Atypical/ second-generation antipsychotics

In general, atypical antipsychotics have a lower risk of extrapyramidal symptoms and anticholinergic side effects when compared to the typicals o Atypical binding to serotonin 5HT2 receptor can exceed affinity for dopamine D2 receptors which may explain the lower EPS risk compared to typicals Side effects of atypical antipsychotics include: weight gain, DM, HLD, hyperprolactinemia, NMS, sudden death, increased mortality in treating elderly with dementia o Profiles vary with the drugchoosing antipsychotic requires weighing benefit and side effects

Risperidone offers the advantages of extensive clinical experience, availability in multiple forms, and lower cost generic versions. It has a somewhat greater risk of extrapyramidal symptoms, weight gain, and prolactin elevation than other SGAs. Olanzapine's advantages include extensive clinical experience and multiple formulations, but at a higher cost. Weight gain, hyperglycemia, and hyperlipidemia are greater with olanzapine than with other SGAs. Quetiapine has a low incidence of extrapyramidal symptoms even at higher doses. Disadvantages include sedation and hypotension, moderate risk of weight gain, and recommended twice daily dosing for the immediate release formulation. Ziprasidone's advantages include lower risks of weight gain, diabetes, and hyperlipidemia. Disadvantages include twice daily dosing and prolonged QT interval. It should be taken in conjunction with a meal of at least 500 calories. Aripiprazole's advantages include a lower risk of weight gain, increased lipid or prolactin levels, extrapyramidal effects and sedation. Disadvantages include a long elimination time, and the need to avoid co-administration with other antipsychotic drugs. Akathisia is more commonly seen in patients with mood disorders. Paliperidone, iloperidone, asenapine, and lurasidone are newer antipsychotics that have been subject to fewer studies and less clinical experience than other second-generation drugs. Clinically significant findings to date include: Paliperidone can be used to treat psychosis in patients with hepatic impairment. It can prolong the QT interval and should not be used with other drugs that have similar effects. It has a similar risk profile to risperidone, including prolactin elevation. Iloperidone has not been extensively tested in older adults. Known risks of QT prolongation and hypotension suggest that caution be exercised with the drug in this population. However, it has a low risk for extrapyramidal symptoms and akathisia. Lurasidone has lower risk of weight gain, lipid dysregulation, and QT prolongation compared to other drugs in this class. Clozapine is unique among second-generation antipsychotic drugs for its efficacy in treating psychotic symptoms of schizophrenia that persist in response to other antipsychotics and reduced rates of extrapyramidal symptoms and tardive dyskinesia. Potential adverse effects include agranulocytosis, seizure, and myocarditis. Patients taking clozapine require weekly to monthly monitoring of white blood cell counts