Are there antipsychotics that do not give hypotension?

Fråga: Are there antipsychotics that do not give hypotension?

Sammanfattning: All neuroleptics can cause hypotension, but the risk seems lower for classical high potency medicines such as haloperidol, flupenthixol or fluphenazine.

Svar: All antipsychotics have been reported to cause orthostatic hypotension [1,2]. Neuroleptics block alpha 1-adrenoreceptors, which leads to vasodilatation and consequently hypotension. This is more pronounced when the patient stands up, but can occur otherwise too [2]. Hypotension is most commonly seen for atypical antipsychotics such as clozapine, olanzapine, quetiapine, iloperidone, chlorpromazine and thioridazine [1] whereas classical high potency neuroleptics such as haloperidol, flupenthixol and fluphenazine have a lower risk of hypotension and other cardiovascular effects [2,3].

Even the Swedish physicians´ desk reference for medicines mentions orthostatic hypotension for all neuroleptics and for e.g. clozapine circulatory collapse due to hypotension is listed as an adverse reaction [4].

For patients who need antipsychotic treatment but have symptomatic orthostatic hypotension or symptoms of cerebral hypoperfusion, pharmacological treatment for the hypotension can be tried. The alternatives are intravascular volume expansion with fludrocortisone or desmopressin, or increased adrenergic tonus with sympathomimetics such as pseudoephedrine or phenylephrine [1]. This treatment should only be given to stable patients, i.e. not during acute treatment for myocardial infarction.