Second Generation Antipsychotics - Better, Not Perfect

As seen in Consultant Connection November 2012 Issue
By: Scott Spitnale ONU Pharm D Candidate

By now everyone should be aware that surveyors and other healthcare organizations are really targeting those residents receiving antipsychotics. The American Health Care Association and the National Center for Assisted Living have a quality initiative goal of reducing off-label use of antipsychotics by 15% by the end of the year. Their scrutiny of these medications comes with good reason. These medications have many potentially severe adverse effects. However, this article isn’t to tell you that antipsychotics should never be used, but it is to make you aware of the differences in adverse effects between the two types of antipsychotics and to bring your attention to some changes in the frequency of monitoring requirements listed in the table below.

Second Generation Antipsychotics (SGAs) have greatly increased our capabilities to care for patients with psychiatric illnesses. SGAs can often allow patients to live a full productive life with as little interference as possible. With the introduction of First Generation Antipsychoti cs (FGAs) health care professionals were able to treat the positive symptoms of psychosis; however, this came at a great cost with extensive side effects. Even at clinically effective doses FGAs could produce  extrapyramidal symptoms such as dystonic reactions, drug-induced parkinsonism, akathisia, and tardive dyskinesia. The extensive side effects of FGAs often led to discontinuation of the treatment due to intolerance of side effects. With the introduction of SGAs an elimination of extrapyramidal symptoms was seen as well as the ability to treat negative symptoms of psychosis such as withdrawal, apathy, and the lack of verbal communication.

The introduction of the SGAs led to higher compliance rates and quality of life. Although the elimination of extrapyramidal symptoms was a huge gain when switching to SGAs they came with metabolic side effects such as dramatic weight gain, diabetes, increased LDL levels, increased triglyceride levels, decreased HDL levels, and diabetic ketoacidosis. While the metabolic side effects are a problem for the entire class often switching between medications in the class may alter the side effect profi le for the patient. When switching between SGAs a cross taper should be performed where the original SGA should be gradually discontinued while the SGA is slowly brought to clinical levels. Abrupt discontinuation of Antipsychotics should be avoided.

Due to Second SGAs metabolism side effects creating long lasting cardiovascular effects, close monitoring of the following parameters is suggested:

These monitoring parameters can be used more frequently in patients who are at higher risk of side effect complications. Increased monitoring is seen at the beginning of a SGA regimen for early detection of side effects. Once a patient is stable on a SGA and is not at risk from the side effects monitoring should be decreased in frequency as seen above.

SGAs are very valuable despite their side effects and need for monitoring. With the use of SGAs expanding the need for appropriate monitoring expands with it. As with all medications, the risks and benefi ts of therapy should be weighed before making a change to a medication regimen. Increased awareness of SGAs and their possible side effects should lead to an increase in the quality of care and quality of life provided to these patients.

1. American Diabetes Association; The American Psychiatric Association; The American Association of Clinical Endocrinologists; and The North American Association for the Study of Obesity. Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes.
Diabetes Care 2004; 27(2):596-601.
2. Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; September 19, 2012. 3. Magellan Health Services. Second Generation Antipsychotic Tip Sheet. N.p.: Magellan Health Services, 12/11. Essential Tools for Atypical Antipsychotics Monitoring. Independence, Dec. 2011. Web. 19 Sept. 2012. <


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