Evidence-Based Reviews

UPDATE ON ATYPICALS: Practical tips to manage common side effects

Current Psychiatry. 2003 March;2(3):49-57

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Priapism has been reported with all atypicals except ziprasidone.⁴⁹ The vascular tone of the penis is in part sympathetically mediated, and alpha-1 blockade can inhibit detumescence via its indirect tendency to increase nitric oxide levels.⁵⁰ Although priapism does not appear to be common, it is a urologic emergency with potential long-term consequences, including permanent erectile dysfunction. Patients developing abnormally prolonged and painful erections must be counseled to seek immediate medical attention.

Aripiprazole: Preliminary impressions

The recently approved antipsychotic aripiprazole differs from the now-familiar dopaminergic theme by being a partial agonist at the D2 receptor. Aripiprazole has the greatest affinity for the D2 receptor of any available drug, activates the postsynaptic complex at about 30% of the full endogenous DA affect, and appears to lack the metabolic consequences of the other atypicals.

In our research laboratory, aripiprazole has shown a profound prolactin lowering effect, superior subjective tolerability, and a more salutary impact on sexual function, compared with other antipsychotics. Although not devoid of EPS, aripiprazole appears to alter a patient’s subjective distress in a way that alters the risk/benefit ratio. Although aripiprazole’s clinical niche has yet to be established, it would be reasonable to use it for overweight patients intolerant of the dysphorogenic effects of other antipsychotics.

Related resources

Wirshing DA, Wirshing WC, Kysar L, et al. Novel antipsychotics: comparison of weight gain liabilities J Clin Psychiatry 1999;60(6)358-63.
Wirshing DA, Spellberg B, Erhart SM, Marder SR, Wirshing WC. Novel antipsychotics and new-onset diabetes. Biol Psychiatry 1998;44(8):778-83.
Wirshing DA, Pierre JM, Marder SR, Saunders CS, Wirshing WC. Sexual side effects of novel antipsychotic medications. Schizophr Res 2002;56(1-2):25-30.

Drug brand names

Aripiprazole • Abilify
Clozapine • Clozaril
Olanzapine • Zyprexa
Quetiapine • Seroquel
Risperidone • Risperdal
Ziprasidone • Geodon

Disclosure

Dr. Donna Wirshing receives grant/research support from Pfizer Inc., Eli Lilly and Co., Janssen Pharmaceutica, and AstraZeneca Pharmaceuticals; is a consultant to Bristol-Myers Squibb Co., Janssen Pharmaceutica, and Pfizer Inc., and is a speaker for Eli Lilly and Co., Pfizer Inc., and Janssen Pharmaceutica.

Itai Danovitch reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Pierre receives grant/research support from Cephalon Inc.; is a consultant to Eli Lilly and Co., Bristol-Myers Squibb Co., AstraZeneca, and Pfizer Inc.; and is a speaker for Novartis Pharmaceuticals Corp., AstraZeneca Pharmaceuticals, and Janssen Pharmaceutica.

Dr. William Wirshing receives grant/research support from Janssen Pharmaceutica, Eli Lilly and Co., Otsuka America Pharmaceutical, Abbot Laboratories, Pfizer Inc., Sanofi-Synthelabo, Organon, Bristol-Myers Squibb Co., and Knoll Pharmaceuticals, and is a consultant to Janssen Pharmaceutica, Hoechst Marion Roussel, and Eli Lilly and Co.