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EPSE & NMS Sue Henderson

EPSE & NMS Sue Henderson . Those tablets you gave me are great but they’re making me walk like a crab. Well, I did warn you about the side effects. Low potency V High potency.

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EPSE & NMS Sue Henderson

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  1. EPSE & NMS Sue Henderson Sue Henderson

  2. Those tablets you gave me are great but they’re making me walk like a crab Well, I did warn you about the side effects Sue Henderson

  3. 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

  4. High Anti-cholinergic & Sedative effects Chlorpromazine 100 mg Haloperidol 2 mg High EPSE Low Potency V High Potency Sue Henderson

  5. Extra pyramidal side effects (EPSE) • Acute dystonias: Oculogyric crisis, Torticollis, Lock jaw, Laryngeal spasm, Opisthotonos • Akathisia • Parkinsonism (Rigidity, bradykinesia, tremor) • Tardive dyskinesia Sue Henderson

  6. Dystonia: Oculogyric Crisis • Muscles that control eyes movements spasm. • Eyes roll up & person is unable to look downward. Sue Henderson

  7. Oculogryric Crisis Sue Henderson

  8. Dystonia: Torticollis • Spasm of neck muscles. • Neck is flexed backwards or to the side. Sue Henderson

  9. Dystonia: Lock jaw (Trismus) • Spasm of jaw muscle, also often involves the muscles of the tongue and floor of the mouth. Sue Henderson

  10. Dystonia: Opisthotonos • Spasm of paravertebral muscles with arching of back. Sue Henderson

  11. 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

  12. Treatment Laryngeal spasm • Emergency. • Stat parenteral benztropine (cogentin). • Maintain airway • Prevention: Concurrent antiparkinson or diazepam for young males on high potency antipsychotics Sue Henderson

  13. 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

  14. 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

  15. Pyramid shape Drug induced Parkinsonism (reversible) Dopamine blockade, upsets balance = tremor, rigidity, akinesia Dopamine & acetylcholine in balance = normal function Sue Henderson

  16. 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

  17. Sue Henderson

  18. 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

  19. 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

  20. Side Effect Drugs Sue Henderson

  21. S/E Drugs: Classification • Antiparkinson: Benztropine (Cogentin), benzhexol, biperiden, orphenadrine • Other drugs used to treat EPSE’s • Benzodiazepines. • Dopamine agonist: Bromocriptive (NMS) • Beta blocker: Propanolol (Inderal) & Clonidine (Catapres, Dixarit) Sue Henderson

  22. Indication • Reduce EPSE of antipsychotics Sue Henderson

  23. Side Effect Drugs: Action Excess levels of dopamine (positive schizophrenia) DA ACh < Dopamine blocking antipsychotic drugs decrease effect of dopamine ACh = DA Sometimes antipsychotic drugs block too much dopamine creating a pseudo-parkinsonism ACh > DA Antiparkinson block ACh restoring a relative balance. ACh = DA Sue Henderson

  24. 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

  25. 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

  26. 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

  27. 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 EPSE risk factor tool Sue Henderson

  28. Antiparkinson effectiveness for EPSE Good response: • Parkinsonism • Dystonias Poor Response • Akathisia Made Worse: • Tardive dyskinesia Sue Henderson

  29. Summary EPSE management Sue Henderson

  30. 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

  31. 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

  32. 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

  33. 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. Sue Henderson

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