Monitoring and Management of Side Effects.23
| Frequency | Monitoring | Management | |
|---|---|---|---|
| Metabolic Syndrome | 4 months after initiation, annually thereafter | Weight, circumference, lipid panel, fasting glucose or HbA1C | Lifestyle changes with diet and exercise are a first-line treatment, consider switching to antipsychotic with lower propensity for metabolic side effects if this will not destabilize the patient (d), medical treatment of metabolic syndrome may be necessary. Antipsychotics that have the lowest risk of metabolic syndrome are asenapine, aripiprazole (LAI available), lurasidone, ziprasidone, haloperidol (LAI available), cariprazine, brexpiprazole, and lumetaperone.24 |
| Movement Disorders | Each visit clinically, formally q6 months-annually | Abnormal Involuntary Movement Scale, etc. | Lower dose or switch to lower potency antipsychotic if it will not destabilize the patient, such as clozapine or quetiapine. If unable to change/switch, first choice medication is a VMAT2 inhibitor for Tardive Dyskinesia and anticholinergic drugs for drug-induced parkinsonism.25 |
| Agranulocytosis | First visit after initiation, then annually | ANC, discontinue if ANC <1000 | Discontinue if ANC <1000.23 and initiate broad spectrum antibiotics. Switch to another antipsychotic if it will not destabilize the patient, the antipsychotics with highest risk are clozapine, quetiapine, and olanzapine. If the patient must be re-trialed on the same medication, obtain a hematology consultation, wait until ANC normalizes above 1000.23, and consider only the oral form.26 |
| Prolonged QTc | After initiation in patients with sudden cardiac events in family or known risk for QT prolongation (ie, metabolic derangements, on other medications known to prolong QTc, etc.) | 12-lead EKG | If QTc is greater than 500 ms, consider dose reduction or switch to alternate medication with low QTc prolongation and a referral to cardiology. If QTc greater than 470 ms in women or 440 in men but less than 500, decrease the dose of the medication or switch to drug with lower risk of prolongation if this will not destabilize the patient. Antipsychotics with the lowest risk of QTc prolongation are perphenazine, aripiprazole, paliperidone, asenapine (no LAI available), and lurasidone (no LAI available).27 |
Abbreviations: QTc, heart rate–corrected QT interval; ANC, absolute neutrophil count; LAI, long-acting injectable antipsychotics.