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Extrapyramidal Side Effect

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Extrapyramidal Side Effect, Extrapyramidal Reaction, Drug-Induced Dyskinesia, Akinesia, Dystonic Reaction, Dyskinesia, Tardive Dyskinesia, Oculogyric Crisis

  • See Also
  • Pathophysiology
  1. Typically caused by antipyschotic agents, which may over-blockade Dopaminergic receptors
  2. Results in excess Cholinergic activity due to a loss of typical Dopamine-mediated inhibition
  • Symptoms
  1. Akathisia
    1. Motor restlessness
  2. Parkinsonian Effects (longstanding Antipsychotic use)
    1. Shuffling gait
    2. Cogwheel rigidity
    3. Psychomotor retardation
  3. Dystonias
    1. Involuntary major muscle contractions
    2. Acute laryngospasm may occur
    3. Spasmodic Torticollis (spasm of neck muscles, esp. sternocleidomastoid muscle)
    4. Oculogyric Crisis (eyes fixed, staring upward or rolling back in head)
  1. Haloperidol (Haldol) or Haloperidol decanoate
  2. Perphenazine (Trilafon)
  3. Thiothixene HCl (Navane)
  4. Fluphenazine HCl (Prolixin)
  5. Trifluoperazine (Stelazine)
  6. Risperidone (Risperdal)
  • Causes
  • Tardive Dyskinesia
  1. Antipsychotics
    1. Longterm use of high dose, high potency agents (e.g. Haloperidol)
    2. Atypical Antipsychotics
  2. Other medications (esp. Dopamine blockers)
    1. Antiparkinsonism agents (e.g. Levodopa)
    2. Metoclopramide (Reglan)
    3. Anticonvulsants (e.g. Phenytoin)
    4. Antidepressants
      1. Tricyclic Antidepressants (e.g. Amitriptyline)
      2. Serotonin Reuptake Inhibitors or SSRI (e.g. Fluoxetine, Sertraline)
  • Adverse Effects
  • Reversible Extrapyramidal signs and symptoms
  1. Conditions responsive to anti-Parkinsons Agents
    1. Akinesia (lack of movement, Parkinson-like)
    2. Dystonic Reaction (facial muscle spasm, neck, back)
    3. Dyskinesia (Blinking or twitches)
    4. Akathisia (Can not to sit still, inner restlessness)
    5. Perioral Tremor (Rabbit Syndrome)
  2. Neuroleptic Malignant Syndrome
    1. Presents as Catatonia, fever, unstable Blood Pressure
    2. Life-threatening; Stop Antipsychotic immediately
  • Adverse Effects
  • Irreversible
  1. Evaluate for these signs monthly while on Antipsychotic
  2. Tardive Dyskinesia
    1. Hyperkinesia (lingual or facial)
      1. Blinking
      2. Lip smacking
      3. Sucking or chewing
      4. Rolls or protrudes Tongue
      5. Grimaces
    2. Choreoathetoid extremity movement
      1. Clonic jerking fingers, ankles, toes
    3. Tonic contractions of neck or back
  • Management
  1. Reversible Extrapyramidal Effects
    1. Tolerance to affect
    2. Decrease or Increase OR discontinue drug dose
    3. Shift patient to an agent without Extrapyramidal Side Effects
    4. Benztropine (Cogentin)
    5. Antihistamine (Benadryl)
  2. Tardive Dyskinesia
    1. Lower dose or discontinue medication
      1. Consider Clozapine as alternative Antipsychotic
    2. Avoid adding Anticholinergic Agent (e.g. benztropine)
      1. May worsen Tardive Dyskinesia (despite benefit in acute Dystonia)
    3. Ingrezza (valbenazine)
      1. Decreases Dopamine in nerve endings
      2. Reduces symptoms by 50% with 6 weeks of treatment (Number Needed to Treat: 4)
      3. Very expensive ($5000 per month)
  • References
  1. (2017) Presc Lett 24(6): 36
  2. Mason, Swadron and Herbert in Herbert (2019) EM:Rap C3 3(2): 8