Treatment For Adverse Effects of Psychotropics

III.
Treatment for Adverse

Effects of Psychotropics
-Amantadine -Dantrolene
-β-adrenergic receptor -Dopamine Receptor

antagonists Agonists
-Anticholinergics -Sildenafil
-Antihistamines -Yohimbine
MEDICATION-INDUCED
MOVEMENT DISORDERS:
1.Neuroleptic-induced Parkinsonism
- Resting tremor, rigidity (cogwheel or

leadpipe), bradykinesia (slowed thinking),
excessive salivation, drooling, shuffling
gait dysphoria.
MEDICATION-INDUCED
MOVEMENT DISORDERS:
2. Neuroleptic Malignant Syndrome
- Muscular rigidity and dystonia,

akinesia, mutism, obtundation,
agitation; autonomic symptoms: high
fever, sweating, and inc. BP/HR;
elevated CPK
MEDICATION-INDUCED
MOVEMENT DISORDERS:
3. Neroleptic-induced Acute Dystonia
- Brief or prolong contractions of

muscles that results in abnormal
movement.; oculogyric crisis, tongue
protrusion, trismus, torticollis, laryngeal-
pharyngeal dystonias, dystonic postures
MEDICATION-INDUCED
MOVEMENT DISORDERS:
4. Neuroleptic-induced Acute Akathisia

- Subjective feelings of restlessness,
objective signs of restlessness
5. Neuroleptic-induced Tardive Dyskinesia

- Late-appearing disorder of
involuntary, choreoathetoid movements.
MEDICATION-INDUCED
MOVEMENT DISORDERS:
6. Medication-induced Postural Tremor
- Rhytmical alteration in movement

that usually exceeds 1 beat per second;
Lithium Valproate, antidepressants.
β-ADRENERGIC RECEPTOR
ANTAGONISTS
1.Beta blockers; Beta antagonists
2.Peripheral effects in the treatment of

hypertension, angina, certain cardiac
arrhythmias, and migraine
3.Propanolol, Nadolol, Pindolol, Labetalol,

Metoprolol, Atenolol and Acebutolol
β-ADRENERGIC RECEPTOR
ANTAGONISTS
4. Do not interfere with standard

laboratory tests.
5.Excreted in the breastmilk.

THERAPEUTIC INDICATIONS:
1.Anxiety Disorders
- Social phobia (PERFORMANCE TYPE)
*Propanolol 10 – 40 mg 20 to 30
minutes before performance
1. Anxiety Disorders
- less effective for the treatment of

panic disorder than are benzodiazepines
or selective serotonin reuptake inhibitors
(SSRIs)
2. Lithium-induced Postural Tremor
- Initial approach:
lower dose of lithium
eliminate aggravating factors
administer lithium at HS
*Propanolol 20 -160 mg/day,

BID/TID
3. Neuroleptic-induced Akathisia
- more effective than

anticholinergics and benzodiazepines
- not effective in acute dystonia and

parkinsonism
4. Aggression and Violent Behavior
- Impulse Disorders
- Schizophrenia
- Aggression asso. with brain
injuries and degenerative disorders.
*Propanolol 50 – 800 mg/day,

BID/TID
5. Alcohol Withdrawal
- adjuvant to benzodiazepines
- Suggested dosage schedule:
no propanolol for HR<50

50 mg for HR 50 – 80
100 mg for HR 80 and above
6. Antidepressant Augmentation
- Pindolol administered at the onset

of antidepressant therapy may shorten
and hasten the by several days.
- may induce depression

EFFECTS ON SPECIFIC
ORGAN SYSTEM:
1.Antagonize the normal physiological

response to hypoglycemia
2.Worsen A-V conduction defects and

lead to complete A-V heart block – death
EFFECTS ON SPECIFIC
ORGAN SYSTEM:
3. Produce bradycardia
4.Blocks bronchodilating effects of

epinephrine
PRECAUTIONS:
1.Contraindications:
- asthma
- insulin-dependent diabetes
- congestive heart failure
- significant vascular disease
- persistent angina
- hyperthyroidism
ADVERSE REACTIONS:
1.hypotension and bradycardia most
common
2.depression asso. with propanolol

(rare)
3.nausea, vomiting, diarrhea and

constipation
4.agitation, confusion, hallucinations

(rare)
ADVERSE EFFECTS AND
TOXICITY:
1.Cardiovascular
- Hypotension
- Bradycardia
- Dizziness
- Congestive failure (in patients
with compromised myocardial fxn)
ADVERSE EFFECTS AND
TOXICITY:
2. Respiratory
- asthma (less risk with B1-
selective drugs)
3. Metabolic
- worsened hypoglycemia in
diabetic patients on insulin or oral
agents
ADVERSE EFFECTS AND
TOXICITY:
4. Gastrointestinal
- nausea, diarrhea, abdominal
pain
5. Sexual
- impotence
ADVERSE EFFECTS AND
TOXICITY:
6. Neuropsychiatric
- lassitude - vivid nightmares

- fatigue - depression (rare)
- dysphoria - psychosis (rare)
- insomnia
ADVERSE EFFECTS AND
TOXICITY:
7. Other (rare)
- Raynaud’s phenomenon
- Peyronie’s disease
8. Withdrawal syndrome
- rebound worsening of angina
pectoris when discontinued
DRUG INTERACTIONS:
1.Increased plasma concentrations of
antipsychotics, anticonvulsants,
theophylline, and levothyroxine
(Propanolol)
2.Barbiturates, Phenytoin and cigarette

smoking increase the elimination of β-
antagonists that are metabolized by the
liver
DRUG INTERACTIONS:
3. Co-administration with MAOI’s =

hypertensive crisis and bradycardia
4.Co-administration with Calcium channel

inhibitors = depressed myocardial
contractility and A-V nodal cond
CLINICAL GUIDELINES:
1.Pulse and BP should be taken

regularly.
2.Drug use should be temporarily

discontinued if it produces severe
dizziness, ataxia or wheezing.
CLINICAL GUIDELINES:
3. Treatment should never be

discontinued abruptly.
*Propanolol tapered by 60
mg/day until dose of 60 mg/day is
reached, then tapered 10-20
mg/day every 3 to 4 days.
AMANTADINE
1.Used primarily for treatment of

medication-induced movement disorders
2.Antiviral agent for Influenza A infection
3.Augments dopaminergic
neurotransmission in the CNS
4.Well-absorbed from GIT; t1/2 12-18

hrs; excreted unmetabolized in the urine
AMANTADINE
5. Primary indications: Parkinsonism,
Akinesia, Rabbit Syndrome (focal
perioral tremor of choreoathetoid type)
6.Not generally considered as effective in

acute dystonic reactions and not effective
in tardive dyskinesia and akathisia.
7.Beneficial to elderly persons prone to

anticholinergic side effects
ADVERSE EFFECTS:
1.CNS:
- mild dizziness, insomnia, and

impaired concentration (5 - 10%)
- irritability, depression, anxiety,
dysarthria and ataxia (1-5%)
- seizures, and psychotic symptoms
ADVERSE EFFECTS:
2. PNS:
- nausea (most common),

headache, loss of appetite, blotchy
skin spots
- Livedo reticularis (purple
discoloration of the skin caused by
dilation of BV)
PRECAUTIONS:
1.Relative contraindication: Renal
disease and seizure d/o
2.Should be used with caution in

persons with edema and
cardiovascular disease
3.May be teratogenic
PRECAUTIONS:
4. Excreted in milk
5.Overdosage: toxic psychoses

(confusion, hallucinations,
aggressiveness), cardiopulmonary
arrest.
DRUG INTERACTIONS:
1.Amantadine + MAOI = increase in
resting BP
2.Amantadine + CNS stimulants =

insomnia, irritability, nervousness,
possible seizures, and irregular
heartbeat.
3.Should not be co-administered with

anticholinergics because adverse
effects may be exacerbated.
GUIDELINES:
1.The usual starting dosage is 100 mg
p.o. BID; may increase up to 200 mg
BID.
2.Should be used in persons with

renal impairment only in consultation
with the physician treating the renal
condition.
3.If successful, should be continued

for 4 – 6 weeks.
GUIDELINES:
4. Should be tapered over 1 – 2

weeks once a decision has been
made to discontinue use.
5.Persons taking amantadine should

not drink alcoholic beverages.
ANTICHOLINERGICS
1.Anti-muscarinics because specific
for muscarinic receptors.
2.Anticholinergics:
-Benztropine (Cogentin) -Orphenadrine (Norflex)
-Biperiden (Akineton) -Procyclidine (Kemadrin)
-Ethopropazine (Parsidol) - Trihexyphenidyl (Artane)

ANTICHOLINERGICS
3. Well absorbed in GIT; lipophilic
4.IM administration is preferred

because of low risk for adverse effects
ANTICHOLINERGICS
5. Trihexyphenidyl is the most

stimulating; Benztropine is the
least stimulating.
6.No known laboratory interferences.

1.Neuroleptic-induced Parkinsonism -
most common in the elderly; occurs
after 2-3 weeks of treatment
2.Neuroleptic-induced acute dystonia-

most common in young men
3. Akathisia – not generally

considered as effective as the β-
adrenergic antagonists or
benzodiazepines.
PRECAUTIONS AND
ADVERSE EFFECTS:
1.Prostatic hypertrophy, urinary

retention, and narrow-angle glaucoma
PRECAUTIONS AND
ADVERSE EFFECTS:
2. Adverse effects: anticholinergic intoxication

- delirium, coma, seizures, agitation,
hallucinations, severe hypotension,
supraventricular tachycardia, peripheral
manifestations such as flushing, mydriasis,
dry skin, hyperthermia and decreased bowel
sounds.
*Tx: Physostigmine (Antilirium) 1-2 mg IV

or IM every 30 or 60 minutes.
DRUG INTERACTION:
1.Dopamine receptor antagonists,

tricyclic and tetracyclics, MAOI’s.
2.Anticholinergic Intoxication
Syndrome
DOSAGE AND GUIDELINES:
1.Neuroleptic-induced Parkinsonism
- Benztropine 1 – 4 mg OD to QID;
should be administered for 4 – 8
weeks; tapered over 1 – 2 weeks.
- In young men, prophylaxis may be

indicated.
2. Neuroleptic-induced Acute Dystonia
- Benztropine 1-2 mg IM repeated

20-30 min if needed
- Lorazepam 1 mg IM or IV
3. Laryngeal Dystonia
- medical emergency
- Benztrophine 4 mg 10 min period,

followed by Lorazepam 1-2 mg slow IV
4. Prophylaxis is indicated in persons

who had 1 episode or in persons
who are at high risk; given for 4 -8
weeks and then gradually tapered
over 1 – 2 weeks.
ANTIHISTAMINES
1.H1 Receptor Antagonists
2.Diphenhydramine – neuroleptic-
induced acute dystonia and
parkinsonism
ANTIHISTAMINES
3. Hydroxyzine, Promethazine –
sedative, anxiolytics
4.Cyproheptadine – anorexia nervosa

and inhibited male and female orgasm
caused by serotonergic agents.
PRECAUTIONS AND
ADVERSE EFFECTS:
1.Use in the elderly because it is
associated with sedation, dizziness and
hypotension
2.Paradoxical excitement and agitation
3.Persons whould be warned about

driving and operating machinery because
of poor motor coordination.
PRECAUTIONS AND
ADVERSE EFFECTS:
1.Epigastric distress, nausea,

vomiting, diarrhea and constipation
2.Mild anticholinergic activity
3.Co-administration with opioids can

increase euphoria
PRECAUTIONS AND
ADVERSE EFFECTS:
4. Excreted in breastmilk
5.Potential for teratogenicity

DRUG INTERACTIONS:
1.Add to sedative property of CNS
depressant
2.Add to anticholinergic effects

resulting in severe anticholinergic
intoxication
3.Cyproheptadine may antagonize the

beneficial effects of SSRI’s.
LABORATORY INTERFERENCES:
1.May eliminate the wheal and

induration that form the basis of
allergy skin tests.
2.Promethazine may interfere with

pregnancy test and increase blood
glucose concentration.
LABORATORY INTERFERENCES:
3. Diphenhydramine may yield a

false-positive urine test for PCP.
4.Hydroxyzine can falsely elevate

certain tests for 17-
hydroxycorticosteroids.
1.Diphenhydramine 25-50 mg IV
effective for acute dystonia.
2.Diphenhydramine 25 mg TID up to
50 mg QID for parkinsonism, akinesia
and buccal movements.
3. Diphenhydramine 50 mg OD- mild

transient insomnia
4.Hydroxyzine 50-100mg QID for

long term treatment of anxiety; 50 -
100 mg IM every 4 – 6 hours for
short-term treatment of anxiety.
DANTROLENE
1.Direct-acting skeletal muscle
relaxant; directly affects contractile
response of the muscles at the site
beyond the myoneural junction.
2.May cause muscle weakness,

slurring of speech and drooling,
diarrhea, headache and depression,
elevated liver function tests.
DANTROLENE
3. Primary indication: muscle rigidity

in neuroleptic malignant syndrome
DOPAMINE RECEPTOR AGONISTS
1. Levodopa, Bromocriptine, Pergolide,

Pramipexole, Ropinirole
2. Parkinsonism, EPS, Akinesia, Focal

perioral tremors, Hyperprolactinemia,
Galactorrhea, Neuroleptic Malignant
Syndrome.
3. Improve erectile dysfunction
4.Adverse effects: nausea, vomiting,

orthostatic hypotension, headache,
dizziness, and cardiac arrythmias.
5. Patients may experience choreiform
and dystonic movements and
psychiatric disturbance after long
term use.
6.Long-term use of Bromocriptine and

Pergolide can produce retroperitoneal
and pulmonary fibrosis, pleural
effusions and pleural thickening.
7. Pramipexole and ropinirole may

cause irresistible sleep attacks.
8.Contraindicated in pregnant women

and nursing mothers.
9. With TCAC’s (trichloroacetyl chloride)

= neurotoxicity
10.With diuretics and Anti-HPN =

potentiate effects
11. BZD, Phenytoin, Pyridoxine =

interfere with therapeutic effects
12. Bromocriptine + ergot alkaloids =

hypertension and myocardial
infarction
SILDENAFIL
1.PDE5, which acts on arteriolar

smooth muscle of corpus cavernosum
2.Inhibits PDE5, allowing blood to fill

the corpus cavernosum and cause
erection
3.For erectile dysfunction

SILDENAFIL
4. Most potential adverse effect in

Myocardial infarction
5.Contraindicated in patients taking

organic nitrates
6.No laboratory interferences

YOHIMBINE
1.Alpha-2 adrenergic receptor

antagonist
2.For idiopathic and medication-

induced sexual disorders
YOHIMBINE
3. A/E: anxiety, inc. BP/HR, inc.

psychomotor activity, irritability,
tremors, headache, flushing,
dizziness, urinary frequency,
nausea , vomiting, sweating.
4.No known laboratory interferences

THANK YOU &
GOOD DAY!

Treatment For Adverse Effects of Psychotropics

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Treatment For Adverse Effects of Psychotropics

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III.

Treatment for Adverse

-β-adrenergic receptor -Dopamine Receptor

- Resting tremor, rigidity (cogwheel or

2. Neuroleptic Malignant Syndrome

- Muscular rigidity and dystonia,

3. Neroleptic-induced Acute Dystonia

- Brief or prolong contractions of

4. Neuroleptic-induced Acute Akathisia

5. Neuroleptic-induced Tardive Dyskinesia

6. Medication-induced Postural Tremor

- Rhytmical alteration in movement

1.Beta blockers; Beta antagonists

2.Peripheral effects in the treatment of

3.Propanolol, Nadolol, Pindolol, Labetalol,

4. Do not interfere with standard

5.Excreted in the breastmilk.

- Social phobia (PERFORMANCE TYPE)

- less effective for the treatment of

*Propanolol 20 -160 mg/day,

- more effective than

- not effective in acute dystonia and

*Propanolol 50 – 800 mg/day,

- Suggested dosage schedule:

no propanolol for HR<50

- Pindolol administered at the onset

- may induce depression

1.Antagonize the normal physiological

2.Worsen A-V conduction defects and

4.Blocks bronchodilating effects of

2.depression asso. with propanolol

3.nausea, vomiting, diarrhea and

4.agitation, confusion, hallucinations

- lassitude - vivid nightmares

2.Barbiturates, Phenytoin and cigarette

3. Co-administration with MAOI’s =

4.Co-administration with Calcium channel

1.Pulse and BP should be taken

2.Drug use should be temporarily

3. Treatment should never be

1.Used primarily for treatment of

2.Antiviral agent for Influenza A infection

4.Well-absorbed from GIT; t1/2 12-18

6.Not generally considered as effective in

7.Beneficial to elderly persons prone to

- mild dizziness, insomnia, and

- nausea (most common),

2.Should be used with caution in

5.Overdosage: toxic psychoses

2.Amantadine + CNS stimulants =

3.Should not be co-administered with

2.Should be used in persons with

3.If successful, should be continued

4. Should be tapered over 1 – 2

5.Persons taking amantadine should

-Benztropine (Cogentin) -Orphenadrine (Norflex)

-Biperiden (Akineton) -Procyclidine (Kemadrin)

-Ethopropazine (Parsidol) - Trihexyphenidyl (Artane)

3. Well absorbed in GIT; lipophilic