Background
SGAs and weight gain
SGAs and diabetes
SGAs and dyslipidemia
SGAs and prolactin
SGAs and cardiovascular safety
SGAs and neuromotor adverse effects
SGAs and neuroleptic malignant syndrome
Discussion
Adverse events | Clozapine | Olanzapine | Risperidone | Quetiapine | Ziprasidone | Aripiprazole |
---|---|---|---|---|---|---|
Weight gain | ++ | ++ | + | +/− | +/− | + |
Diabetes | ++ | ++ | + | +/− | +/− | + |
Dyslipidemia | + | ++ | + | +/− | +/− | +/− |
Extrapyramidal symptoms | − | + | ++ | +/− | ++ | + |
Cardiac effect (mainly Qtc prologation) | + a
| +/− | + | +/− | ++ | +/− |
Prolactin | − | +/− | + | − | +/− | − b
|
Time | What to do | Results | Possible strategies |
---|---|---|---|
I Step | General and neurological examination (weight, waist circumference, blood pressure…) | Normal | Plan a careful and tailored monitoring program/psychoeducation on drug side effects/healthy lifestyle, including diet and, when possible, exercise |
Baseline | |||
Abnormal | |||
Careful anamnestic interview about personal and familiar history of: Dyslipidemia, DM2, Obesity, Thyroid dysfunction, Arrythmogenic risk (sudden death, syncope, Prolonged QTc, Brugada syndrome) | Negative History | Regular monitoring | |
Positive History | Plan a careful and close monitoring program/psychoeducation on drug side effects/healthy lifestyle/ECG (see below) | ||
Blood examination for haemachrome, liver function, glucose, insulin and lipid profile, (thyroid function and PRL if possible) | Normal | Regular monitoring/healthy lifestyle | |
Glucose, transaminases, insulin and/or lipids significantly increased | Careful and close monitoring/psychoeducation/chose a SGA with lower metabolic impact | ||
ECG (in case of Ziprasidone or positive personal or familiar history) | Normal ECG and QTc<450 msec | Monitoring | |
QTc>450 msec or other arrythmogenic signs | Discuss with paediatric cardiologist about the cardiac safety and the risk- benefit ratio in starting a SGA/if possible chose another drug class or a SGA with lower impact on QTc | ||
II Step | Weight and waist circumference monitoring | Weight gain <7 % of baseline weight | Regular monitoring/healthy lifestyle |
1 month control | |||
Weight gain >7 % of baseline weight | Careful and close monitoring/Healthy lifestyle/Psychoeducation/if possible switch to another SGA | ||
Blood examination for haemachrome, liver function, glucose, insulin and lipid profile | Normal | Regular monitoring/healthy lifestyle | |
Glucose, transaminases, insulin and/or lipids significantly increased | Careful and close monitoring/Healthy lifestyle interventions/Psychoeducation/if possible switch to another SGA | ||
PRL related symptoms (galactorrhea, increased breasts volume, sexual dysfunction…) monitoring | - symptoms | Regular monitoring | |
+ symptoms | Blood prolactin determination/if possible lower the SGA dose/if possible switch to another SGA/if possible add Aripiprazole/discuss with paediatric endocrinologist the possible add on of a prolactin-lowering drug (cabergoline or bromocriptine) | ||
EPS and other neurological symptoms monitoring | - EPS | Regular monitoring | |
+ EPS | If possible lower dose/if possible add on anticholinergics or benzodiazepines | ||
NMS symptoms | Hospitalization | ||
ECG (in case of Ziprasidone or positive personal of family history) | Normal ECG and QTc<450 msec | Regular monitoring | |
QTc>450 msec or increase from 60 msec from baseline or other arrythmogenic signs | Discuss with paediatric cardiologist about the cardiac safety and the risk- benefit ratio in continuing a SGA/possible SGA discontinuation | ||
III Step | Weight and waist circumference monitoring | Weight gain <7 % of baseline weight | Regular monitoring/healthy lifestyle |
3-, 6- month and periodic (every 6 months) | |||
Weight gain still increasing | Careful and close monitoring/Healthy lifestyle/Psychoeducation/if possible switch to another SGA | ||
Blood examination for haemachrome, liver function, glucose, insulin and lipid profile | Normal | Regular monitoring/healthy lifestyle | |
Glucose, transaminases, insulin and/or lipids significant increased | Careful and close monitoring/Healthy lifestyle interventions/Psychoeducation/if possible switch to another SGA | ||
PRL blood determination | Normal PRL | Regular monitoring | |
PRL↑- associated symptoms | Careful and close monitoring/if possible lower SGA dose/if possible switch to another SGA/if possible add Aripiprazole/discuss with pediatric endocrinolgist to add on cabergoline or bromocriptine | ||
PRL↑ + associated symptoms | |||
EPS and other neurological symptoms monitoring | - EPS | Regular monitoring | |
+ EPS | If possible lower dose/if possible add on anticholinergic or benzodiazepines | ||
NMS symptoms | Hospitalization | ||
ECG (if possible and feasible; mandatory in case of Ziprasidone or positive personal of family history) | Normal ECG and QTc<450 msec | Regular monitoring | |
QTc>450 msec or increase from 60 msec from baseline or other arrythmogenic signs | Discuss with paediatric cardiologist about the cardiac safety and the risk benefit ratio of SGA continuation/possible SGA discontinuation |