Antipsychotic Side Effect Management: Movement Related Disorders Defined by the tetrad of fever, rigidity, mental status change, and autonomic instability Neuroleptic Malignant Syndrome Consult with pyschiatry before Stop antipyschotic and hospitalize restarting antipsychotic in the future Extrapyramidal Symptom Disorders Tardive Dyskinesia Acute Dystonia Akathisia Parkinsonism Reduce dose or switch to a Reduce dose or switch to a Stop offending different antipsychotic (if an different antipsychotic (if an medication and proceed Taper antipsyhotic and discontinue antipsychotic is needed) and antipsychotic is indicated) and with symptomatic anticholinergic agents proceed with symptomatic proceed with symptomatic treatment concurrently treatment concurrently treatment concurrently 1. Benztropine 1. Beta blocker 1. Benztropine 2. Diphenhydramine 2. Benztropine Consider neurology referral 2. Diphenhydramine 3. Benzodiazepine 3. Benzodiazepine ANTIPSYCHOTIC SIDE EFFECTS Antidiabetic/ Metformin DOSING: IR - Starting dose 500mg once or twice daily. Increase by 500mg/dose increments every 1-2 weeks, based on tolerability. Glucophage Max dose 1000mg twice daily. ER - Starting dose 500mg daily. Increase by 500mg/day increments weekly, based on tolerability. Weight Loss Max dose 2000mg/day. Agent SIDE EFFECTS: (common) diarrhea, nausea, flatulence, abdominal bloating; (rare, serious) lactic acidosis. NOTES: FDA Safety Alert - Lactic Acidosis DOSING: Benztropine Antiparkinson/ Acute Dystonia: Starting dose 1-2mg once (Preferentially IM/IV). Subsequent doses 1-2mg once or twice daily Cogentin Anticholinergic Parkinsonism: Starting dose 0.5mg nightly. Increase by 0.5mg/day every 5 days as clinically indicated and tolerable. May administer in divided doses. Max dose 8mg/day NOTES: Consider SIDE EFFECTS: (common) sedation, dry mouth, blurred vision, constipation, urinary retention; (rare, serious) confusion or delirium, parental administration may worsen angle-closure glaucoma. for severe dystonia. Diphenhydramine DOSING: Acute Dystonia - Starting dose 25-50mg once (Preferentially /IVIM ). Subsequent dose 25mg every 4-6 hours as needed Benadryl for continued symptoms. SIDE EFFECTS: (common) Sedation, dry mouth, ataxia, constipation, urinary retention, blurred vision; (rare, serious) tachycardia. NOTES: FDA Safety Alert- September 2020. The FDA has issued a drug safety communication arningw that taking higher than recommended doses of diphenhydramine can lead to serious heart problems, seizures, coma, or even death. Benzodiazipines Diazepam DOSING: 5mg- 10mg once. Subsequent doses 5-10mg every 6 hours as needed. Max dose 40mg/day. Valium SIDE EFFECTS: (common) somnolence, grogginess, ataxia; (rare, serious) anterograde amnesia, paradoxical reaction, increased fall NOTES: Use with risk, respiratory depression. caution in patients on NOTES: FDA has issued a Drug Safety Communication requiring an update to the Benzodiazepine Box Warning to include the opioids or using alcohol. risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions in order to help improve their safe use. FDA box warning- Risks from concomitant use with opioids. Lorazepam DOSING: Starting dose 0.5mg- 1mg twice daily. May increase dose based on response and tolerability up to 10mg/day in divided Ativan doses. SIDE EFFECTS: (common) somnolence, grogginess, ataxia; (rare, serious) anterograde amnesia, paradoxical reaction, increased fall risk, respiratory depression. NOTES: FDA has issued a Drug Safety Communication requiring an update to the Benzodiazepine Box Warning to include the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions in order to help improve their safe use. FDA box warning- Risks from concomitant use with opioids. β-Blockers Propranolol DOSING: Akathisia- IR - Starting dose 10mg twice daily. Increase by 10-20mg/day in minimum one week as clinically indicated and Inderal tolerable. Max dose 120mg/day. ER - Starting dose 20mg/day. Increase by 10mg/day in minimum one week as clinically indicated and tolerable. Max dose 80mg/day. SIDE EFFECTS: (common) dizziness, fatigue, bradycardia, hypotension, may exacerbate asthma, COPD; (rare, serious) may mask clinical signs of hypoglycemia and hyperthyroidism. NOTES: FDA box warning- Following abrupt discontinuation of therapy with β-blockers, exacerbations of angina pectoris and MI have occurred. 11.