Antipsychotics: metabolic monitoring, movement disorders and NMS

Baseline and follow-up monitoring

Intervals follow the ADA, APA and consensus recommendations; use the schedule your guideline names.

Telling the movement disorders apart

1. 01

   Acute dystonia

   Hours to days after starting or raising a high-potency antipsychotic. Painful muscle spasms of the neck, jaw or eyes (oculogyric crisis). Treat with benztropine or diphenhydramine. A laryngeal dystonia is an emergency.

2. 02

   Akathisia

   An inner restlessness with an urge to move, within days to weeks. Often mistaken for agitation or worsening psychosis. Reduce the dose, switch agents, or add propranolol; benzodiazepines may help.

3. 03

   Parkinsonism

   Tremor, rigidity, bradykinesia within weeks. Lower the dose or switch to a drug with less dopamine blockade. Anticholinergics can be used if needed.

4. 04

   Tardive dyskinesia

   Involuntary movements of the mouth, tongue or limbs after months to years. Screen with the AIMS. Options include switching to a lower-risk agent and a VMAT2 inhibitor such as valbenazine or deutetrabenazine.

Drug-specific points the exam likes

• ·Clozapine: reserved for treatment-resistant schizophrenia and reduced suicidal behavior. Severe neutropenia, myocarditis, seizures, sialorrhea and constipation are the key risks. Check current labeling for the neutrophil monitoring requirements.
• ·Olanzapine and clozapine carry the largest weight gain and metabolic risk.
• ·Prolactin elevation with risperidone and paliperidone: amenorrhea, galactorrhea, sexual dysfunction.
• ·QT prolongation: ziprasidone and, to a lesser degree, others. Consider an ECG and electrolytes when risk factors are present.
• ·Boxed warning: increased mortality in elderly patients with dementia-related psychosis.