Extrapyramidal reaction

Background

Adverse effect of antipsychotics.
More common with high-potency typical antipsychotics, but can also occur with atypical agents
Due to antagonism of dopamine-2 receptors in basal ganglia

Early-onset syndromes
- hours to days after drug initiation
- reversible
- Acute dystonic reaction
  - involuntary, uncoordinated skelatal muscle contraction
- Akathisia
  - subjective sensation of intense motor restlessness
  - may be misdiagnosed as manifestation of psychiatric disease
Parkinsonism
- onset weeks to months after starting medication
- similar presentation to Parkinson's disease (e.g. cogwheel rigidity, pill-rolling tremor, shuffling gait, bradykinesia)
Tardive dyskinesia
- usually irreversible or only partially reversible
- associated with prolonged use of antipsychotics
- stereotyped, repetitive facial movements (e.g. tongue protrusion, grimacing, lip smacking)

Stop or reduce offending agent
- may need to discuss with psychiatrist to prescribe new medication or for recs on taper
Acute dystonia, akasthisia, parkinsonism
- diphenhydramine 25-50mg PO or IV
- OR benztropine 1-2mg PO or IV/IM
- continue PO antihistamines for 2 days after stopping antipsychotic
- +/- benzodiazepines
Tardive dyskinesia
- may only be partially reversible, so minimize occurrence, stop or reduce offending agent promptly
- Do NOT give anticholinergics, will exacerbate symptoms

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