyskinesia—is tem. chronic. Haloperidol and the piperazine deriva­ tives of phenothiazines seem to produce the acute syndromes more frequently than other anti­ psychotics, while the dibenzoxazepines and thioxanthenes have the lowest incidence of these side effects. Severe extrapyramidal side effects Central Nervous System Effects sometimes delayed by several days, can also occur after depot phenothiazines; however, patients The totality of actions of the antipsychotic maintained on fluphenazine decanoate develop drugs within the central nervous system is not fewer extrapyramidal side effects than those on yet thoroughly understood. The antipsychotics fluphenazine enanthate. appear to affect all neurotransmitters but particu­ Parkinsonism is probably due to a functional larly influence levels of dopamine and norepineph­ dopamine deficiency. It may be indistinguishable rine. By blocking central dopaminergic trans­ from idiopathic parkinsonism. The most notice­ mission, secondary extrapyramidal side effects are able signs are tremor at rest and rigidity; “pill roll­ produced. Dopamine, norepinephrine, and other ing” movements are common; and there is a gen­ neurotransmitters are also implicated in the elec- eralized slowing of volitional movements and a troencephalographic (EEG) and psychobehavioral mask-like facies. The syndrome responds to re­ changes, but the mechanisms are less well under­ duction of dosage, to anticholinergic agents, and stood. according to a recent report, to amantadine.2 All phenothiazines other than promazine and The second acute type, akathisia, is not a spe­ prochlorperazine lower the seizure threshold. cific movement or symptom; it refers rather to an Haloperidol also lowers the seizure threshold and inability of the patient to remain quiescent. The its effects on the EEG are similar to those of the patient feels a compelling need to move, which he phenothiazines. These agents produce slowing of may find impossible to control, and this movement the EEG and increased occurrence of theta waves. may be mistaken for psychological agitation. The The variability of frequencies decreases, while cause of akathisia is not known. It has been shown voltage and burst activity increase. The piperazine that previous hyperthyroidism or hyper­ phenothiazines differ slightly in that they produce parathyroidism increases the risk of acquiring the increased alpha wave activity as well. disorder. Akathisia responds less frequently to In nonpsychotic individuals, the antipsychotics anticholinergics than other extrapyramidal side ef­ may impair vigilance on various psychomotor fects do; its treatment, therefore, may require re­ tests, may interfere with complex intellectual duction in antipsychotic dosage and the use of functions, and may reduce spontaneous motor ac­ diazepam. tivity. In psychotic patients, neuroleptic medica­ The third acute syndrome, dystonia, is a com­ tions produce psychomotor slowing, emotional mon side effect that may occur early during anti­ quieting, and affective indifference, termed the psychotic treatment. It is most often seen in chil­ neuroleptic activity by Delay and Deniker.1 Addi­ dren and young adults. Torticollis and facial tionally, many neuroleptics produce sedation, al­ grimacing are present and may be accompanied by though there is no correlation between the seda­ oculogyric crises. Dystonia is thought to be due to tive property and therapeutic effectiveness of the transient dopaminergic hyperactivity and is occa­ antipsychotic drugs. The sedative effect may be sionally mistaken for hysteria or seizures, but can useful in the treatment of anxious or agitated pa­ be readily differentiated from them by its response tients. Tolerance develops rapidly to the sedative to anticholinergic agents. The dystonia is self­ effects of these medications but not to the limited and will generally abate without treatment. neuroleptic effects. Mild withdrawal symptoms Severe symptoms may be treated with in­ can occur. tramuscular anticholinergics (eg, benztropine 1 to The administration of antipsychotic drugs may 2 mg), intravenous caffeine sodium benzoate (500 induce several neurological syndromes of which mg), or intramuscular diphenhydramine (50 mg). three—parkinsonism, akathisia, and dystonia— While clinical management for these three acute 994 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 5, 1978 ANTIPSYCHOTIC DRUGS Table 1. Common Side Effects of Antipsychotic Drugs Organ System Drug Family Side Effects Autonomic All antipsychotics anticholinergic: dry mouth blurring of vision urinary retention constipation Phenothiazines perspiration Neurologic Phenothiazines lowered seizure threshold Butyrophenones All antipsychotics extrapyramidal reactions: parkinsonism akathisia dystonia All antipsychotics tardive dyskinesia Endocrinous All antipsychotics hypothalamic susceptibility to hyperpyrexia and hypopyrexia appetite increase All antipsychotics galactorrhea All antipsychotics amenorrhea or dysmenorrhea Cardiovascular Phenothiazines ECG changes Phenothiazines arrhythmias Phenothiazines hypotension Phenothiazines cardiomyopathy Dermatologic All antipsychotics skin rash Phenothiazines photosensitivity y Phenothiazines pigmentation Ocular Phenothiazines lens pigmentation Phenothiazines pigmentary retinopathy Hematologic All antipsychotics leukopenia and agranulocytosis Hepatic phenothiazines obstructive jaundice the j o u r n a l OF FAMILY PRACTICE, VOL. 6, NO. 5, 1978 995 ANTIPSYCHOTIC DRUGS Table 2. Antipsychotic Drug Interactions Antipsychotic Drug Other Medication Interaction Phenothiazines Antiparkinsonian drugs Interference with antipsychotic efficacy Butyrophenones Thioxanthenes Increased risk of tardive dyskinesia Phenothiazines Anticholinergics Additive anticholinergic effects Butyrophenones Tricyclic antidepressants Aggravation of tardive dyskinesia Thioxanthenes Phenothiazines Estrogens Increased plasma levels of antipsychotic drugs Butyrophenones Thioxanthenes Increased risk of extrapyramidal reactions Phenothiazines Barbiturates Reduced plasma levels of antipsychotic drugs Lithium Phenothiazines Antihypertensives Additive hypotensive effect Butyrophenones Thioxanthenes Chlorpromazine Guanethidine and false transmitter antihypertensives Rise in blood pressure Phenothiazines Sympathomimetics Pressor effect inhibited Butyrophenones Thioxanthenes Phenothiazines Norepinephrine Retains hypertensive effect Butyrophenones Thioxanthenes Phenothiazines CNS Depressants Additive CNS depression Butyrophenones Thioxanthenes Chlorpromazine Anticoagulants Potentiate anticoagulant activity 996 THE JOURNAL OF FAMILY PRACTICE,
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