EPSE & NMS Sue Henderson

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EPSE NMS Sue Henderson
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Well, I did warn you about the side effects
Those tablets you gave me are great but theyre
making me walk like a crab
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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

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Low Potency V High Potency
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Extra pyramidal side effects (EPSE)

• Acute dystonias Oculogyric crisis, Torticollis,
  Lock jaw, Laryngeal spasm, Opisthotonos
• Akathisia
• Parkinsonism (Rigidity, bradykinesia, tremor)
• Tardive dyskinesia

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Dystonia Oculogyric Crisis

• Muscles that control eyes movements spasm.
• Eyes roll up person is unable to look downward.

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Oculogryric Crisis
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Dystonia Torticollis

• Spasm of neck muscles.
• Neck is flexed backwards or to the side.

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Dystonia Lock jaw (Trismus)

• Spasm of jaw muscle, also often involves the
  muscles of the tongue and floor of the mouth.

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Dystonia Opisthotonos

• Spasm of paravertebral muscles with arching of
  back.

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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.

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Treatment Laryngeal spasm

• Emergency.
• Stat parenteral benztropine (cogentin).
• Maintain airway
• Prevention Concurrent antiparkinson or diazepam
  for young males on high potency antipsychotics

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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.

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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).

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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.

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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.

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Treatment NMS

• Early detection vital to recovery
• Stop anti-psychotic
• Hydration
• Transfer to ICU
• Bromocriptine 5-10 mg tds but if no response
• Dantrolene

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Side Effect Drugs
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S/E Drugs Classification

• Antiparkinson Benztropine (Cogentin), benzhexol,
  biperiden, orphenadrine
• Other drugs used to treat EPSEs
• Benzodiazepines.
• Dopamine agonist Bromocriptive (NMS)
• Beta blocker Propanolol (Inderal) Clonidine
  (Catapres, Dixarit)

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Indication

• Reduce EPSE of antipsychotics

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S/E Drugs Prescription

• Routine prescription not advised because
• Not all people develop EPSEs
• Decrease effect of antipsychotics.
• Risk of worsening Tardive Dyskinesia.

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Side effect drugs cont

• EPSE drugs have side effects also.
• Potential for abuse.
• Severity of EPSEs fluctuate
• Exception Young males on high potency
  antipsychotic (high risk of EPSE)

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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.

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EPSE risk factor tool

• Patient factors
• Age gt 40
• Sex Females, males gt 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

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Antiparkinson effectiveness for EPSE

• Good response
• Parkinsonism
• Dystonias
• Poor Response
• Akathisia
• Made Worse
• Tardive dyskinesia

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Summary EPSE management
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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.

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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.

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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.

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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.