Antipsychotics triggering anxiety?

[F0nzie]

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I recently had an intake on a patient that is on Saphris 10mg, for Bipolar maintenance complaining of "anxiety" with increased doses (15mg+), also had the same reaction with Zyprexa on doses (15mg+) On lower doses his mania is more likely to get triggered and on higher doses he reports "anxiety, feeling overwhelmed, tension, and sometimes pacing" Specifically denies restlessness or rigidity. He is also on more than adequate doses of Lamictal, Carbamazepine, and Lithium. Other than the pacing (self-report), on exam no restlessness, no muscle rigidity, no increased psychomotor activity, no tremor, AIMS score is 0. This is the first time I've had a patient experience "anxiety" on an atypical. Is this a mild form of EPS? Akithesia? Any ideas for pharmacologic management?

 

[nitemagi]

Check vitals. I don't know the cholinergic activity of saphris, but zyprexa can hit a good amount of anticholinergics, and lead to tachycardia which may feel like "restlessness."

 

[Divine Furor]

I recently had an intake on a patient that is on Saphris 10mg, for Bipolar maintenance complaining of "anxiety" with increased doses (15mg+), also had the same reaction with Zyprexa on doses (15mg+) On lower doses his mania is more likely to get triggered and on higher doses he reports "anxiety, feeling overwhelmed, tension, and sometimes pacing" Specifically denies restlessness or rigidity. He is also on more than adequate doses of Lamictal, Carbamazepine, and Lithium. Other than the pacing (self-report), on exam no restlessness, no muscle rigidity, no increased psychomotor activity, no tremor, AIMS score is 0. This is the first time I've had a patient experience "anxiety" on an atypical. Is this a mild form of EPS? Akithesia? Any ideas for pharmacologic management?

I don't know about the Safris, but I've had a small number of patients complain of similar symptoms with dosing changes, up and down, on Zyprexa. My attendings veered toward calling it akisthesia, but I suspect it's a difficult call if the patient actively denies a subjective feeling of restlessness. It's certainly seems to be how they're acting, though, if they're pacing and tense. I'm not familiar with pharm management for bipolar disorder that involves Li++ AND two mood stabilizers, neither of which have good evidence for mania control AND antipsychotics. Maybe it's a question of too many meds? How does a low dose of antipsychotics while on good control with Lithium trigger his mania, exactly?

 

[billypilgrim37]

By more than adequate doses of Zyprexa and Lamictal while on CBZ, do you mean that the person prescribing recognized the absurd drug interactions and dosed accordingly?

 

[F0nzie]

By more than adequate doses of Zyprexa and Lamictal while on CBZ, do you mean that the person prescribing recognized the absurd drug interactions and dosed accordingly?

Pretty much

 

[whopper]

Is this a mild form of EPS? Akithesia? Any ideas for pharmacologic management?

This does sound like akithesia though it'd be better to ask an attending you're working with to double check since I'm not actually seeing the patient.

http://www.medafile.com/zyweb/Barnes.htm

Regarding akithesia, treatment approaches could be trying the patient on a different antipsychotic, especially one with less potent D2 blockage, B-blockers, Benztropine or Artane, benzos (though be careful because they could lead to addiction/dependence), Vit B6, or N-acetyl cysteine.

You could possibly encounter a patient where the only med that seems to work well on their psychosis mania unfortunately is one that causes akithesia. In cases like that, I'd try to establish the specific dose where the akithesia occurs, and then attempting augmentation with Depakote or Lithium to see if it can handle the rest of the psychosis without pushing up the antipsychotic.