When to start an anticholinergic on Haldol?

[cyano22]

Hi,
So I'm trying to find literature to support starting Benztropine on a young guy in his 20's who is on Haldol. My attending is against it, however, I am truly concerned about him having EPS symptoms. We are only doing Haldol 5 mg BID, but will plan on doing Decanoate later on as we uptaper the dose.

If anyone has any guidelines they have for this, I'd love to hear them.

Also, for Risperdal and Atypicals like Zyprexa, do you guys typically do Benztropine?

My logic is, he is young and has lots of muscle mass.

Thanks

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[Dharma]

Does he have EPS? If so, what and how are you sure it is EPS? Current AIMS?

Why not switch to an atypical instead if convinced of EPS?

 

[michaelrack]

Does he have EPS? If so, what and how are you sure it is EPS? Current AIMS?

Why not switch to an atypical instead if convinced of EPS?

may not be able to afford it.

I start cogentin when haldol dose reaches 3 mg

 

[SmallBird]

Hi,
So I'm trying to find literature to support starting Benztropine on a young guy in his 20's who is on Haldol. My attending is against it, however, I am truly concerned about him having EPS symptoms. We are only doing Haldol 5 mg BID, but will plan on doing Decanoate later on as we uptaper the dose.

If anyone has any guidelines they have for this, I'd love to hear them.

Also, for Risperdal and Atypicals like Zyprexa, do you guys typically do Benztropine?

My logic is, he is young and has lots of muscle mass.

Thanks

Don't sweat it too much, no problem starting the cogentin and you can check in a month or two how he is doing and try tapering it off. People start both together all the time, or they just start the haldol and see how things go. I think it's easier to sell a patient on two meds then it is to convince them to keep at it after they develop EPS.

 

[PistolPete]

I think we tend to be conservative as a group and start cogentin more often that not. Agree with the suggestion to start the cogentin and f/u in a month then taper off if no issues. I always tell my patients to have Benadryl on hand in case they develop any muscle spasms, and to call me.

 

[ahmedqman]

In my residency, we never start it straight up. You gotta have symptoms...

 

[675015]

Isn't there pretty compelling evidence that chronic anti-cholingeric use is linked to dementia/cognitive impairment? That would suggest not starting them, especially in someone young who would be left on them forever, without symptoms? I like the idea of starting so the patient doesn't have side-effects and then tapering from there but I don't feel hopeful that if someone is started on Haldol and Cogentin in an inpatient setting that the next outpatient doctor is going to taper them off...

 

[Blitz2006]

may not be able to afford it.

I start cogentin when haldol dose reaches 3 mg

what about seroquel? Least chance among atypicals to develop EPS

 

[PistolPete]

what about seroquel? Least chance among atypicals to develop EPS

Other than clozaril, of course 🙂

 

[Dharma]

Other than clozaril, of course 🙂

Seen a pretty mean case of oculogyric crisis w a patient on clozapine alone. Guess you never know!

 

[SmallBird]

Isn't there pretty compelling evidence that chronic anti-cholingeric use is linked to dementia/cognitive impairment? That would suggest not starting them, especially in someone young who would be left on them forever, without symptoms? I like the idea of starting so the patient doesn't have side-effects and then tapering from there but I don't feel hopeful that if someone is started on Haldol and Cogentin in an inpatient setting that the next outpatient doctor is going to taper them off...

I agree with your point about the risk that it won't be tapered. The cognitive impairment issue is well established in elderly populations - there was a large prospective study published in the BMJ a few years back and showed a slight increase (less than 1 point) in decline on MMSE. It's unclear if this is really an issue in younger individuals and in clinical practice not something that I've seen people typically worry about for a few weeks to months of treatment. Choosing seroquel instead is a bad idea as this will almost certainly cause more significant side effects!

 

[Blitz2006]

I agree with your point about the risk that it won't be tapered. The cognitive impairment issue is well established in elderly populations - there was a large prospective study published in the BMJ a few years back and showed a slight increase (less than 1 point) in decline on MMSE. It's unclear if this is really an issue in younger individuals and in clinical practice not something that I've seen people typically worry about for a few weeks to months of treatment. Choosing seroquel instead is a bad idea as this will almost certainly cause more significant side effects!

I agree, but I was speaking purely from an EPS standpoint.

BTW, of the atypicals, what is the order for sedation?

Is it clozaril>seroquel>zyprexa>risperdal>latuda>abilify?

 

[Crayola227]

I agree with your point about the risk that it won't be tapered. The cognitive impairment issue is well established in elderly populations - there was a large prospective study published in the BMJ a few years back and showed a slight increase (less than 1 point) in decline on MMSE. It's unclear if this is really an issue in younger individuals and in clinical practice not something that I've seen people typically worry about for a few weeks to months of treatment. Choosing seroquel instead is a bad idea as this will almost certainly cause more significant side effects!

wait, I thought you guys said Seroquel was less likely to cause EPS side effects.

or, do you mean that Haldol + cogentin superior to Seroquel for side effects?

 

[Blitz2006]

wait, I thought you guys said Seroquel was less likely to cause EPS side effects.

or, do you mean that Haldol + cogentin superior to Seroquel for side effects?

Seroquel is the least likely to cause EPS (apart from clozaril)

I'm asking a different question, sedation.

 

[SmallBird]

wait, I thought you guys said Seroquel was less likely to cause EPS side effects.

or, do you mean that Haldol + cogentin superior to Seroquel for side effects?

Less likely to cause EPS but causes a ton of weight gain.

 

[birchswing]

Seroquel munchies are the worst. If you don't give into them and just go to sleep without eating (hard to do), you will wake up an hour later, and in the heaviest grog you will run into walls, as you head to the fridge to find any carb at all—things you would never eat in the daytime, like corn chips dipped in strawberry jam.

Or so I've heard.

 

[Crayola227]

Seroquel munchies are the worst. If you don't give into them and just go to sleep without eating (hard to do), you will wake up an hour later, and in the heaviest grog you will run into walls, as you head to the fridge to find any carb at all—things you would never eat in the daytime, like corn chips dipped in strawberry jam.

Or so I've heard.

so I've heard

 

[Crayola227]

I know someone who recently broke their pinky toe stumbling to the bathroom under the influence of a cocktail of Seroquel, Lamictal, clonazepam,
all because the Lithium they take at night makes them so thirsty they can't help but drink 2 L of water with it. Went down like a tree in the forest.

Thankfully a young patient. But now I understand why the concern re: Seroquel munchies, dizziness, increased thirst, DI, BPH, osteoporosis... polypharm can kill.

 

[JustAGuy]

I wouldn't start cogentin unless the patient has eps.

 

[psychattending]

The research is pretty consistent and demonstrates that EPS begins when D2 blockade is in the 75-80% range whereas antipsychotic efficacy is more in the 65-70% range. Thus, when I use a D2 antagonist that is missing anticholinergic activity, I look daily for EPS and hold the dose once I get there. With this approach I infrequently have to add cogentin (I just lower the dose). Research shows that haldol doses as low as 3mg can produce EPS. Using such an approach takes a good understanding of the literature and a willingness to alter ones practice.

 

[cyano22]

Thanks for the suggestions. I am actually looking for articles or research on this too. I always thought that younger men with more muscle mass would be more susceptible to this side effect, not true?

Thanks

 

[SourceOfDenial]

The research is pretty consistent and demonstrates that EPS begins when D2 blockade is in the 75-80% range whereas antipsychotic efficacy is more in the 65-70% range. Thus, when I use a D2 antagonist that is missing anticholinergic activity, I look daily for EPS and hold the dose once I get there. With this approach I infrequently have to add cogentin (I just lower the dose). Research shows that haldol doses as low as 3mg can produce EPS. Using such an approach takes a good understanding of the literature and a willingness to alter ones practice.

Came here to echo this. 10mg haldol is a lot of haldol, wondering what the dose titration was leading to improvement. 70% receptor occupancy puts you at 4mg ish haldol...you're gaining side effects at higher doses(or someone who has been chronically treated and their D2 receptors have upregulated.)

 

[psychattending]

Thanks for the suggestions. I am actually looking for articles or research on this too. I always thought that younger men with more muscle mass would be more susceptible to this side effect, not true?

Thanks

The rule is young black males (with rapid up titration) are the ones that are at higher risk of getting acute dystonia. I am not really familiar with the primary literature in this area and do not know if different prescribing practices have been ruled out as the cause. This does not appear to be the case for cogwheel rigidity and akathisia.

With respects to dosing papers there are multiple imaging studies from both the Karolinska and well as Toronto groups that demonstrate the % binding needed.

McElvoy in a 1991 Archives paper nicely showed that once you get above EPS (called the neuroleptic threshold), increasing the dose gets no more improvement, just more side effects.

Rifkin in a 1991 Archives paper showed that 30 and 80 mg of haldol were no more efficacious than 10 mg. Van Putten in a 1990 Archives paper showed that 20 mg was about the same as 10 mg but that more EPS occurred in the 20 mg group. 20mg appeared to be slightly better than 5 mg in that study.