CLINICAL HANDBOOK OF SCHIZOPHRENIA

176 III. SOMATIC TREATMENTreasons that it is commonly titrated up to a target dose. Because of the risk of falls relatedto postural hypotension in susceptible patients, and the rare possibility of severe posturalhypotension leading to syncope, patients should be warned to get up from a seated orprone position slowly. If symptomatic orthostasis persists, switching to a different atypicalantipsychotic should be considered. In general, the ability of an antipsychotic to produceorthostasis can be predicted by its level of alpha-1 receptor blockade. The abovementionedagents (i.e., clozapine, chlorpromazine, and thioridazine) have significantalpha-1 blocking activity.HEMATOLOGICAL SIDE EFFECTSThe only antipsychotic associated with clinically significant hematological toxicity isclozapine. Although relatively uncommon (1% of treated patients), the ability of clozapineto cause agranuloctyosis necessitates regular monitoring and prompt action in response tosubstantial reductions in white blood cell counts. The appropriate use of clozapine is discussedin detail by Sajatovic, Madhusoodanan, and Fuller (Chapter 18, this volume).OVERDOSAGEAntipsychotics, in general, have a low potential for causing death when taken by themselvesin overdose situations. Although there is substantially less experience with atypicalantipsychotics compared to conventional antipsychotics in overdose situations, the atypicalantipsychotics appear safer, although isolated published reports of death exist. Generally,the most serious results of an antipsychotic overdose are coma and hypotension. Cardiacarrhythmias and seizures have also been reported. Central nervous system depression andexcitation have both been reported in patients who overdose on antipsychotics.KEY POINTS• Atypical antipsychotics represent the treatment of choice for patients with schizophreniawhen clinicians consider efficacy and safety.• Atypical antipsychotics, compared to conventional agents, are associated with a decreasedrisk of EPS and TD but still have a substantial side effect potential.• The risk of metabolic side effects associated with atypical antipsychotics necessitates baselineand follow-up monitoring of patients.• Clozapine and olanzapine have the greatest potential to cause weight gain, dyslipidemia,and impaired glucose control.• Selection of an antipsychotic should be made on a patient-by-patient basis to minimize thepotential for antipsychotic-related side effects.REFERENCES AND RECOMMENDED READINGSAmerican Diabetes Association, American Psychiatric Association, American Association of ClinicalEndocrinologists, & North American Association for the Study of Obesity. (2004). Consensusdevelopment conference on antipsychotic drugs and obesity and diabetes. Diabetes Care, 27,596–601.Ananth, J., Venkatesh, R., Burgoyne, K., Gadasalli, R., Binford, R., & Gunatilake, S. (2004). Atypicalantipsychotic induced weight gain: Pathophysiology and management. Annals of Clinical Psychiatry,16, 75–85.