side by side comparison

Antipsychotic Comparison: Typical vs Atypical — EPS Risk vs Metabolic Risk

A client on haloperidol develops a rigid, feverish presentation — is it EPS or NMS? A client on olanzapine gains 30 pounds in three months — expected or reportable? Mixing up which generation carries which risk profile leads you to monitor the wrong thing and miss the real danger.

Comparison

Side-by-side2 compared
Dimension
Typical (1st-Gen)
Atypical (2nd-Gen)
Class & mechanism
  • D2 dopamine blockade
  • D2 + 5-HT2A serotonin blockade
Indications
  • Acute psychosis, agitation
  • Positive symptoms (hallucinations, delusions)
  • First-line schizophrenia; bipolar
  • Positive AND negative symptoms
Route & forms
  • PO, IM, long-acting depot injection
  • PO, ODT, some long-acting IM
Key assessment
  • Watch for EPS at each visit
  • Baseline AIMS for tardive dyskinesia
  • Baseline weight, BMI, waist
  • Fasting glucose & lipid panel
Monitoring
  • Few routine labs; track AIMS scores
  • Glucose, lipids, weight on schedule
  • ★Clozapine: monitor ANC/WBC
Adverse effects
  • ★EPS: dystonia, akathisia, parkinsonism
  • Anticholinergic (low-potency agents)
  • ★Metabolic syndrome: weight, glucose, lipids
  • Sedation, orthostatic hypotension
Black box & toxicity
  • Elderly dementia: ↑ mortality (black box)
  • Tardive dyskinesia — may be irreversible
  • Elderly dementia: ↑ mortality (black box)
  • Clozapine: agranulocytosis (boxed)
Cautions & interactions
  • NMS: fever, rigidity, ↑ CK, autonomic instability
  • QT prolongation — monitor ECG
  • NMS: fever, rigidity, ↑ CK, autonomic instability
  • QT prolongation — monitor ECG
Patient teaching
  • Report fever or muscle rigidity (NMS)
  • Rise slowly; do not stop abruptly
  • Report fever or muscle rigidity (NMS)
  • Diet, exercise; report excessive thirst
Class & mechanism

Typical (1st-Gen)

  • D2 dopamine blockade

Atypical (2nd-Gen)

  • D2 + 5-HT2A serotonin blockade
Indications

Typical (1st-Gen)

  • Acute psychosis, agitation
  • Positive symptoms (hallucinations, delusions)

Atypical (2nd-Gen)

  • First-line schizophrenia; bipolar
  • Positive AND negative symptoms
Route & forms

Typical (1st-Gen)

  • PO, IM, long-acting depot injection

Atypical (2nd-Gen)

  • PO, ODT, some long-acting IM
Key assessment

Typical (1st-Gen)

  • Watch for EPS at each visit
  • Baseline AIMS for tardive dyskinesia

Atypical (2nd-Gen)

  • Baseline weight, BMI, waist
  • Fasting glucose & lipid panel
Monitoring

Typical (1st-Gen)

  • Few routine labs; track AIMS scores

Atypical (2nd-Gen)

  • Glucose, lipids, weight on schedule
  • ★Clozapine: monitor ANC/WBC
Adverse effects

Typical (1st-Gen)

  • ★EPS: dystonia, akathisia, parkinsonism
  • Anticholinergic (low-potency agents)

Atypical (2nd-Gen)

  • ★Metabolic syndrome: weight, glucose, lipids
  • Sedation, orthostatic hypotension
Black box & toxicity

Typical (1st-Gen)

  • Elderly dementia: ↑ mortality (black box)
  • Tardive dyskinesia — may be irreversible

Atypical (2nd-Gen)

  • Elderly dementia: ↑ mortality (black box)
  • Clozapine: agranulocytosis (boxed)
Cautions & interactions

Typical (1st-Gen)

  • NMS: fever, rigidity, ↑ CK, autonomic instability
  • QT prolongation — monitor ECG

Atypical (2nd-Gen)

  • NMS: fever, rigidity, ↑ CK, autonomic instability
  • QT prolongation — monitor ECG
Patient teaching

Typical (1st-Gen)

  • Report fever or muscle rigidity (NMS)
  • Rise slowly; do not stop abruptly

Atypical (2nd-Gen)

  • Report fever or muscle rigidity (NMS)
  • Diet, exercise; report excessive thirst

★ marks the fact that sets a column apart.

Clinical Pearl

Typicals trap movement (EPS); atypicals trap metabolism (weight, sugar, lipids) — NMS is the emergency for both.

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Component Topics

Atypical Antipsychotics — Metabolic EffectsTypical Antipsychotics — EPS & Adverse Effects
See all Pharmacology topics