Part 1: Non-pharmacologic Management
Antipsychotic side effects present a significant challenge in maintaining patient adherence and quality of life. As we start to see antipsychotics prescribed for more than just schizophrenia, it is vital to be aware of the stress these drugs may place on our patients.
Over the next three months, we will explore potential ways to mitigate unwanted effects safely.
Not all antipsychotics have the same side effects. Some of the most common side effects are: movement disorders (abnormal gait, tremor, restlessness, repetitive facial movements), dry mouth, constipation, weight gain, and sedation.
Before adding another drug to treat a side effect, non-pharmacologic adjustments should be discussed with the prescriber. Many of these adjustments are related to dosing strategy. Options include:
- decrease the dose, go slow; remember gradual dose reduction
- split the dose to twice daily (check with the pharmacy to see if this is appropriate)
- move entire dose to bedtime if the worst side effect is sedation,
- switch to a different antipsychotic (considering a depot injection),
- avoid medications with similar side effects.
Next, we will discuss a few drugs that may lessen the side effect burden.
Part 2: General Pharmacologic Management
In Part 1, we learned antipsychotics can have troublesome side effects that may require our attention. We discussed non-pharmacologic ways to manage these side effects; however, it is sometimes necessary to treat a patient’s antipsychotic-related side effect(s) with another drug.
Most often, we are treating a movement disorder. Cogentin (benztropine) is frequently used to quiet positive-movement signals in a patient’s muscles or to decrease restlessness. Benzodiazepines such as clonazepam and lorazepam, and antihistamines such as diphenhydramine (Benadryl), may also be used. Beta blockers such as propranolol may be used when a patient is complaining of restlessness or is showing an abnormally high heartrate.
Regarding other antipsychotic side effects, below are a few broad approaches:
- Weight gain: Currently, there is a lack of research related to treating antipsychotic-induced weight gain, but metformin has shown some efficacy.
- Constipation: Stimulant or osmotic laxatives such as Senna, Dulcolax, Milk of Magnesium, or MiraLAX are preferred for constipation.
- High blood pressure and/or cholesterol: Standard dosing of hypertension and cholesterol medications are appropriate when given in response to antipsychotic-induced increases in blood pressure, or for bad cholesterol.
Next, we will learn about two newer drugs specifically designed to mitigate a bothersome movement disorder.
Part 3: Tardive Dyskinesia-specific Pharmacologic Management
In the last article of this series about antipsychotic side effect management, we will cover two drugs designed specifically for a movement disorder called tardive dyskinesia. Tardive dyskinesia is a facial movement disorder characterized by repetitive, involuntary movements such as tongue-twisting, chewing motions, lip-smacking, and grimacing. This side effect does not typically set in until 1-2 years into treatment. These movements are significantly stigmatizing for patients, but until recently, the treatment options for tardive dyskinesia were significantly limited.
There are currently two medications on the market specifically designed to treat tardive dyskinesia. They are: Ingrezza (valbenazine) and Austedo (deutetrabenazine). Their differences are highlighted in the table below:
| Ingrezza (valbenazine) | Austedo (deutetrabenazine) | |
| Dosing | Once daily | Twice daily |
| Side effects | QTc prolongation, dry mouth | Fatigue, somnolence, nausea, irritated nasal passages, insomnia, increased risk of depression or suicidal ideation |
| Contraindications | None | Liver impairment, untreated depression, suicidal thoughts |
Over the past three articles, we have learned about non-pharmacologic and pharmacologic ways to manage our patient’s antipsychotic-related side effects. We hope these articles empower you with enhanced knowledge to advocate for our patients!