psychiatry.asia May 2016

Sign & Symptoms, EPS prevention

Antipsychotic medication commonly produce extrapyramidal symptoms (EPS) as side effects. The extrapyramidal symptoms include acute dyskinesia and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia and neuroleptic malignant syndrome.

In general, (EPS) maybe categorized according to the following criteria: a. Acute, tardive or mixedb. Side-effects of treatment, or independent of antipsychotic drugsc. Single syndromes, such as akathisia, or a mixture of syndromes.d. Reversible or irreversiblee. Recognized or not recognized by the patient.How to minimize the occurrence of Extrapyramidal symptoms

Key factors that can help to reduce the occurrence of EPS include:a. More knowledge of EPS among doctors and the medical staff.b. More awareness of the signs and symptoms of EPS. c. The introduction of specific EPS examination procedures and more knowledge of alternate treatments.

The crucial tests can aid the identification of EPS as listed in table 1. Many psychiatrists do not carry out these simple, but very valuable observations. Rating scales such as the St Hans rating scale for extrapyramidal syndromes may encourage a systematic approach and prevent Parkinsonism being overlooked.

Extrapyramidal Symptoms and the new Antipsychotics by Mian Sajid Mahmood and Adnan Akram �1

Authors Dr Mian Sajid Mahmood Consultant Physician Dr Adnan AkramRegistrar in Psychiatry

Dr Mian Sajid Mahmood is a Consultant Physician with special interest in Geriatric Medicine. He often encounters patients presenting at his out patient clinic in Karachi Pakistan with mental health disorders and EPS. He developed an interest in antipsychotics and research in EPS that led to writing an article with his psychiatry colleague. Dr Adnan Akram is a Registrar in Psychiatry. He has interest in adult inpatient and substance misuse psychiatry. Dr Adnan works at a private psychiatry clinic in Karachi Pakistan.

Address for correspondence 242 Fatima Jinnah road Karachi 75530Pakistanemail: camp [at] psychiatry.asia

Article: Extrapyramidal symptoms and the new antipsychoticsSajid Mahmood, Adnan Akram

psychiatry.asia May 2016

Table 1. EPS Observation principles

The prevention of EPSA number of principles emerge for preventing the occurrence of EPS:a. Closely observe particularly vulnerable patients such as the elderly, and patients with a previous history of EPS. b. Restrict the use of D2-blocking antipsychotics. The use of antipsychotics in negative symptoms may well increase with the advent of new antipsychotics which avoid EPS. c. Minimize D2-receptor blockade by using the lowest effective dose, antipsychotics with low D2 blockade (such as clozapine o other new agents), and potential non-dopamine antipsychotics. d. Anticholinergics have only symptomatic effect: they reduce akathisia, dystonia/acute dyskinesia, Parkinsonism, but aggravate tardive dyskinesia and tardive akathisia.

The new antipsychotics are as different from each other as they are from stndard agents. They include the D2 antagonists, sulpride and amisulpride: the D2-5HT2-alpha1 antagoists, risperidone, ziprasidone, and sertindole; and the multi receptor antagonists clozapine, quetiapine and olanzapine. Risperidone and zipasidon show classical D2-receptor blockade, and in high doses they will cause traditional EPS and also some autonomic side-effects due to alpha1 blockage. Sertindole. clozapine, olanzapine, and quetiapine are all interesting drugs because they all produce a relatively low D2 receptor blockade, in contrast to all other antipsychotics. In vitro studies show that Sertindole provides strong D2 blockade, but studies in vivo show only mild D2 antagonism. Clozapine is a multi receptor antagonist. Olanzapine closely resembles clozapine but does not block many receptors. Quetiapine is unique due to its atypical receptor profile.

Studies have confirmed that clozapine produces much less EPS than the classical drugs, such as haloperidol. Tardive dyskinesia may disappear when patients are prescribed clozapine.Aside from EPS, other side effect must also be considered. Depression and emotional indifference are

Extrapyramidal Symptoms and the new Antipsychotics by Mian Sajid Mahmood and Adnan Akram �2

psychiatry.asia May 2016

clearly lower on clozapine compared with haloperidol. Sexual problems, caused by effects on prolactin levels, are also less pronounced with clozapine. In conclusionEPS are disabling and distressing, and in some patients are painful and irreversible. EPS are often not recognized by the physician or patient and may become accepted as unavoidable. People working in psychiatry should be taught more about EPS and be trained in simple EPS examination and techniques.Prevention and treatment strategies should focus on reducing D2-receptor blockade. Clozapine produces less EPS but has other side effects. Drugs such as quetiapine, olanzapine an sertindole offer low D2-receptor antagonism, which promises a god EPS profile.

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