Pharmaceutical Care Plan
We developed a systematic approach to assess the presence, severity, and management of extrapyramidal symptoms (EPS) in patients treated with antipsychotics. Patients were evaluated by the Modified Simpson-Angus scale, Abnormal Involuntary Movement Scale, and Dyskinesia Identification System: Condensed User Scale. We completed 235 sets of evaluations in 83 patients. A pharmaceutical intervention was proposed in 54% (130) of evaluations, of which 82% (107) were accepted and followed. In 93% (99) evaluations in which a recommendation was followed, clinical outcome was positive. The most common intervention was reducing the dosage or discontinuing the antidyskinetic agent, most often an anticholinergic (55% of cases). Our results show that detailed monitoring of EPS in a clinical pharmacist-operated clinic promotes rational drug therapy, limits unnecessary drugs, and improves clinical outcome of patients with EPS.
Antipsychotic drugs are routinely administered in the management of mentally ill patients, primarily those with formal thought and affective disorders. Until the early 1990s and the advent of atypical antipsychotics (e.g., clozapine, risperidone, olanzapine, quetiapine), typical antipsychotics (e.g., haloperidol, fluphenazine, chlorpromazine) were the principal agents given to manage symptoms such as paranoia, hallucinations, and delusions. Typical antipsychotics are associated with a number of intolerable side effects that contribute to high rates of noncompliance and disruptions in therapy. In addition to side effects related to anticholinergic, antihistaminergic, and a1-adrenergic blockade, the drugs have high binding affinity for dopamine D2 receptors in the basal ganglia. This D2 blockade is responsible for high rates of extrapyramidal symptoms (EPS), including tardive dyskinesia (TD). In addition, increased turnover of dopamine in the mesocortical and mesolimbic regions of the brain from antipsychotic drugs is believed to result in formation of toxic oxygen radicals. Although controversial, it is suspected that these oxygen radicals (dopamine quinones, hydrogen peroxide) contribute to the development of movement disorders. Atypical antipsychotics introduced an entirely new dynamic property -- serotonin blockade -- into the management of schizophrenia and with it a decreased propensity to contribute to EPS and TD.
Traditionally, EPS are considered to be pseudoparkinsonism, akathisia, or dystonia, whereas TD is often described as a separate but related movement disorder. The reported frequency of EPS varies, but is estimated to occur in nearly 50-60% of patients treated with typical antipsychotics. Tardive dyskinesia occurs in approximately 5% of patients treated with typical agents, although some researchers estimate rates as high as 20% with extended treatment.
We developed a systematic approach to assess the presence, severity, and management of extrapyramidal symptoms (EPS) in patients treated with antipsychotics. Patients were evaluated by the Modified Simpson-Angus scale, Abnormal Involuntary Movement Scale, and Dyskinesia Identification System: Condensed User Scale. We completed 235 sets of evaluations in 83 patients. A pharmaceutical intervention was proposed in 54% (130) of evaluations, of which 82% (107) were accepted and followed. In 93% (99) evaluations in which a recommendation was followed, clinical outcome was positive. The most common intervention was reducing the dosage or discontinuing the antidyskinetic agent, most often an anticholinergic (55% of cases). Our results show that detailed monitoring of EPS in a clinical pharmacist-operated clinic promotes rational drug therapy, limits unnecessary drugs, and improves clinical outcome of patients with EPS.
Antipsychotic drugs are routinely administered in the management of mentally ill patients, primarily those with formal thought and affective disorders. Until the early 1990s and the advent of atypical antipsychotics (e.g., clozapine, risperidone, olanzapine, quetiapine), typical antipsychotics (e.g., haloperidol, fluphenazine, chlorpromazine) were the principal agents given to manage symptoms such as paranoia, hallucinations, and delusions. Typical antipsychotics are associated with a number of intolerable side effects that contribute to high rates of noncompliance and disruptions in therapy. In addition to side effects related to anticholinergic, antihistaminergic, and a1-adrenergic blockade, the drugs have high binding affinity for dopamine D2 receptors in the basal ganglia. This D2 blockade is responsible for high rates of extrapyramidal symptoms (EPS), including tardive dyskinesia (TD). In addition, increased turnover of dopamine in the mesocortical and mesolimbic regions of the brain from antipsychotic drugs is believed to result in formation of toxic oxygen radicals. Although controversial, it is suspected that these oxygen radicals (dopamine quinones, hydrogen peroxide) contribute to the development of movement disorders. Atypical antipsychotics introduced an entirely new dynamic property -- serotonin blockade -- into the management of schizophrenia and with it a decreased propensity to contribute to EPS and TD.
Traditionally, EPS are considered to be pseudoparkinsonism, akathisia, or dystonia, whereas TD is often described as a separate but related movement disorder. The reported frequency of EPS varies, but is estimated to occur in nearly 50-60% of patients treated with typical antipsychotics. Tardive dyskinesia occurs in approximately 5% of patients treated with typical agents, although some researchers estimate rates as high as 20% with extended treatment.