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Medication Side Effects
If our children have ever taken any medication from
antibiotics to antipsychotics, most of us are familiar with side effects. Most
side effects are relatively minor, pass quickly and are no cause for
alarm. There are a few types of side effects that can happen, some particular
to psychiatric medications, that we as parents must be aware and alert to spot
because of the serious consequences if not recognized quickly. Below you will
find
information on some of the most serious adverse reactions associated with
psychiatric medications: Movement Disorders, Neuroleptic Malignant Syndrome,
Steven Johnson Syndrome, Serotonin Syndrome and Suicidal Antidepressant
Reactions.
Movement Disorders It is not uncommon for those who take antipsychotics, and sometimes other medications, to experience movement disorders. This can be slight tics that are possibly noticeable to only the most observant person or something as drastic as spastic large muscle group movement, undoubtedly noticeable to anyone in the vicinity. Unfortunately, the very thing causing these problems can be the medications that are helping regulate the moods of bipolar disorder. You might hear these problems called tardive dyskinesia (TD) or extrapyramidal symptoms/syndrome (EPS). EPS occurs early in the treatment with an antipsychotic medication or with an increase of a current one but can also occur after years of antipsychotic medication treatment. It can be any one or combination of involuntary movements. It can be treated by removing the offending medication, addition of a medication that helps alleviate the symptoms or both. Medications often used to treat this are Cogentin (benztropine), Benadryl (diphenhydramine), benzodiazepines, or a combination of these. It is important to treat these problems early in order to reverse their effects. If allowed to continue unchecked, they can become permanent. Usually, tardive dyskinesia refers to involuntary movements of the tongue, face, or mouth called orofacial movements, and neck or vocal cords. These are termed. TD can also include involuntary movement of the trunk or extremities. This type of movement disorder usually shows up as a late effect of prolonged antipsychotic medication usage. When the offending medication is removed or the dose is reduced the involuntary movements may or may not go away. In cases where removing the medication does not stop TD, treatment of the condition over time may reduce the symptoms. In both EPS and TD, it is important to consider whether the positive, therapeutic effects of an offending medication outweigh the negative side effects. In other words, which is the lesser of the two evils? Sometimes it can be more important to continue a medication and to treat the side effects and learn to cope with what cannot be managed medically.
Neuroleptic Malignant Syndrome (NMS)
(considered a movement disorder)
Another movement disorder that can be seen
with antipsychotic medications is Neuroleptic Malignant Syndrome. This very
rare syndrome is an acute and very dangerous situation. It is characterized
by generalized muscle rigidity often referred to as “lead pipe”, may also
appear myoclonic, tremulous or show ‘cogwheeling’ – movement that has a
‘rachety’ appearance; hyperpyrexia – a state of extreme fever (as high as
110ºF) that is a dysfunction unrelated to immune system response to invasion,
heart palpitations or other chest pain, unstable blood pressure, temperature,
heart rate and respirations; altered mental status – confusion,
unresponsiveness. This constitutes a medical emergency that can be fatal.
Because it can be mistaken for some other conditions (thyroid storm, heat
stroke, others) it is important that emergency personnel be notified that the
person takes antipsychotic medications so treatment can be started
immediately.
What to look for: This syndrome occurs in people who are
taking neuroleptic medications (antipsychotics). Signs are fever over
100.4, muscle rigidity, and at least five of the following 12 symptoms;
mental status change (confusion, agitation, coma), tremor, racing heart,
incontinence, fluctuating blood pressure, increase in total body acid
(metabolic acidosis), abnormally fast breathing (tachypnea) or not enough
oxygen to the body (hypoxia), elevated CPK enzyme, perspiration
(diaphoresis), drooling or excessive salivation (sialorreah), and white
blood cell count greater than 11,000 per mm (leukocytosis).
Recognizing NMS via Fever Mnemonic National Institute of Health on Neuroleptic Malignant Syndrome
Steven Johnson Syndrome
What to look for: SJS can be caused by a wide variety of
medications, including antibiotics, Tylenol, and anticonvulsants (used in BP
for mood stabilizing). Before onset of the rash, you would see fever, cough,
and fatigue. When the rash starts, it is a diffused inflammation with
rose-colored patches of variable size. The rash spreads over the body
symmetrically in 1-3 days. In the later stages, the rash has irregular,
atypical borders, blisters form, and the mouth, eyes and genital tract may
be involved. This syndrome may cause permanent disfigurement, vision loss,
and even death. Early identification and management are essential to better
outcome.
Serotonin Syndrome
What to look for: This syndrome occurs in people who are
taking medications that raise the serotonin level in the brain. Mental
status changes (confusion, agitation, coma), racing heart, high or low blood
pressure, gastrointestinal problems (diarrhea, nausea, pain), muscle
rigidity, muscle twitches or jerks, high blood pressure, slow pulse or fast
pulse, fever, flushing, bladder or bowel dysfunction, headache, sweating,
anxiety, nasal congestion, muscle spasm, restlessness, tremor, incoordination, shivering, involuntary eye movement, seizures, abnormally
fast breathing, and extremely high fever. Obviously early identification is
critical. Mild to moderate cases usually resolve in 24-72 hours. Severe
cases can require hospitalization, ICU, ventilator and have an 11% mortality
rate.
NMS vs SS
Help defining the differences between Serotonin Syndrome
and Neuroleptic Malignant Syndrome.
Antidepressant Suicidal Reactions
What to look for:
Increase in depression, thinking of suicide, planning for
suicide or death, agitation, aggression. There are currently no studies on
how this specific side effect manifests, so unfortunately our
recommendations are more general in nature.
Terminology Used in Describing Side Effects
Akathesia – body restlessness Ataxia – lack of ability to coordinate muscle movement Dyskenisia – lack of ability to control movements, characterized by spasmodic or repetitive movements or lack of coordination Dystonia – an involuntary muscle contraction that causes sustained twisted or abnormal posturing Myoclonus – lightening like jerky movements, usually of the arms or legs Tic – patterned movement that is frequently preceded by the urge or need to move, can sometimes be suppressed for a short period of time, completion of the movement brings relief Oculogyric crisis – a spasmodic movement of the eyeballs into a fixed position, usually upward; can last several minutes to hours Torticollus – involuntary contractions of the muscles of the neck Tremor – a vibrating type shaking, can be mild or severe Restless leg syndrome – sense of restlessness of the legs with accompanying urge to move; this is involuntary, can be the cause of poor sleep/insomnia Vocal tics – tics that involve the vocal muscles resulting in audible, repetitive sounds Deciphering medical terms: a- without, lacking dys- abnormal kathisia – to sit kinesia – movement myo- muscle oro- of the mouth ocular- of the eye taxi- order, arrangement ton- (tone) – normal state of tension or relaxation of muscles
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