Manage the side effects of antipsychotics

For example, try to avoid QT-prolonging med combos, such as adding amiodarone (Cordarone) or a macrolide (azithromycin) to haloperidol or ziprasidone.

Overview

As a clinical pharmacist, you may be asked to help manage oral antipsychotic side effects in patients with schizophrenia. Second-generation or atypical antipsychotics [risperidone (Apexidone, Risperdal)] are often tried before first-generation or typical medications [haloperidol (Halonace, Safinace)]. But efficacy is mostly similar and side effects can overlap.

Management

Cardiovascular side effects

Cardiovascular concerns, such as QT prolongation and orthostatic hypotension, can occur with many antipsychotics.

For example, try to avoid QT-prolonging medication combos, such as adding amiodarone (Cordarone) or a macrolide (azithromycin) to haloperidol or ziprasidone (Zeldox).
Monitor blood pressure (BP) closely, advise to rise slowly when standing and adjust BP medications if needed.

Movement disorders

Movement disorders, including akathisia, dystonia, or parkinsonism, are more common with first-generation antipsychotics. Work with the outpatient physicians. Consider adding propranolol (Inderal) for akathisia or an anticholinergic like benztropine (Cogintol, Cogentin) for dystonia or parkinsonism, especially if schizophrenia is well managed. Or discuss switching to a lower-risk option, such as quetiapine (Seroquel, Quitapex) or ziprasidone (Zeldox).

Anticholinergic effects

Anticholinergic effects, such as constipation or dry mouth, often occur.

Think of asenapine (Asenadia) or lurasidone (Tudasidone) as less problematic.
For patients with dry mouth, advise staying hydrated and using sugar-free gum or candy or OTC saliva substitutes. SEDATION IS COMMON, but may improve over time.

If it's a problem, try to switch to bedtime dosing. Or tell patients to ask their outpatient physicians about a less sedating medication, such as paliperidone (Invega) or haloperidol.

Be aware that aripiprazole (Abilify, Aripiprex) can cause insomnia.

Metabolic side effects

Metabolic changes, including glucose, lipid, and weight increases, are more likely with second-generation medications. Point out that ziprasidone (Zeldox) and lurasidone (Tudasidone) are lower-risk options.

References

Keepers GA, Fochtmann LJ, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. Am J Psychiatry. 2020 Sep 1;177(9):868-872.
Huhn M, et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet. 2019 Sep 14;394(10202):939-951.
Marder SR, Cannon TD. Schizophrenia. N Engl J Med. 2019 Oct 31;381(18):1753-1761.