Extrapyramidal side effects in first-episode schizophrenia treated with flupenthixol decanoate

• Published in: The South African journal of psychiatry 2021, Vol.27 (1), p.1568-e7
• Main Authors: Joubert, Francois-Pierre, Chiliza, Bonginkosi, Emsley, Robin, Asmal, Laila
• Format: Article
• Language: English
• Subjects: akathisia; Antipsychotic drugs; Complications and side effects; Drug therapy; Dystonia; Extrapyramidal disorders; flupenthixol; Original Research; parkinsonism; Risk factors; Schizophrenia; Tardive dyskinesia
• ISSN: 1608-9685; 2078-6786
• DOI: 10.4102/sajpsychiatry.v27i0.1568

Background Concern for the development of extrapyramidal side effects (EPSEs) represents a barrier to the routine use of long-acting injectable (LAI) antipsychotic medication in patients with first-episode schizophrenia (FES). Flupenthixol decanoate is a first-generation antipsychotic, which is readily available in the public healthcare system in South Africa.Aim The aim of this study was to describe the nature, occurrence and severity of EPSEs and their impact on patients with FES over 12 months of treatment with flupenthixol decanoate (fluanxol depot).Setting The study was based in Cape Town, South Africa, and patients with FES were recruited from inpatient services at Stikland and Tygerberg Hospitals and surrounding psychiatric clinics. This was a sub-study of a larger study, which examined several outcomes in patients with FES treated with the lowest effective dose of flupenthixol decanoate.Methods The Extrapyramidal Symptom Rating Scale (ESRS) was used to assess both subjective experience and objective measures of EPSEs in a cohort of patients with FES (N = 130). The relationship between demographic and clinical risk factors for individual subsets of EPSEs was also determined.Results In the context of an overall good 12-month tolerability, EPSEs peaked at month 3. Patients with akathisia were more likely to have greater symptoms of depression, and Parkinsonism was predicted by higher Positive and Negative Syndrome Scale scores (independent of medication dosage). Black and white patients showed higher total ESRS and higher subjective ESRS scores, compared with patients of mixed ancestry, and white patients scored higher on Parkinsonism ratings.Conclusion Flupenthixol decanoate is well tolerated in patients with FES. Certain clinical features of schizophrenia may be related to EPSEs. Ethnicity is a socio-cultural construct, and hence the differential risk of EPSEs should be interpreted according to ethnicity. Variations in the environment, diet, substance use and genetics may all affect the pharmacokinetics and pharmacodynamics of psychotropic drugs and warrant further investigation.