Second-generation antipsychotics for treating schizophrenia

Risperdal Consta is given as a shot by a doctor every 2 weeks. Because a doctor gives the shot and it lasts longer than other medicines, some experts think this makes it more likely a person will follow a treatment plan.

The exact action of these antipsychotic medicines is not known. It is believed that they affect the way brain chemicals (neurotransmitters) work.

These medicines treat the symptoms of schizophrenia. They also cause fewer movement side effects than first-generation antipsychotic medicines, such as haloperidol (Haldol).

Because they may be better tolerated, second-generation antipsychotics—sometimes called atypical or newer antipsychotics—are often used as first-line treatment for those newly diagnosed with schizophrenia. But some health professionals feel that first-generation antipsychotics started at low doses may be just as effective and at a lower cost.

These medicines reduce or eliminate the positive symptoms (such as hallucinations or delusions) and sometimes help reduce the negative symptoms (such as lack of emotion or motivation) of schizophrenia.

Studies suggest that some second-generation antipsychotics might help better than first-generation antipsychotics with controlling negative symptoms.¹

Second-generation antipsychotics also help reduce the risk of movement disorder side effects (such as tardive dyskinesia) and improve memory and ability to concentrate in those with schizophrenia.²

The side effects of the new second-generation antipsychotic medicines vary. Side effects can include drowsiness, fatigue, weight gain, high cholesterol, and high blood sugar. The makers of Abilify, Risperdal, Zyprexa, and Seroquel have added warnings indicating an increased risk of high blood sugar or type 2 diabetes in people taking these medicines.

The makers of Risperdal (risperidone) have issued a warning that there may be an increased risk of stroke among older adults with dementia taking this medicine. Discuss this risk with your doctor before trying Risperdal.

Among second-generation antipsychotic medicines with other side effects:

• Olanzapine may increase your chances of hyperlipidemia, or increased levels of fats in the bloodstream. It may also increase your chances of insulin resistance, in which body cells do not fully respond to the action of insulin. This can cause blood sugar levels to become abnormally high.
• Quetiapine can cause constipation and dry mouth.
• Risperidone less commonly can cause reduced interest in sex, trouble maintaining an erection in men, disturbances in a woman's menstrual cycle, and increased risk of stroke in older adults with dementia.³
• Risperidone may increase levels of the hormone prolactin. This can lead to breast enlargement in both men and women, and abnormal menstrual cycles in women.
• Sertindole can cause a runny nose and a fast heartbeat.
• Ziprasidone side effects most often include nausea, headache, constipation, dizziness, tiredness, and problems sleeping. Occasionally ziprasidone can slow down the heart. This side effect occurs more often while a person is taking ziprasidone than other second-generation antipsychotics but less often than with first-generation antipsychotics.⁴ Ziprasidone should also not be used by people with a history of cardiac arrhythmia.
• Paliperidone may cause restlessness, movement disorders, rapid heartbeat, and sleepiness.⁵

In rare cases, second-generation antipsychotic medicines can cause some people to develop neuroleptic malignant syndrome. This syndrome causes dangerous problems with your body's ability to regulate its temperature.

Sometimes people with schizophrenia also need to take medicines for other illnesses. These people need to pay special attention to how the side effects of all of their medicines affect them and to any potential interactions between medicines.

In rare instances, these medicines may cause uncontrollable body movements, including tardive dyskinesia. But the chances of developing these movements is less than if the person takes first-generation antipsychotic medicines.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

Warnings have recently been issued of a possible increased risk of stroke in older adults with dementia taking risperidone (Risperdal). Discuss this risk with your doctor before trying these medicines.

People who have certain body movement disorders (such as Parkinson's disease or seizures) or liver disease may be unable to take risperidone. Tell your health professional if you have any other medical conditions.

To reduce interactions, ziprasidone should not be combined with certain medicines, such as amiodarone (Cordarone), cisapride (Propulsid), or disopyramide (Norpace).

Since ziprasidone can slow down the electrical conduction of the heart, it should not be taken with other medicines that also have this effect or by people who have heart problems. While you are taking ziprasidone, your doctor may suggest that you have an occasional electrocardiogram (EKG, ECG) to measure your heart's electrical activity.

Because ziprasidone does not cause significant weight gain as do other antipsychotics, it may be a good choice for people with schizophrenia who also have diabetes.

If one antipsychotic medicine does not reduce or eliminate the symptoms of schizophrenia, another medicine is tried. Second-generation antipsychotics may help people who were not helped by the first-generation medicines.

The amount of medicine needed to treat the symptoms of schizophrenia varies for each person and with each medicine. People who take mood-stabilizing medicines along with antipsychotics may have fewer symptoms of schizophrenia. They may also be able to decrease the amount of antipsychotic medicines they take, reducing their side effects.

The second-generation antipsychotics should be used with caution in people who drink alcohol or take other medicines. Tell your health professional if you drink alcohol or take medicines to treat any other condition.

The effects of the second-generation antipsychotic medicines have not been studied in children, older adults, or pregnant women. Older adults who take these medicines may develop side effects.

The second-generation antipsychotic medicines may pass into breast milk and cause problems in a baby, including behavior changes.

Always take your medicine as directed by your health professional. Store it away from heat or light, and do not store it in the kitchen or bathroom, where heat and moisture may cause it to lose its strength.

If you miss a dose of medicine, take it as soon as you remember. But if it is close to the time of your next dose, skip the missed dose and continue to take the medicine according to schedule. Do not take double doses. Call your health professional if you have any questions about missed doses.

Second-generation antipsychotics are usually less likely to cause certain side effects than first-generation antipsychotics. Because of this, people may be more likely to take these medicines regularly. But second-generation medicines have their own side effects, and in some cases, first-generation antipsychotics may be as effective. One study found perphenazine, an older first-generation antipsychotic, is as effective, as well tolerated, and less expensive than other second-generation antipsychotics.⁶

The second-generation antipsychotic medicines cost more than the older ones. Many companies who manufacture medicines have programs for people who cannot afford to pay the high cost of medicines. If you are concerned about your ability to pay for your medicines, ask your health professional whether you qualify to receive free medicine.

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Citations

1. Davis JM, et al. (2003). A meta-analysis of the efficacy of second-generation antipsychotics. Archives of General Psychiatry, 60(6): 553–564.

2. Goff DC, et al. (2001). Schizophrenia. Medical Clinics of North America, 85(3): 663–689.

3. U.S. Food and Drug Administration (2003). Safety alert—Risperdal (risperidone). MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Available online: http://www.fda.gov/medwatch/SAFETY/2003/risperdal.htm.

4. Ziprasidone (Geodon) for schizophrenia (2001). Medical Letter on Drugs and Therapeutics, 43(1106): 51–52.

5. U.S. Food and Drug Administration (2006). FDA approves new drug for schizophrenia. FDA News P06-208. Available online: http://fda.gov/bbs/topics/NEWS/2006/NEW01534.html.

6. Rosenheck RA (2006). Cost-effectiveness of second-generation antipsychotics and perphenazine in a randomized trial of treatment for chronic schizophrenia. American Journal of Psychiatry, 163(12): 2080–2089.