We saw a pt today who looked like he had classic Parkinson's Disease - masked facies, cogwheel rigidity, trouble swallowing, stooped posture, trouble initiating movements, and a resting, pill-rolling tremor. Turns out, he had Parkinsonism, likely from the risperidone he had been taking for many years for his bipolar disease. So what do you do about pts with bipolar/psychosis/schizophrenia (too much dopamine) who have Parkinson's features (too little dopamine)?
Olanzapine (Zyprexa), risperidone (Risperdal), and aripriprazole (Geodon), all atypical antipsychotics, worsen motor function. Clozapine (Clozaril) is an acceptable alternative due fewer extrapyramidal side effects, but since it requires vigilant monitoring for agranulocytosis, the drug of choice is quietapine (Seroquel).
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