Behavioral Health Red Flag Series: Antipsychotic Medications

It is important for providers to be aware of “red flag” symptoms associated with adverse events of medications and to use office visits as opportunities to identify potentially severe medication side effects, even if the visit is not medication focused. Within this article, the third in the series, we will cover Antipsychotic medication “red flags”.

Medication: Antipsychotics (Aripiprazole, Risperidone, Lurasidone, Quetiapine)

Concern: Metabolic abnormalities, Extrapyramidal (movement) disorders, and Neuroleptic Malignant Syndrome

Monitoring: Blood glucose/A1C, Lipid labs/LDL-C labs, and Abnormal Involuntary Movement Scale (AIMS)

Refer to the following link for Lab monitoring assistance and schedule: W248303-PFK_APM-Lab-Monitoring-Tool_2020.pdf (partnersforkids.org)

Refer to the following link for the AIMS form: ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS) (aacap.org)

Instructions for a physical exam to assist with completion of AIMS be found here: tool_aims.pdf (cqaimh.org)

Considerations before beginning antipsychotic medications or increasing the doses:

Review full medical history, especially those related to the “red flags” and the other considerations below.
Cardiac history: Antipsychotics may increase risk of QTc prolongation, with the risk being greater in those with preexisting cardiac concerns.
History of seizure or epilepsy: Antipsychotics may lower the seizure threshold. Providers may utilize BH-TIPS for assistance with medication selection.
Behavioral Health Treatment Insights and Provider Support (BH-TIPS) (nationwidechildrens.org)

RED FLAG Presentation: Differs depending on affected system, see chart below

*Due to interpatient variability among pediatrics, medication selection will be patient-specific. If concerned, utilize Behavioral Health or Neurology consultation to guide treatment.
For assistance with management of Metabolic dysfunction and Extrapyramidal symptoms, a Nationwide Children’s Hospital psychiatrist may be consulted via private Zoom conference. Schedule a meeting here: Behavioral Health Treatment Insights and Provider Support (BH-TIPS) (nationwidechildrens.org)

Risk	Presentation	Actions
Metabolic dysfunction	Elevated Glucose/HbA1C, possible overt Diabetes Elevated Lipids/ LDL-C, possible overt Hyperlipidemia Increased BMI	Consider dose reduction or switch to a medication with less risk of metabolic disturbance Encourage healthy eating habits and routines when applicable Consult Endocrinology
Extrapyramidal (Movement) disorders	Acute symptoms, may occur within days of initiating of an antipsychotic: Muscle spasms of the face, back and extremities that may be painful Abnormal posture Akathisia – a sense of restlessness and inability to stay still Often distressing to a patient Delayed Symptoms, typically occur months to years after initiation of an antipsychotic: Involuntary painless movements of face and limbs Puckering or smacking lips, tongue rolling and moving in and out of the mouth Abnormal posture Instability while walking, or abnormal gait Akathisia – a sense of restlessness and inability to stay still May become permanent if not addressed	Mild or minimally bothersome to patient: If not already using AIMS to track movements, initiate AIMS monitoring and record changes If worsening symptoms, reduce dose Moderate-Severe and/or bothersome to patient: Reduce dose, discontinue medication or select an agent with less risk of movement symptoms When dose reduction is not feasible, consider addition of a medication for symptom control* Refer to behavioral health specialist
Neuroleptic Malignant Syndrome	Acute symptoms, usually within 2 weeks after initiation or dose increase of an antipsychotic. Higher risks with higher doses and drug-drug interactions: High fever Sweating Unstable blood pressure Impacted cognition – disorientation, dizziness, “brain fog” Muscle rigidity	Discontinue medication immediately Refer to emergency care

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