The possible side effects of antipsychotics are extensive, varied, frequently intolerable, too often serious, and sometimes fatal. Clinicians cannot be expected to use these drugs optimally in the care of their patients when inexperienced with the antipsychotic prescribed or unfamiliar with the adverse possibilities and how to monitor for them. This book aims to support clinicians in improving the safe, long-term use of antipsychotic drugs by their patients. Specifically, this book is designed to:
- (1) help inform antipsychotic treatment selections for individual patients (Section 1); and
- (2) support monitoring of antipsychotic-related side effects over the course of therapy (Sections 2 & 3).
- (1) the best available evidence;
- (2) identification of best practices; and
- (3) incorporation of our clinical and expert opinion.
Development
There is little or no research that directly assesses the best methods for the monitoring of antipsychotic treatment tolerance or safety. However, selected research and information on the effectiveness, tolerability, and safety of antipsychotics can be used to develop appropriate monitoring practices. Extensive effortwas made to locate and review this information. Aided by our research assistants, we conducted searches and literature reviews. Electronic resources used were Medline, EMBASE, the Cochrane Library, PsycINFO, Web of Science, Micromedex Drug Information, and reports from regulatory authorities (e.g. the US Food and Drug Administration, Health Canada). Drug monographs from antipsychotic manufacturers as well as from independent sources (e.g. AHFS Drug Information) along with specialty references (e.g. Meyler’s Side Effects of Drugs and Joseph and Young’s Movement Disorders in Neurology and Neuropsychiatry) and health technology assessments were used as appropriate to identify tolerability and safety information. Clinical practice guidelines and published monitoring recommendations were also reviewed.When several studieswere identified that addressed the same issue (e.g. diabetes risk with antipsychotic use), the best available evidence as determined by the hierarchy of evidence was selected and used to inform the content.
Limitations
The book offers a unique and clinically valuable resource but is not in itself sufficient for achieving its goals, which are tied directly to the clinician’s monitoring practices and systemic supports for monitoring.
Most monitoring recommendations in this book do not derive from studies that were designed to identify the most efficient or effective method for monitoring antipsychotic-related adverse effects. Such studies are effectively non-existent. Rather, the recommendations are a result of several informative components including an assessment of evidence of the risk, frequency, and timing of adverse effects caused by antipsychotics, an assessment of various methods to detect these potential harms, and our clinical judgement.
This guide does not provide information or advice regarding the management of antipsychotic-related adverse effects. The management (or preferably the prevention) of these adverse effects is of critical importance; however, it is beyond the scope of the book. It also does not provide guidance on how to monitor for the desired effects of antipsychotic treatment or what to do if not achieved. For this you are referred to the appropriate clinical practice guideline. This edition also does not specifically review the potential side effects of switching or stopping antipsychotics or how to monitor for them. The information provided applies generally; details related to the side effects and monitoring of antipsychotics when used in unique patient populations, such as the very young and old or during pregnancy and lactation, are not the focus.
The book is intended to supplement good clinical care practice. However, it should not be considered complete in its coverage of potential adverse effects related to antipsychotics or in its recommendations for detecting and monitoring potential adverse effects for all patients. Adjustments or additions to the recommended monitoringmay be required for selected patients; for example in pediatric and elderly patients, those on complex drug regimens, or for those with communication limitations. Moreover, application of the information in this guide may not limit or prevent the occurrence of minor or serious adverse effects related to antipsychotics. Users of this book are expected to use their training, knowledge, and judgement regarding the care of their antipsychotic-treated patients in an effort to achieve the desired benefits of treatment while minimizing the treatment-related harms. The guidance offered in this book is not written for non-practitioners.
Guide to using Antipsychotics and their Side Effects
This book was developed to support healthcare professionals involved in the care of patients receiving antipsychotic drugs long term. It is hoped that this book will be useful for psychiatrists, family practitioners, nurses, pharmacists, and mental healthcare workers. Some components of the book will also be of benefit to other health professionals, including dieticians and other medical specialists, during their care of patients receiving antipsychotics. Although this book was not developed for patients or their families, they too may find the content useful for making informed treatment decisions and for monitoring guidance.
This book has three major sections, each having a unique clinical utility. Section 1 includes the introduction and 20 concise chapters describing antipsychotic side effects along with the related monitoring recommendations. Each chapter begins with background information about the problem and then provides a summary of the evidence related to specific antipsychotics. General information on how to monitor for the problem, including in some instances how to interpret clinical observations or laboratory results, is provided, followed by an antipsychotic-specific monitoring schedule. Each chapter’s monitoring recommendations are consistent in terms of the proposed schedule, and the same symbols are used throughout. These chapters can be used by practitioners to help select an antipsychotic for a specific patient based on the comparative risks for various adverse effects among the different antipsychotics. It also supports practitioners in identifying reasonable methods for the monitoring of adverse effects.
For Section 2, we have created individual antipsychotic monitoring monographs, presented in alphabetical order, that provide clear monitoring recommendations for each antipsychotic. Each monitoring monograph is a reorganization of the information found in Section 1 such that practitioners can easily identify what to monitor and when for each individual antipsychotic. This section of the book will be most useful once the practitioner has selected an antipsychotic and wishes to put a monitoring schedule in place.
In Section 3, we have attempted to distill and somewhat simplify the monitoring recommendations from Sections 1 and 2 into a single general monitoring form that covers most antipsychotic side effects included in the book. To do this, we had to make some compromises, as the monitoring requirements of a patient taking one antipsychotic can be quite different from those when taking a different antipsychotic. However, we recognize that a general, non-specific monitoring schedule is better than no schedule at all. The monitoring form offered should be combinedwith the monitoring schedule suggested for the specific antipsychotic prescribed (see Section 2). Moreover, and of critical importance, the clinician should use his or her judgement in modifying the monitoring guide to meet the patient’s health needs. Upon first reviewing the form, we expect that it may appear demanding and a bit unclear. To help with the latter, we have provided a guide on how to use the form. To address the concern that the monitoring recommendationsmay be too demanding, we encourage you to try it out for three to five patients and then determine if it is too demanding or not. We hope your ultimate decision about the value of the form will come from experiencing it. If you would like to create copies of this form and/or would like to adapt it to your needs, it can be downloaded at www.cambridge.org/9780521132084.
Back to: Antipsychotics and their Side Effects by David M. Gardner (Cambridge University Press) 2011