Extrapyramidal reaction: Difference between revisions
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**hours to days after drug initiation | **hours to days after drug initiation | ||
**reversible | **reversible | ||
**Acute [[ | **Acute [[dystonic reaction]] | ||
***involuntary, uncoordinated skelatal muscle contraction | ***involuntary, uncoordinated skelatal muscle contraction | ||
**Akathisia | **Akathisia | ||
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*Parkinsonism | *Parkinsonism | ||
**onset weeks to months after starting medication | **onset weeks to months after starting medication | ||
**similar presentation to [[Parkinson's disease]] (e.g. cogwheel | **similar presentation to [[Parkinson's disease]] (e.g. cogwheel rigidity, pill-rolling tremor, shuffling gait, bradykinesia) | ||
*Tardive dyskinesia | *[[Tardive dyskinesia]] | ||
**usually irreversible or only partially reversible | **usually irreversible or only partially reversible | ||
**associated with prolonged use of antipsychotics | **associated with prolonged use of antipsychotics | ||
** | **stereotyped, repetitive facial movements (e.g. tongue protrusion, grimacing, lip smacking) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*Stop or reduce offending agent | *Stop or reduce offending agent | ||
**may need to discuss with psychiatrist to prescribe new medication or for recs on taper | **may need to discuss with psychiatrist to prescribe new medication or for recs on taper | ||
*Acute dystonia, akasthisia, parkinsonism | *Acute [[dystonic reaction|dystonia]], akasthisia, parkinsonism | ||
**[[diphenhydramine]] 25-50mg PO or IV | **[[diphenhydramine]] 25-50mg PO or IV | ||
**'''OR''' [[benztropine]] 1-2mg PO or IV/IM | **'''OR''' [[benztropine]] 1-2mg PO or IV/IM | ||
**continue PO antihistamines for 2 days after stopping antipsychotic | **continue PO antihistamines for 2 days after stopping antipsychotic | ||
**+/- [[benzodiazepines]] | **+/- [[benzodiazepines]] | ||
*Tardive dyskinesia | *[[Tardive dyskinesia]] | ||
**may only be partially reversible, so minimize occurrence, stop or reduce offending agent promptly | **may only be partially reversible, so minimize occurrence, stop or reduce offending agent promptly | ||
**Do NOT give anticholinergics, will exacerbate symptoms | **Do NOT give anticholinergics, will exacerbate symptoms | ||
Revision as of 02:29, 3 October 2019
Background
- Adverse effect of antipsychotics.
- More common with high-potency typical antipsychotics, but can also occur with atypical agents
- Due to antagonism of dopamine-2 receptors in basal ganglia
Clinical Features
- Early-onset syndromes
- hours to days after drug initiation
- reversible
- Acute dystonic reaction
- involuntary, uncoordinated skelatal muscle contraction
- Akathisia
- subjective sensation of intense motor restlessness
- may be misdiagnosed as manifestation of psychiatric disease
- Parkinsonism
- onset weeks to months after starting medication
- similar presentation to Parkinson's disease (e.g. cogwheel rigidity, pill-rolling tremor, shuffling gait, bradykinesia)
- Tardive dyskinesia
- usually irreversible or only partially reversible
- associated with prolonged use of antipsychotics
- stereotyped, repetitive facial movements (e.g. tongue protrusion, grimacing, lip smacking)
Differential Diagnosis
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Hypocalcemia
- Strychnine toxicity
- Acute tetanus
- Parkinson's disease
- Mono amine oxidase inhibitor toxicity
- Phencyclidine toxicity
- Anti-NMDA receptor encephalitis
Evaluation
Management
- Stop or reduce offending agent
- may need to discuss with psychiatrist to prescribe new medication or for recs on taper
- Acute dystonia, akasthisia, parkinsonism
- diphenhydramine 25-50mg PO or IV
- OR benztropine 1-2mg PO or IV/IM
- continue PO antihistamines for 2 days after stopping antipsychotic
- +/- benzodiazepines
- Tardive dyskinesia
- may only be partially reversible, so minimize occurrence, stop or reduce offending agent promptly
- Do NOT give anticholinergics, will exacerbate symptoms