Complications
Orthostatic hypotension, caused by alpha-adrenergic activity of antipsychotic medication, is often present at initiation of treatment or at increase of the dose.[85]
This complication is often transitory, lasting a few hours or days. Any patient may develop hypotension; for older patients this can be persistent and dose-limiting. Precautionary measures include patient education to assume upright position slowly.
Can occur at any time in the first few months after starting a neuroleptic agent. The presentation includes autonomic dysfunction, muscular rigidity, hyperthermia, and altered consciousness. It is imperative NMS is diagnosed early as it is life-threatening. Beside immediate drug discontinuation and intravenous fluids, patients need supportive interventions, preferably in an intensive care unit.[93]
Based on schizophrenia data, substance misuse can be said to be high: as many as one third of patients with schizophrenia use drugs at any time.[88] Substance use may precede the disease onset or develop during the course of the illness.
There appears to be an increased risk of blood-borne viruses in patients with severe mental illness, including schizoaffective disorder. One Swedish population-based study found that, after accounting for sociodemographic factors, the odds of HIV were 2.57 times higher in people with severe mental illness than in the general population; the odds of hepatitis B virus (HBV) were 2.29 times higher, and the odds of hepatitis C virus (HCV) were 6.18 times higher. Substance misuse was found to contribute most to this increased risk, indicating a need to identify and target comorbid substance misuse in patients with schizoaffective disorder, as well as to identify other interventions to prevent infection with blood-borne viruses.[89]
Patients with schizoaffective disorder smoke more heavily than the general population, and therefore have higher morbidity and mortality from smoking-related illnesses.[90] Bupropion may decrease tobacco use and increase abstinence rates without affecting symptom stability.
Characterised by repetitive, involuntary, purposeless movements. The Abnormal Involuntary Movement Scale is a useful tool for early detection of tardive dyskinesia and for ongoing monitoring. The risk is higher with high-potency antipsychotic medications (e.g., haloperidol, risperidone).[91]
A Parkinson-like clinical picture with postural stiffness, lack of movement fluency, small steps, and limited facial expressions may develop secondary to antipsychotic agents; typical agents carry a higher risk.
Diphenhydramine or benztropine instituted at the start of treatment, with a typical antipsychotic agent, is recommended to decrease the risk of parkinsonism.
Older or cognitively impaired patients should not be started on anticholinergic medications along with typical antipsychotics, owing to risk of cognitive impairment.
Several agents are more likely to cause weight gain (e.g., clozapine, olanzapine, quetiapine, and risperidone). If a weight gain of 5% occurs, a change of medication should be considered.[94] Switching from a drug with high weight gain potential to one with a lower potential (e.g., ziprasidone or aripiprazole) might be an effective intervention.[95] Body weight should be checked every 6 months for patients on antipsychotics.
Fasting glucose and lipid panel should be monitored.[96] Patients can remain on a medication that is causing metabolic abnormalities only when a risk-benefit assessment is done and the metabolic adverse effect is controlled.[97] Switching from a drug with high risk for a metabolic syndrome (e.g., olanzapine) to a drug with a lower metabolic risk (e.g., quetiapine, aripiprazole) might be an effective intervention.[95]
A metabolic panel should be obtained every 6 months for patients on antipsychotics.
Symptoms can be divided into peripheral (e.g., dry mouth, constipation, blurred vision, urinary retention) and central (e.g., delirium).
Patients usually develop tolerance to adverse effects such as dry mouth. Rinsing with water or chewing sugarless gum helps. For blurred vision, a temporary reduction of the medication dose may be indicated. If acute urinary retention or delirium occurs, medication needs to be discontinued.
Antipsychotic medication with higher dopamine blockade, such as haloperidol, fluphenazine, and risperidone, can cause increased prolactin, with galactorrhoea, gynaecomastia, and amenorrhoea.[71] If this occurs, the dose should be decreased or the medication changed.
QT prolongation, T-wave flattening, and torsades de pointes has been reported.[98] A baseline ECG is unnecessary in most cases. Special attention is justified in patients with known conduction abnormalities.
Agranulocytosis has been reported with most antipsychotic medications. Cumulative evidence shows a 0.8% risk with clozapine, far higher than with other antipsychotics.[99]
Only patients treated with clozapine require routine WBC monitoring (every week for the first 6 months and every 2 weeks indefinitely after that).
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