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Overview: The Management of Neuroleptic-induced Acute Extra-pyramidal Syndromes

From Innovative Psychopharmacotherapy

Vernon M. Neppe and Nicholas G. Ward

Anticholinergic medication is commonly used in psychiatry for neuroleptic induced extra-pyramidal symptoms (EPSs). The group is generally very effective. This implies their appropriate application. Recognition of subtle EPSs is a cornerstone of use: the special problems associated with acute dystonia, Parkinsonism, akathisia, akinesia and rabbit syndrome are discussed, in the context of both diagnosis and choice of alternatives like amantadine and propranolol, as well as the specific anticholinergic agent. Dosing is also an issue. There are disadvantages to the use of the anticholinergics: they commonly produce minor side-effects and rarely major ones; they are potentially lethal in overdose; they may induce dependence and they may exacerbate tardive dyskinesia. In addition, they complicate management by possible drug interactions in the liver; they are required only in a minority of cases; they may induce psychosis; they may diminish compliance and they distort the recognition of appropriate dose of neuroleptic. Drugs with anticholinergic properties will accentuate their effects.

Special issues are also addressed: the role of anticholinergic prophylaxis, underdosing of anticholinergics, drug interactions; cholinergic supersensitivity; overdosing; the place of prophylaxis; and cessation of treatment. The present status of amantadine for EPSs is evaluated, as is the role of beta-adrenergic blockers in akathisia. Other treatment approaches involve considering the roles of calcium, other electrolytes and levo-dopa. These approaches are prioritized and a personalized approach suggested. Guidelines for use and alternatives are recommended.

Keywords

acute dystonia, akathisia, akinesia, amantadine, anticholinergics, benzhexol, beta blockers, biperiden, calcium, drug interactions, drug induced extra-pyramidal syndrome, dystonia electrolytes, indications, lethality, levo-dopa, memory, orphenadrine, Parkinsonism, propranolol, side-effects syndrome, supersensitivity, tardive dyskinesia.

 

 


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