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.
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- D2 dopamine blockade
- D2 + 5-HT2A serotonin blockade
- Haloperidol IM: acute agitation
- Mainly positive symptoms
- First-line schizophrenia
- Bipolar disorder
- Positive AND negative symptoms
- Haloperidol/fluphenazine decanoate IM
- ODT: olanzapine, risperidone
- Watch for EPS at each visit
- Baseline AIMS for tardive dyskinesia
- Baseline weight, BMI, waist
- Fasting glucose & lipid panel
- Baseline AIMS for tardive dyskinesia
- Few routine labs
- Glucose, lipids, weight on schedule
- ★Clozapine: monitor ANC/WBC
- ★EPS: dystonia, akathisia, parkinsonism
- Haloperidol: highest EPS risk
- ★Weight gain, ↑ glucose, ↑ lipids
- Lower EPS risk
- Black box: ↑ death in elderly dementia
- Higher tardive dyskinesia risk
- Black box: ↑ death in elderly dementia
- Clozapine: agranulocytosis (boxed)
- NMS: fever, rigidity, ↑ CK, unstable VS
- QT prolongation — monitor ECG
- NMS: fever, rigidity, ↑ CK, unstable VS
- QT prolongation — monitor ECG
- Report fever or muscle rigidity (NMS)
- Rise slowly
- Report spasms or restlessness (EPS)
- Report fever or muscle rigidity (NMS)
- Diet + exercise for weight gain
- Report excess thirst or urination
- Rise slowly
Typical (1st-Gen)
- D2 dopamine blockade
Atypical (2nd-Gen)
- D2 + 5-HT2A serotonin blockade
Typical (1st-Gen)
- Haloperidol IM: acute agitation
- Mainly positive symptoms
Atypical (2nd-Gen)
- First-line schizophrenia
- Bipolar disorder
- Positive AND negative symptoms
Typical (1st-Gen)
- Haloperidol/fluphenazine decanoate IM
Atypical (2nd-Gen)
- ODT: olanzapine, risperidone
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
- Baseline AIMS for tardive dyskinesia
Typical (1st-Gen)
- Few routine labs
Atypical (2nd-Gen)
- Glucose, lipids, weight on schedule
- ★Clozapine: monitor ANC/WBC
Typical (1st-Gen)
- ★EPS: dystonia, akathisia, parkinsonism
- Haloperidol: highest EPS risk
Atypical (2nd-Gen)
- ★Weight gain, ↑ glucose, ↑ lipids
- Lower EPS risk
Typical (1st-Gen)
- Black box: ↑ death in elderly dementia
- Higher tardive dyskinesia risk
Atypical (2nd-Gen)
- Black box: ↑ death in elderly dementia
- Clozapine: agranulocytosis (boxed)
Typical (1st-Gen)
- NMS: fever, rigidity, ↑ CK, unstable VS
- QT prolongation — monitor ECG
Atypical (2nd-Gen)
- NMS: fever, rigidity, ↑ CK, unstable VS
- QT prolongation — monitor ECG
Typical (1st-Gen)
- Report fever or muscle rigidity (NMS)
- Rise slowly
- Report spasms or restlessness (EPS)
Atypical (2nd-Gen)
- Report fever or muscle rigidity (NMS)
- Diet + exercise for weight gain
- Report excess thirst or urination
- Rise slowly
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Typicals trap movement (EPS); atypicals trap metabolism (weight, sugar, lipids) — NMS is the emergency for both.
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