Sue Henderson EPSE & NMS Sue Henderson. Sue Henderson Well, I did warn you about the side effects...
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Transcript of Sue Henderson EPSE & NMS Sue Henderson. Sue Henderson Well, I did warn you about the side effects...
Sue Henderson
Well, I did warn you about the
side effects
Those tablets you gave me are great but they’re making me walk
like a crab
Sue Henderson
Low potency V High potency
• Low potency Chlorpromazine (Largactil) 100mg is equivalent to 2mg of Haloperidol (serenace) a high potency anti-psychotic.
• High potency: high rates of Extra Pyramidal Side Effects (EPSE)
• Low potency: high rates of anti-cholinergic side effects
Sue Henderson
Low Potency V High Potency
High Anti-cholinergic & Sedative effects
High EPSE
Haloperidol 2 mg
Chlorpromazine
100 mg
Sue Henderson
Extra pyramidal side effects (EPSE)
• Acute dystonias: Oculogyric crisis, Torticollis, Lock jaw, Laryngeal spasm, Opisthotonos
• Akathisia
• Parkinsonism (Rigidity, bradykinesia, tremor)
• Tardive dyskinesia
Sue Henderson
Dystonia: Oculogyric Crisis
• Muscles that control eyes movements spasm.
• Eyes roll up & person is unable to look downward.
Sue Henderson
Dystonia: Torticollis
• Spasm of neck muscles.
• Neck is flexed backwards or to the side.
Sue Henderson
Dystonia: Lock jaw (Trismus)
• Spasm of jaw muscle, also often involves the muscles of the tongue and floor of the mouth.
Sue Henderson
Dystonia: Laryngeal spasm
• Rare but potentially fatal reaction causing difficulty with breathing. High risk: Young males on high potency antipsychotic with no anti-parkinson drug.
Sue Henderson
Treatment Laryngeal spasm
• Emergency.
• Stat parenteral benztropine (cogentin).
• Maintain airway
• Prevention: Concurrent antiparkinson or diazepam for young males on high potency antipsychotics
Sue Henderson
Akathisia (Most common EPSE)
• Restlessness, an irresistible urge to move (unable to sit still, pacing) and a feeling of “nervous energy”.
• Often mistaken for agitation. Worsened by additional antipsychotic dosage.
• Common cause of non compliance.
Sue Henderson
Parkinsonism
• Muscle stiffness, rigidity, (cogwheel & lead pipe) shuffling gait, tremor, pill rolling, loss of facial expression, slowed movement (bradykinesia), reduced arm swing, absent movement (akinesia), drooling, stooped posture, tremor of lips (rabbit syndrome).
Sue Henderson
Pyramid shapeDrug induced
Parkinsonism
(reversible)
Dopamine & acetylcholine in balance = normal function
Dopamine blockade, upsets balance = tremor, rigidity, akinesia
Sue Henderson
Tardive Dyskinesia
• Serious, potentially irreversible, effect of prolonged antipsychotics. Abnormal, involuntary movements of the face, eyes, mouth, tongue, trunk, limbs.
• Most common: twisting, protruding, darting tongue movements.
• Chewing & sideways jaw movements.
• Facial grimacing.
Sue Henderson
Neuroleptic Malignant Syndrome (NMS)
• Rare but potentially fatal• Muscular rigidity (may be localised to
head & neck), incontinence, confusion or delirium, excessive variation in BP& P & high Temp.
• Presentation highly variable: hours after 1st dose to unexpected appearance after months of uneventful treatment.
Sue Henderson
Treatment NMS
• Early detection vital to recovery
• Stop anti-psychotic
• Hydration
• Transfer to ICU
• Bromocriptine 5-10 mg tds but if no response
• Dantrolene
Sue Henderson
S/E Drugs: Classification
1. Antiparkinson: Benztropine (Cogentin), benzhexol, biperiden, orphenadrine
2. Other drugs used to treat EPSE’s
3. Benzodiazepines.
4. Dopamine agonist: Bromocriptive (NMS)
5. Beta blocker: Propanolol (Inderal) & Clonidine (Catapres, Dixarit)
Sue Henderson
Side Effect Drugs: Action
<
=
>
=
ACh
ACh
ACh
ACh
DA
DA
DA
DA
Excess levels of dopamine (positive schizophrenia)
Dopamine blocking antipsychotic drugs decrease effect of dopamine
Sometimes antipsychotic drugs block too much dopamine creating a pseudo-parkinsonism
Antiparkinson block ACh restoring a relative balance.
Sue Henderson
S/E Drugs Prescription
Routine prescription not advised because:
• Not all people develop EPSE’s
• Decrease effect of antipsychotics.
• Risk of worsening Tardive Dyskinesia.
Sue Henderson
Side effect drugs cont…
• EPSE drugs have side effects also.
• Potential for abuse.
• Severity of EPSE’s fluctuate
• Exception: Young males on high potency antipsychotic (high risk of EPSE)
Sue Henderson
Antiparkinson SE (anticholinergic)• Common: dry mouth, dilated pupils, urinary
hesitancy, constipation & G.I. Upset, nausea, blurred vision.
• Less common: tachycardia, dizziness, hallucinations, euphoria, excitement, delirium, hyperpyrexia.
• Mneumonic for anticholinergic (O/D)
• Dry as a bone, red as a beet, blind as a bat, hot as a furnace, mad as a hatter.
Sue Henderson
EPSE risk factor tool
Patient factors:• Age > 40• Sex: Females,
males > 30 years• History ECT,
previous EPSE• Cognitive or
mood disorder
Treatment factors:• High/moderate
potency• Prolonged exposure• Depot injections• 2 or more
antipsychotics• No prophylactic
antiparkinson
Sue Henderson
Antiparkinson effectiveness for EPSE
Good response:
1. Parkinsonism
2. Dystonias
Poor Response
• Akathisia
Made Worse:
• Tardive dyskinesia
Sue Henderson
Summary EPSE management
DISCONTINUEAFTER 2/52
BENZTROPINE(Cogentin)
DYSTONIA90% occur in1st 4.5 days
CHANGE TOATYPICAL ANTIPSYCHOTIC
BENZTROPINE(Cogentin)
REDUCEANTI-PSYCHOTIC
PARKINSONISM90% occur in1st 72 days
BENZTROPINE(Cogentin)
CHANGE TO ATYPICALANTIPSYCHOTIC
BENZODIAZEPINE(Valium)
BETA BLOCKER(Propranalol)
REDUCEANTI-PSYCHOTIC
AKATHISIA90% occur in1st. 73 days
LOWEST POSSIBLEDOSE
CHANGE TOATYPICAL ANTIPSYCHOTIC
CEASE ANTI PSYCHOTICIF POSSIBLE
Regular AIM S assess.to detect early
TARDIVE DYSKINESIAoccurs in 3% onanti-psychotics
Sue Henderson
References
• Aronne, L. J. (2001). Epidemiology, morbidity, and treatment of overweight and obesity. Journal of Clinical Psychiatry, 62(Suppl 23), 13-22.
• Fortinash, K. M., & Holoday-Worret, P. A. (2000). Psychiatric mental health nursing ( 2nd ed.). St. Louis: Mosby.
• Galbraith, A., Bullock, S. & Manias, E. (2001). Fundamentals of pharmacology (3rd ed.). Melbourne: Prentice Hall.
Sue Henderson
References
• Kapur, S., Zipursky, R., Jones, C., Remington, G., & Houle, S. (2000). Relationship between dopamine D-2 occupancy, clinical response, and side effects: A double-blind PET study of first-episode schizophrenia. American Journal of Psychiatry, 157(4), 514-520.
• Kapur, S., Zipursky, R., Jones, C., Shammi, C. S., Remington, G., & Seeman, P. (2000). A positron emission tomography study of quetiapine in schizophrenia - A preliminary finding of an antipsychotic effect with only transiently high dopamine D-2 receptor occupancy. Archives of General Psychiatry, 57(6), 553-559.
Sue Henderson
References
• Lindenmayer, J. P. (2001). Hyperglycemia associated with the use of atypical antipsychotics. Journal of Clinical Psychiatry, 62 Suppl 23, 30-38.
• Melkersson, K. I., & Hulting, A. L. (2001). Insulin and leptin levels in patients with schizophrenia or related psychoses - a comparison between different antipsychotic agents. Outcomes Management, 154(2), 205-212.
Sue Henderson
References
• Therapeutic guidelines. (2000). Psychotropic version 4. Melbourne: Therapeutic Guidelines Limited. Call Number: 615.788 P974P2000
• Turrone, P., Kapur, S., Seeman, M. V., & Flint, A. J. (2002). Elevation of prolactin levels by atypical antipsychotics. American Journal of Psychiatry, 159(1), 133-135.
• Wirshing, D. A., Spellberg, B. J., Erhart, S. M., Marder, S. R., & Wirshing, W. C. (1998). Novel Antipsychotics and New Onset Diabetes. Biological Psychiatry, 44(8), 778-783.