Pharmacy Student Newsletter

Managing common side effects of antipsychotics

By: Vanja Adzovic
PharmD Student (2016) Leslie Dan Faculty of Pharmacy
With appreciation to Mike Boivin

Meet our patient - Priscilla

Patients like Priscilla are commonly seen in practice. Adherence rates for mental health medications are far from optimal. Many patients are concerned about potential adverse effects and the impact these medications might have on their health. Pharmacists are ideally positioned to address nonadherence by actively engaging patients and addressing their concerns.

Role of antipsychotics

Although our patient is using antipsychotics for schizophrenia, they are also commonly used for bipolar disorder, acute agitation, anorexia, and as add-on therapy for depression and obsessive-compulsive disorder (OCD).1 The two classes of antipsychotics used in schizophrenia include first-generation antipsychotics (FGAs) & second-generation antipsychotics (SGAs).1
SGA are considered first line treatment for schizophrenia as they carry a lower risk of extrapyramidal symptoms (drug-induced movement disorders) and tardive dyskinesia (disorder distinguished by involuntary movements of the face and jaw).2 With the exception of clozapine, all antipsychotics have similar efficacy.2-4

Adherence to antipsychotics

Antipsychotic nonadherence is a risk factor for schizophrenia relapse.5 Most hospital readmissions in patients with schizophrenia are secondary to non-adherence.5 Adherence is associated with better outcomes, including improved symptoms and functioning.5

Antipsychotics adverse effects are different for FGAs and SGAs1,4

Most common adverse effects of SGA Most common adverse effects of FGA
Metabolic side effects (weight gain, diabetes, dyslipidemia) Extrapyramidal symptoms (EPS)
Hypotension Hyperprolactinemia
Sedation Sedation
Clinical Practice Tip
Pharmacist’s Letter has developed a Comparison of Atypical Antipsychotics to help pharmacists quickly compare the different risks with this class.

Weight gain and diabetes are concerns of many patients

Metabolic side effects, including central obesity, dyslipidemia, hypertension and glucose intolerance, can occur with these medications. Weight gain increases the patient’s cardiovascular disease risk, can affect adherence and further stigmatize this vulnerable patient population.6 The mechanism underlying the development of antipsychotic-induced metabolic abnormalities is unknown.4
Clinical Practice Tip 8-10
Medications with propensity to cause weight gain and diabetes: clozapine > olanzapine > quetiapine > risperidone > lurasidone, paliperidone > ziprasidone, aripiprazole, asenapine.

Poll Question

1. How comfortable would you be screening and evaluating patients for antipsychotic-induced metabolic abnormalities in your pharmacy practice?
a) Very comfortable
b) Somewhat comfortable
c) Not comfortable
Participate now

Managing weight gain and diabetes with antipsychotics

The first step to managing any emergent adverse effect is to have a discussion with the patient and assess the impact of this adverse effect on their life. If the patient is greatly affected and hoping for a solution, consider: 4-6
1. Switch to antipsychotic with lower liability for weight gain or dyslipidemia
2. Treat developing problems symptomatically
a) Antihypertensive for hypertension
b) Statin for dyslipidemia
c) Behavioral weight loss interventions for weight gain
d) Screening and evaluation of metabolic symptoms associated with diabetes

Movement adverse effects can be very bothersome for patients

Extrapyramidal symptoms (EPS) are drug-induced movement disorders caused by the interference of dopamine transmission, which is involved in the control of muscle movement. They include akathisia, parkinsonian syndrome, and dystonias.4 Although SGAs are less likely to cause EPS than the FGAs, it is still a potential side effect.4
Clinical Practice Tip 1,9
Medications with propensity to cause movement effects: paliperidone > risperidone > aripiprazole > ziprasidone, asenapine, lurasidone > olanzapine > quetiapine > clozapine.

Managing movement adverse effects

The management of EPS depends on the specific type of EPS the patient is experiencing. Movement effects are more severe with higher doses. There are three broad management strategies: 4
1. Reduce the dose of the antipsychotic
2. Switch to agent with lower propensity for EPS
3. Consider adjunctive treatment

Using long-acting injectable antipsychotics to address non-adherence

Long-acting injectable (LAI) antipsychotics are an option for patients who forget to take oral medications daily or lack access to stable living arrangements (e.g. homelessness). Recent guidelines recommend offering LAI antipsychotics for people with schizophrenia when any of the following is affecting adherence to oral antipsychotics: 5,11
Patient would prefer LAI after an acute episode
When non-adherence to antipsychotic medication is a clinical priority
The following LAI antipsychotics are currently available:
LAI antipsychotic Frequency of administration
risperidone every 2 weeks
zuclopenthixol decanoate (clopixol depot) every 2 weeks
flupentixol dihydrochloride (fluanxol depot) every 2-3 weeks
pipotiazine palmitate (piportil L4) every 2-3 weeks
fluphenazine decanoate every 2-3 weeks; frequency individualized
haloperidol every 4 weeks
paliperidone palmitate once monthly
aripiprazole once monthly
Advantages of LAI antipsychotics5 Frequency of administration5
Assure stable blood levels, leading to a decreased risk of relapse
Bring the patient in regular contact with the healthcare team
Make it possible to rule out nonadherence in nonresponsive patient
Slow dose titration
Long time needed to reach steady state
Pain at injection site
Patient may not wish to receive injection
Did You Know?
Most patients who have tried LAI prefer it over oral antipsychotics, stating that they feel better and find injections easier to remember.5

Addressing efficacy with antipsychotics

Clozapine is indicated for treatment-resistant schizophrenia (TRS) as it has superior efficacy compared to the other antipsychotics.4 TRS is defined as a clinically inadequate response to two antipsychotics11. Clozapine is restricted to the treatment of TRS as it can cause agranuloctyosis (a dangerous decrease in white blood cells). In patients on clozapine, blood tests are regularly ordered to assess for blood abnormalities.4 The risk of agranulocytosis is highest in the first 6 months of treatment, requiring weekly monitoring of blood cell counts.4 After 6 months, blood monitoring is reduced to every 2 weeks. 4
Clinical Practice Tip:
Patients taking clozapine should be counseled to contact their physician if experiencing signs of infections (fever, chills, sore throat).4
Other side effects of clozapine include sedation, hypersalivation, hypotension, tachycardia, and significant anticholinergic side effects.4 There is an excellent article reviewing the management of clozapine adverse effects.

Revisit the patient case

The reasons for nonadherence can vary for each patient. It is important to ask the patient and discuss the reasons for nonadherence. When you speak with Priscilla, you find that she has gained 10 lbs while on olanzapine and this weight gain is affecting her life. You discuss alternative SGAs and how some SGAs cause less weight gain than others. You contact her psychiatrist and recommend an agent less likely to cause weight gain, such as aripiprazole or ziprasidone.


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