Antipsychotics tardive dyskinesia

Tardive dyskinesia can occur in patients taking the antipsychotics. The nurse must remain alert for any signs and symptoms of tiiis condition. 

Extrapyramidal symptoms (EPS) Adverse effects of medications such as antipsychotics. EPS include dystonia (involuntary muscle contractions), tardive dyskinesia (repetitive, involuntary movements), parkinsonian symptoms (akinesia and tremors), and akathisia (motor restlessness or anxiety). 

Tardive dyskinesia A chronic disorder of the nervous system characterized by involuntary jerky or writhing movements of the face, tongue, jaws, trunk, and limbs, usually developing as a late side effect of prolonged treatment with antipsychotic drugs. 

Binder, R. L., Kazamatsuri, H., Hishimura, T. etal. (1987). Tardive dyskinesia and antipsychotic-induced parkinsonism in Japan. Am. J. Psychiatry, 144( 11), 1494-6. 

Extrapyramidal side effects These are caused by antipsychotic drugs. They are characterised by motor and postural disturbances, of which the most serious is late-onset tardive dyskinesia. 

Tardive dyskinesia A collection of involuntary movements that are a side effect of long-term administration of typical antipsychotic drugs. 

Ari pi prazole, olanzapine, quetiapine, risperidone, and ziprasidone are effective as monotherapy or as add-on therapy to lithium or valproate for acute mania. Prophylactic use of antipsychotics can be needed for some patients with recurrent mania or mixed states, but the risks versus benefits must be weighed in view of long-term side effects (e.g., obesity, type 2 diabetes, hyperlipidemia, hyperprolactinemia, cardiac disease, and tardive dyskinesia). 

Tardive dyskinesia from antipsychotic agents (dopamine D2 and D3 receptor variants)... 

Jeste DV, Lacro JP, Palmer B et al. (1999) Incidence of tardive dyskinesia in early stages of low-dose treatment with typical antipsychotics in older patients. Am I Psychiatry 156(2) 309-311 Klotz U (1998) Effect of age on pharmacokinetics and pharmacodynamics in man. Int I Clin Pharmacol Ther 36(11) 581-585... 

By contrast, studies of the dopamine D -like receptors have found evidence for the association of the receptor with disease (66) these studies have been replicated (41,42). From among the multitude of these studies, only selected examples are reviewed here. For example, evidence both for and against the association of the dopamine D -like receptors with schizophrenia has been reported. Polymorphisms of the dopamine receptor, including the third intracellular loop VNTR, alter dopamine receptor expression. In addition to association with schizophrenia (3,67-70), the dopamine polymorphisms have been associated with the genetic basis of the variable efficacy of antipsychotics such as clozapine (or neuromuscular toxicity—tardive dyskinesia) (69,71,72). Similarly, promoter SNPs have been associated with altered clozapine efficacy (67,68,73). 

Some medication side effects also occur only after prolonged administration and, as such, are products of the adaptive response to the continued administration of the medication. For example, taking a so-called conventional or typical antipsychotic for a long period of time can cause involuntary movements called tardive dyskinesias. These dyskinesias are believed to occur after chronic administration of the antipsychotic has caused changes in the density and/or sensitivity of dopamine receptors in brain regions that coordinate movement. 

Atypical Antipsychotics. The so-called atypical antipsychotics have revolutionized the treatment of schizophrenia and other psychotic disorders since their introduction in the 1990s. Similarly, they are replacing the older antipsychotics in the treatment of BPAD as well. They offer a similar degree of antimanic efficacy without a lessened long-term risk of tardive dyskinesia. For more information regarding the atypical antipsychotics, please refer to Chapter 4 Schizophrenia. 

Clozapine (Clozaril). Clozapine was introduced over 30 years ago but has only been available in the United States since 1990. It remains the medication of choice for treatment-resistant schizophrenia. Since its introduction, it has been used to treat acute mania with excellent results. Furthermore, it avoids the potential for tardive dyskinesia posed by haloperidol and the other typical antipsychotics. 

When an antipsychotic is needed, we prefer using one of the newer atypical agents olanzapine, ziprasidone, risperidone, quetiapine, or aripiprazole. Each of these medications reliably reduces agitation and is well tolerated. In particular, they decrease the potential for acute dystonic reactions and tardive dyskinesia caused by the typical antipsychotics. Both ziprasidone and olanzapine are now available in an injectable form that is very rapidly acting and effective in this setting. 

The occurrence of tardive dyskinesia after treatment with conventional antipsychotics for a long term raises some interesting questions. Remember, dyskinesias are a symptom of HD and other neurological disorders in which there is too much dopamine flowing through the nigrostriatal pathway. How can a dopamine-blocking medication produce symptoms similar to HD ... 

Lithium (Eskaiith, Lithobid). Before the recent proliferation of atypical antipsychotics, lithium was tried as an alternative for schizophrenia. By and large, this represented another effort to circumvent the risk of tardive dyskinesia. It is not effective either as monotherapy or as combination therapy with antipsychotics in schizophrenia. 

In the residual phase, the patient is unlikely to have an acute exacerbation even if (s)he stops taking an antipsychotic. Nevertheless, (s)he may still require treatment for residual symptoms. If medications are continued during a residual phase of schizophrenia, an atypical antipsychotic is preferred. Because positive symptoms are no longer a prominent aspect of the illness, there is usually little justification for using a typical antipsychotic and thereby exposing a patient to the risk of tardive dyskinesia. Moreover, atypical antipsychotics likely better treat the remaining negative symptoms of residnal schizophrenia. 

Correll CU, Leucht S, Kane JM. Lower risk for tardive dyskinesia associated with second-generation antipsychotics a systematic review of 1-year studies. Am J Psychiatry 2004 161 414-425. 

Antipsychotics also have a troublesome side effect burden that includes an often-irreversible movement disorder known as tardive dyskinesia (TD). Other side effects include so-called parkinsonism, dystonic reactions (i.e., abrupt onset of muscle spasms), akathisia (an uncomfortable sense of motoric restlessness), sedation, weight gain, dizziness, dry mouth, and constipation among others. These side effects, in particular the risk for TD, limit the usefulness of antipsychotics in the treatment of ADHD, and at this time the typical antipsychotics cannot be considered a reasonable monotherapy in uncomplicated ADHD. 

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