Extrapyramidal symptom

One of the more serious problems occurring from the use of antipsychotics is the production of abnormal movement patterns.36,44 Many of these aberrant movements are similar to those seen in patients with lesions of the extrapyramidal system and are often referred to as extrapyramidal side effects. The basic reason that these motor problems occur is because dopamine is an important neurotransmitter in motor pathways, especially in the integration of motor function that takes place in the basal ganglia. Because antipsychotic drugs block CNS dopamine receptors, it makes sense that 

Torticollis 2. Difficulty in Sitting Still i 2. Puffing of Cheeks 

Facial Grimacing 3. Strong Urge to Move About i 3. Chewing Movements 

1 I I I Pseudo-Parkinsonism 1 1 1 1 1. Motor Retardation I I 2. Mask-Like Facies I I 3. Tremor I I 4. Pill-Rolling I I 5. Rigidity i I 6. Salivation l 7. Shuffling Gait, 1 1 r jU  

TIME FROM ONSET OF NEUROLEPTIC THERAPY (DAYS) 

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Immediately report the occurrence of the following adverse reactions restlessness, inability to sit still, muscle spasms, masklike expression, rigidity, tremors, drooling, or involuntary rhythmic movements of the mouth, face, or extremities. Inform all patients about the risks of extrapyramidal symptoms and tardive dyskinesia Avoid exposure to the sun. If exposure is unavoidable, wear sunblock, keep arms and legs covered, and wear a sun hat. 

Trihexyphenidyl (Artane) and benztropine (Cogentin) are prescription drugs used in the treatment both of Parkinson s disease and the extrapyramidal side effects produced by neuroleptic medication. They are occasionally abused for their mind-altering properties, which occur at toxic doses (Perry et al. 1978). Abusers often try to obtain these drugs by false representation of extrapyramidal symptoms, which are claimed to result from the use of phenothi-azines or other neuroleptics (Rubinstein 1978). 

Ricaurte GA, McCann UD, Szabo Z, et al Toxicodynamics and long-term toxicity of the recreational drug 3,4-methylenedioxy-methamphetamine (MDMA, Ecstasy ). Toxicol Lett 112-113 143-146, 2000 Robinson TN, Killen JD, Taylor CB, et al Perspectives on adolescent substance use a defined population study. JAMA 258 2072-2076, 1987 Rubinstein JS Abuse of antiparkinson drugs feigning of extrapyramidal symptoms to obtain trihexyphenidyl. JAMA 239 2365, 1978 Rumack BH (ed) LSD, in Poisindex, Vol 54. Denver, CO, Micromedex, 1987 Rusyniak DE, Banks ML, Mills EM, et al Dantrolene use in 3,4-methylenedioxymethamphetamine ( ecstasy )-medicated hyperthermia (letter). Anesthesiology 10 263, 2004... 

Amisulpride is a substituted benzamide, which acts as a highly selective blocker of D2 and D3 receptors (Kerwin, 2000). As with all the other drugs, it can easily be demonstrated to be effective compared with placebo and haloperidol, with a lower extrapyramidal symptom profile (Moller et al, 1995). The strength of amisulpride lies in the quality of the evidence to show that it is effective against primary negative symptoms and affective symptoms. Two studies have shown convincing superiority for negative symptoms... 

Phenothiazines may cause sedation, orthostatic hypotension, and extrapyramidal symptoms (EPS) such as dystonia (involuntary muscle contractions), tardive dyskinesia (irreversible and permanent involuntary movements), and akathisia (motor restlessness or anxiety).1,21,22 Chronic phenothiazine use has been associated with EPS, but single doses have also caused these effects.23... 

CRI Chronic renal insufficiency catheter-related infection EPS Extrapyramidal symptoms... 

Thirty-five to eighty-seven percent of the patients studied received antiparkinson drugs. Compared to other countries, Japan and Singapore used the most of these antidotes for drug-induced extrapyramidal symptoms. This is most likely related to the frequent use of high-dosage antipsychotic drugs and poly-antipsychotics (see Table 12.3). 

Extrapyramidal side-effects generally appear with blockade of dopamine D2 receptors in excess of 80%, whereas clinical efficacy in treating psychosis is associated with 60-70% D2 receptor blockade [12]. Recently, a partial agonist for the D2 receptor known as aripiprazole has been developed, which results in approximately 70% antagonism/30% agonism at the D2 receptor. It is an effective antipsychotic, has low risk for extrapyramidal symptoms, and does not cause elevated levels of prolactin as do the full antagonists at D2 receptors. 

A metaanalysis showed that 17% to 18% of dementia patients showed a modest treatment response to atypical antipsychotics. Adverse events included somnolence, extrapyramidal symptoms, abnormal gait, worsening cognition, cerebrovascular events, and increased risk of death. 

Use in combination with lithium or valproate for the acute treatment of mania or mixed states Antagonist of postsynaptic DA2 receptors atypical agents also block 5-HT2a receptors that increase the presynaptic release of DA thus lowering the risk of extrapyramidal symptoms and prolactin release... 

Combining lithium with typical antipsychotics may cause neurotoxicity (e.g., delirium, cerebellar dysfunction, extrapyramidal symptoms). Lithium should be withdrawn and discontinued at least 2 days before electroconvulsive therapy. 

Areca may interact adversely with antipsychotic medications (Deahl 1989). Two cases have been reported of schizophrenic patients who were taking neuroleptics and developed severe extrapyramidal symptoms after areca chewing. Given the functional antagonism between dopamine and acetylcholine in the striatum, it is likely that arecoline amplified the dyskinetic effect of neuroleptic medications. 

Ziprasidone (Geodon). Ziprasidone is indicated for the treatmet of acute mania with typical doses of 40-80 mg twice a day. Ziprasidone is well tolerated, with the most common side effects being sedation, extrapyramidal symptoms, and akathisia. Low magnesium or potassium may cause potentially serious cardiac conduction problems with ziprasidone. 

Delusions/Psychosis. Demented patients who are acutely psychotic and agitated should be treated in much the same manner as demented patients with delirium. Low doses of a high potency conventional antipsychotic like haloperidol were once preferred. This was mainly because it can be given both orally and by injection. In recent years, the atypical antipsychotic ziprasidone, which is now also available in oral and injectable forms, has superseded haloperidol as the preferred agent when treating the acutely psychotic and agitated patient with dementia. As previously noted, ziprasidone affords the same tranquilizing benefit as haloperidol, it can now be administered via injection when necessary, and it avoids the problematic extrapyramidal symptoms of haloperidol to which patients with dementia are often keenly sensitive. 

We prefer low doses of atypical antipsychotics as a first-line treatment. In this way, the threat of extrapyramidal symptoms is largely avoided without having to use a second anticholinergic medication to offset antipsychotic side effects. Risperidone 0.25-0.5mg/day, olanzapine 2.5mg/day, quetiapine 25mg/day, ziprasidone 20mg/day, or aripiprazole 2.5-5mg/day are reasonable starting doses. The typically higher doses used to treat schizophrenia are usually not necessary. 

In addition to parkinsonism, another extrapyramidal side effect is the so-called acute dystonic reaction in which muscles (usually of the face or neck) go into an acute spasm. A dystonic reaction is painful and unpleasant, usually occurs early in treatment, and sometimes occurs after the very first dose of an antipsychotic. Another extrapyramidal symptom is akathisia, a restless inability to relax and sit still. Akathisia can range from a mild restlessness to extreme agitation. Rarely, patients have been known to attempt suicide during severe episodes of akathisia. It is easy to overlook akathisia, because it can easily be mistaken for a worsening of psychosis or anxiety. 

Haloperidol decanoate (Haldol Decanoate) Antipsychotic Inj 50,100 mg/mL 25-100 mg IM q4 weel long acting. Reduce dose in elderly extrapyramidal symptoms, alpha-blocking effects, high doses may prolong QT interval. 

Extrapyramidal symptoms may occur as a side-effect of antipsychotic drugs. 

Put the foibwing in order of precipikiKon of extrapyramidal symptoms, assigning 1 to the drug most likely to induce them and 3 to the drug least likely to induce this side-effect. 

Use in children - Contraindicated in children younger than 2 years of age because of the potential for fatal respiratory depression. The extrapyramidal symptoms that can occur secondary to promethazine administration may be confused with the CNS signs of undiagnosed primary disease (eg, encephalopathy, Reye syndrome). Avoid use in children whose signs and symptoms may suggest Reye syndrome or other hepatic diseases. TRIPROLIDINE HYDROCHLORIDE ... 

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