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