Extra-Pyramidal Side Effects

Description

Medicine treatment

Referral

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ICD-10 code: G21.1/G24.0/G25.8-9/Y11/Y13/Y88.0 + (T43.0-6/T43.8-9)

Description

Extra-pyramidal side effects (EPSE) may occur with any antipsychotic, but are most commonly due to haloperidol, risperidone, and flupenthixol and zuclopenthixol injections.

• At-risk groups include those with underlying medical conditions such as epilepsy, intellectual disability, dementia, and late onset psychosis (more often associated with a medical condition than psychosis in youth).
• People with bipolar disorder are more susceptible to EPSE than those with schizophrenia.

EPSEs may present as a variety of clinical syndromes:

Early appearing:

• Acute dystonic reaction (sustained muscle contraction that causes twisting and repetitive movements, abnormal posture or abnormal eye position, or laryngospasm within a few minutes to days after receiving an antipsychotic tablet or injection.
• Parkinsonism (slow, shuffling gait, delayed responses, masked facies, and a pill rolling tremor).
• Akathisia (a subjective and observed motor restlessness e.g.: pacing, rocking, marching, crossing and uncrossing legs).

Late appearing:

• Tardive dyskinesia (choreoathetoid involuntary movements that particularly involve the face, lips, and tongue (e.g.: lip smacking or chewing, tongue protrusion (“catching flies”), but occasionally also arms, legs or trunk. More common in older women, depression, bipolar disorder, people with cognitive impairment. Only about 50% of cases are reversible.

Medicine Treatment

Acute dystonic reaction

Children

• Anticholinergic, e.g.:
• Biperiden, IM/slow IV, 0.05–0.1 mg/kg to a maximum of:
  • 1–6 years: 1–2 mg immediately
  • 7–10 years: 3 mg immediately
  • > 10 years: 5 mg immediately

LoE:IVb⁷

OR

• Promethazine, IM, 0.125–0.5 mg/kg to a maximum of:
  • 5–10 years: 12.5 mg immediately
  • 10–16 years: 25 mg immediately

LoE:Ivb⁸

Adults

• Anticholinergic, e.g.:
• Biperiden, IM, 2.5 mg immediately.
  • May be repeated every 30 minutes.
  • Maximum of 3 doses within 24 hours.

LoE:Ivb⁹

OR

• Promethazine, IM, 50 mg immediately.

Drug-induced parkinsonism

• Anticholinergic, e.g.:
• Orphenadrine, oral, 50 mg 8 hourly, whilst awaiting review.

LoE:Ivb¹⁰

Referral

• Refer all children urgently.
• All patients for review of psychotropic medication.

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Standard Treatment Guidelines and Essential Medicines List for South Africa Primary Healthcare Level_Chapter 16: Mental Health Conditions_NEMLC Recommendations for Medicine Amendments 2020_2023