1. Antipsychotic-Induced Dysphagia
Marissa Barbaro, PGY3
Morning Report, 8/31/17
Columbia University Medical Center

2. Brief Overview of Antipsychotics
First-generation antipsychotics (haloperidol, fluphenazine, perphenazine, pimozide, chlorpromazine): act via post- synaptic blockade of D2 receptors
Second-Generation Antipsychotics (olanzapine, quetiapine, aripiprazole, clozapine): also exert antipsychotic effect via blockade of D2 receptors
Lower risk of EPS, tardive dyskinesia
Higher risk of metabolic syndrome
Mechanism of action of aripiprazole: D2 receptor partial agonist with partial agonist activity at 5-HT1A receptors and antagonist activity at 5-HT2A receptors
Also low affinity for alpha1 receptor, H1 receptor, muscarinic receptors

3. Typical Neurologic Side Effects of Antipsychotics
Extrapyramidal symptoms (EPS): rigidity, bradykinesia, tremor, dystonia, akathisia
Highest risk with high-potency typical antipsychotics such as haloperidol, fluphenazine
Risperidone carries highest risk of EPS among second- generation antipsychotics
Quetiapine, clozapine are preferred agents in patients at high risk for EPS
Tardive dyskinesia: involuntary movements of the face, tongue, extremities
Ex: lip smacking, jaw thrusting, facial grimacing, writhing of extremities

4. Typical Neurologic Side Effects of Antipsychotics
Anticholinergic (antimuscarinic) effects
Blurred vision
Urinary retention
Dry mouth
Orthostasis: due to alpha adrenergic blockade
Seizures
Clozapine in particular lowers seizure threshold among second-generation antipsychotics
Sedation
Neuroleptic Malignant Syndrome

5. Antipsychotic-Induced Dysphagia
Dysphagia is a known but uncommon side effect of antipsychotic use
Neuroleptics may cause EPS that specifically affect swallowing function
Impact both oral and pharyngeal phases of swallowing
First-generation antipsychotics and second-generation antipsychotics have been associated with dysphagia

6. A Case of Aripiprazole-Induced Dysphagia
54-year-old man with 30-year history of psychosis (including responding to internal stimuli, ritualistic behavior, poor personal care, social withdrawal)
Treatment-naïve (no prior history of treatment with antipsychotics)
Brought to ED for exacerbation of psychotic symptoms and concern for violent behavior
Treated with aripiprazole 10mg daily, up-titrated to 30mg daily within three weeks

7. A Case of Aripiprazole-Induced Dysphagia
Day 3 of treatment with aripiprazole 30mg daily: complained of difficulty swallowing both solid and semisolid foods
Swallowing difficulty persisted despite down-titrating aripiprazole to 20mg daily and adding trihexyphenidyl
Antipsychotic switched from aripiprazole to paliperidone
Able to eat semisolid food four days later
Able to eat full diet within six days
No other EPS

8. A Case of Loxapine-Induced Dysphagia
79-year-old man with hx Alzheimer’s disease admitted for long-term care
Aggressive behavior at home had required treatment with haloperidol, thioridazine
On admission, haloperidol and thioridazine were no longer effective for controlling aggression; therefore, loxapine was started
One week after initiation of loxapine, patient began having difficulty swallowing pills

9. A Case of Loxapine-Induced Dysphagia
Initial swallow evaluation: difficulty with both thin and thick liquids
Modified barium swallow: moderate to severe oral-pharyngeal dysphagia
Oral phase:
Reduced chewing ability
Reduced tongue pumping
Defective tongue movements
Reduced base of tongue movement
Pharyngeal phase:
Delay in initiating swallowing
Pooling of residue in valleculae and pyriform sinuses
Reduced laryngeal movement
Pooled residue led to silent aspiration

10. A Case of Loxapine-Induced Dysphagia
Patient developed aspiration pneumonia
Loxapine was switched to chlorpromazine
One week after switching loxapine to chlorpromazine, patient exhibited improved swallowing function
Repeat modified barium swallow with no significant signs of oral-pharyngeal dysphagia

11. Antipsychotic-Induced Dysphagia
Case reports have also been published of dysphagia associated with various additional antipsychotics, including haloperidol, risperidone, quetiapine, and clozapine

12. References Dysphagia. 1997 Fall;12(4):177-9.
Encephale. 2012 Sep;38(4): doi: /j.encep Epub 2011 Oct 11.
Int J Eat Disord. 2012 Mar;45(2): doi: /eat Epub 2011 May 3.