Extrapyramidal Side Effects

Question 1

Full complement of extrapyramidal side effects from antidopaminergics

Answer 1

1. Acute dystonias
2. Neuroleptic parkinsonism
3. Akithisia
4. Neuroleptic malignant syndrome
5. Tardive dyskinesia / Tardive disorders

Question 2

Risk factors for medication-induced acute dystonic reaction

Answer 2

• Male biological sex
• Young age
• High dose of antipsychotic
• 1st generation antipsychotic

Question 3

Neuroleptic-induced parkinsonism

Answer 3

“Pill-rolling” resting tremor, cogwheel rigidity, bradykinesia/akinesia

Generally occurs within a few weeks of the initiation or increase in dose of an antipsychotic

Question 4

Risk factors for medication-induced parkinsonism

Answer 4

• Older age
• Male biological sex

Question 5

Single most common dopamine-antagonist induced movement disorder

Answer 5

Akathisia

Question 6

Akathisia

Answer 6

Described as a subjective feeling of restlessness, which may include anxiety, pacing, or frequent sitting/standing

Generally occurs within several days to weeks of starting or increasing the dose of a dopamine antagonist

Question 7

Risk factors for medication-induced akathisia

Answer 7

• Older age
• Female biological sex

Question 8

NMS timecourse and treatment

Answer 8

Develops within 30 days of initiation/dose increase of antipsychotics

Question 9

Which dystonic reactions require emergent treatment?

Answer 9

Occulogyric crisis

Laryngospasm

Question 10

Some common/classical dystonic reactions

Answer 10

Occulogyric crisis

Torticollis

Retrocollis

Laryngospasm

Question 11

Treatment of an acute dystonic reaction

Answer 11

Anticholinergics (namely benztropine) OR centrally acting antihistamines with anticholinergic activity (namely diphenylhydramine)

Resolutuon is rapid following administration of these medications, but doses may need to be repeated one or several times.

Once the acute episode is addressed, consideration should be given to decreasing antipsychotic dose, switching to an antipsychotic less likely to cause dystonia, or continuing oral anticholinergic agents.

Question 12

Treating medication-induced akathisia

Answer 12

Beta blockers, if treatment is necessary

However, if the patient is just starting out on antipsychotic therapy, the preferred method is to switch to a different antipsychotic or try a lower dose

Question 13

Treatment of tardive dyskinesia

Answer 13

Remove the offending agent

Clonazepam or valbenazine (selective vesicular monoamine transporter-2 inhibitor) are FDA approved for this condition

Question 14

Treatment of drug-induced parkinsonism

Answer 14

Treated with anticholinergic agents, such as benztropine or diphenylhydramine

Similar thought process to acute dystonias, but more chronically.