Adverse Effects and Management

Antipsychotics - Psychosis Pill Pitfalls

• Extrapyramidal Symptoms (EPS): 📌 DAP-T (Dystonia, Akathisia, Parkinsonism - Tardive)
  • Acute Dystonia (hrs-days): Spasms (torticollis, oculogyric crisis). Rx: Anticholinergics (benztropine, diphenhydramine IM/IV).
  • Akathisia (days-wks): Subjective restlessness. Rx: Propranolol, BZDs, mirtazapine.
  • Parkinsonism (wks-mos): Bradykinesia, rigidity, tremor. Rx: Anticholinergics (benztropine), amantadine.
  • Tardive Dyskinesia (TD) (mos-yrs): Orofacial, limb, truncal dyskinesia. Rx: VMAT2-inhibitors (valbenazine, deutetrabenazine).
• Neuroleptic Malignant Syndrome (NMS): ⚠️ Life-threatening!
  • Key: FEVER (Fever, Encephalopathy, Vitals unstable, Enzymes ↑ [CK], Rigidity 'lead-pipe').
  • Rx: Stop AP, supportive care, dantrolene, bromocriptine.
• Metabolic Syndrome: (Atypicals > Typicals; esp. Olanzapine, Clozapine)
  • Weight gain, ↑glucose/DM, dyslipidemia. Monitor: BMI, waist, BP, HbA1c, lipids.
• Other Adverse Effects:
  • Hyperprolactinemia (Risperidone, Paliperidone, Typicals) → amenorrhea, galactorrhea, gynecomastia.
  • QTc Prolongation (esp. Ziprasidone, Thioridazine, Haloperidol IV) → risk of Torsades de Pointes.
  • Anticholinergic (dry mouth, constipation), Sedation, Orthostatic hypotension.

  ⭐ Clozapine: Unique efficacy for treatment-resistant schizophrenia but carries risks of agranulocytosis (monitor ANC; hold if < 1500/µL, stop if < 1000/µL), myocarditis, cardiomyopathy, seizures (dose-dependent), metabolic effects.

Antidepressants - Happy Pill Hazards

• SSRIs (Selective Serotonin Reuptake Inhibitors):
  • AEs: GI upset, sexual dysfunction, headache, anxiety, insomnia/sedation.
  • Serotonin Syndrome: 📌 SHIVERS (Shivering, Hyperreflexia/myoclonus, ↑Temp, Vital instability, Encephalopathy, Restlessness, Sweating).
    • Rx: Stop agent, supportive care, cyproheptadine.

• TCAs (Tricyclic Antidepressants):
  • AEs: Anticholinergic (dry mouth, urinary retention), orthostatic hypotension, sedation, weight gain.
  • Cardiotoxicity: QRS prolongation. 📌 Tri-C's: Convulsions, Coma, Cardiotoxicity.
  • OD Rx: IV $NaHCO_3$.

  ⭐ TCA Overdose: QRS >100ms (↑seizure risk), >160ms (↑arrhythmia risk). Rx: IV Sodium Bicarbonate.

• MAOIs (Monoamine Oxidase Inhibitors):
  • AEs: Postural hypotension, weight gain, sexual dysfunction, insomnia.
  • Hypertensive Crisis: With tyramine (aged cheese, red wine) or sympathomimetics.
    • Sx: Severe headache, ↑↑BP, sweating. Rx: Phentolamine/nifedipine.

Mood Stabilizers & Anxiolytics - Stability Setbacks

• Lithium (Li+)
  • Therapeutic: 0.6-1.2 mEq/L. Toxic: >1.5 mEq/L (severe >2.0 mEq/L).
  • SE: 📌 LMNOP: Lithium, Movement (tremor), Nephrogenic DI, hypOthyroidism, Pregnancy (Ebstein's anomaly).
  • Monitor: Li+ levels, TFT, RFT.

  ⭐ NSAIDs, thiazides, ACE-inhibitors ↑ Li+ levels, risking toxicity.

• Valproate (VPA)
  • SE: Hepatotoxicity, pancreatitis, thrombocytopenia, neural tube defects (teratogen), weight ↑, alopecia.
  • Monitor: LFTs, CBC.
• Lamotrigine (LTG)
  • SE: ⚠️ Stevens-Johnson Syndrome (SJS) - slow titration essential! Benign rash common.
  • Valproate ↑ LTG levels (↑ SJS risk).
• Carbamazepine (CBZ)
  • SE: Agranulocytosis, aplastic anemia, SIADH, SJS (esp. HLA-B*1502 in Asians). Autoinducer.
  • Monitor: CBC, LFTs.
• Benzodiazepines (BZDs)
  • SE: Sedation, dependence, withdrawal (can cause seizures), anterograde amnesia.
  • Overdose: Flumazenil (use cautiously in chronic users due to seizure risk).
  • Withdrawal: Gradual taper.

High‑Yield Points - ⚡ Biggest Takeaways

• NMS (Neuroleptic Malignant Syndrome) with antipsychotics: FEVER (Fever, Encephalopathy, Vitals unstable, Enzymes ↑, Rigidity); manage with dantrolene/bromocriptine.
• Serotonin Syndrome (SSRIs/MAOIs): autonomic instability, neuromuscular hyperactivity, altered mental status; manage with cyproheptadine.
• Lithium toxicity: coarse tremors, ataxia, confusion; hemodialysis for severe cases.
• Clozapine: risk of agranulocytosis; requires regular WBC monitoring.
• MAOIs: hypertensive crisis with tyramine-rich foods (cheese reaction).
• TCA overdose: cardiotoxicity (QRS prolongation), convulsions, coma; manage with sodium bicarbonate.