A 53-year-old man has been prescribed fluphenazine for many years for schizophrenia. He lives in a group home and is accompanied by his caseworker. His psychotic symptoms have been stable, but he has developed a tremor in his hands and his caseworker has noticed that he walks slower. His medical history is significant for obesity, hypercholesterolemia, and hypertension, for which he takes lisinopril and simvastatin. He has been trying to exercise and eat healthy foods and has managed to lose 5 kg (11 lb) since his last visit 3 months ago. He is concerned about his hands shaking and would like to lose more weight. He wonders if he might do better on a different medication.
Vital signs are normal. BMI is 37 kg/m². Mental status examination is significant for psychomotor retardation, slow speech, and lack of facial expressions. A resting tremor of the hands is noted.
ECG shows normal sinus rhythm without abnormalities.
The physician discusses the risks and benefits of switching to a different antipsychotic medication. Considering the patient's history, which of the following medications would be most appropriate?

Question

Quizplus · Accepted Answer

11ec193a_98a8_8052_853d_49982a9793a3_MD0002_00 Antipsychotic medications for schizophrenia are equally efficacious but have variable side effects. Common side effects include weight gain, metabolic syndrome (obesity, lipid and cholesterol abnormalities, hypertension, impaired glucose metabolism), extrapyramidal side effects (EPS) (acute dystonia, akathisia, parkinsonism), and tardive dyskinesia. High-potency, first-generation antipsychotics (eg, haloperidol, fluphenazine) generally have a higher incidence of EPS and may not be tolerated by many patients. Second-generation antipsychotic (SGA) agents have less potential to cause EPS but may be associated with weight gain and metabolic syndrome to varying degrees. This patient has parkinsonism (tremor, bradykinesia, masked facies), an EPS, and could benefit from a switch to an SGA. Of the SGAs, aripiprazole has a lower potential for causing weight gain or metabolic syndrome and should be considered in this obese, hypertensive patient. Ziprasidone is also associated with comparatively less weight gain but has somewhat greater risk of QT prolongation than other SGAs. (Choices B and D) Clozapine and olanzapine are more likely to cause weight gain and metabolic syndrome compared to other antipsychotics. In addition, clozapine can cause life-threatening agranulocytosis and is reserved for treatment-resistant cases. (Choice C) Like fluphenazine, haloperidol is a high-potency, first-generation antipsychotic and would likely cause a similar degree of EPS. Switching to the SGA aripiprazole is a better choice. (Choice E) Risperidone is more likely to cause EPS when compared with other SGAs, especially at doses greater than 4 mg/day. In addition, it is associated with more weight gain compared to aripiprazole, making the latter a better choice in this obese patient. Educational objective: Antipsychotic medications are equally efficacious but have different side effect profiles. The second-generation antipsychotic (SGA) medications cause fewer extrapyramidal side effects than first-generation antipsychotics but may be associated with weight gain and metabolic syndrome. Among the SGAs, aripiprazole has a lower potential to cause weight gain and metabolic effects and is a preferred drug for minimizing these issues. __________ References: Clinical monitoring and management of the metabolic syndrome in patients receiving atypical antipsychotic medications. (http://www.ncbi.nlm.nih.gov/pubmed/19083283) Metabolic syndrome and obesity among users of second generation antipsychotics: a global challenge for modern psychopharmacology. (http://www.ncbi.nlm.nih.gov/pubmed/26218604) Drug-induced Parkinson's disease. A clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/23887211)

A 53-Year-Old Man Has Been Prescribed Fluphenazine for Many Years