Educational use only. Drug cards are AI-assisted study material for NCLEX preparation.
Mechanism of action
Blocks dopamine D2 and serotonin 5-HT2A receptors; the serotonin antagonism distinguishes atypicals from typicals and reduces (though does not eliminate) extrapyramidal symptoms. Used for schizophrenia, bipolar mania, irritability associated with autism, and (carefully) behavioral disturbances in dementia.
Adverse effects
Life-threatening / NCLEX-tested
- Metabolic syndrome — weight gain, dyslipidemia, hyperglycemia/new-onset diabetes (less than olanzapine, more than aripiprazole)
- Hyperprolactinemia — most prolactin elevation among atypicals; galactorrhea, gynecomastia, menstrual irregularity, sexual dysfunction
- Extrapyramidal symptoms — less than haloperidol but real, especially at higher doses
- Tardive dyskinesia (late, often irreversible)
- Neuroleptic malignant syndrome — life-threatening (rare with atypicals but possible)
- QT prolongation
- Orthostatic hypotension and falls (especially in older adults)
- Increased mortality in older adults with dementia-related psychosis (boxed warning)
Side effects
Common — what to teach
- Sedation (less than olanzapine)
- Weight gain
- Dizziness, orthostatic hypotension
- Constipation, dry mouth
- Insomnia or somnolence
- Mild restlessness/akathisia
Food & drug interactions
CYP2D6 substrate — strong inhibitors (fluoxetine, paroxetine, bupropion) raise levels; inducers (carbamazepine, phenytoin, rifampin) lower levels. CNS depressants (alcohol, benzodiazepines, opioids) compound sedation. QT-prolonging agents compound torsades risk. Anti-hypertensives compound orthostasis. Levodopa/dopamine agonists antagonized.
Nursing implications
Assessment, monitoring, patient teaching
- Baseline and ongoing METABOLIC monitoring: weight/BMI, fasting glucose or A1C, lipid panel, BP — at start, 12 weeks, then yearly (more often if abnormal)
- Counsel on weight, diet, and physical activity from day 1 — metabolic risk is the central long-term concern with atypicals
- Assess for EPS and tardive dyskinesia (AIMS tool); recognize NMS (hot, stiff, altered, autonomic) and stop the drug if suspected
- Long-acting IM (Risperdal Consta, Perseris) is a major adherence option — monitor injection site
- Counsel about prolactin-related symptoms and discuss alternatives if disabling
- Older adults with dementia: limit to short-term, behaviorally-indicated use after non-pharm strategies; document risk-benefit discussion
- Slow position changes; fall precautions in older adults
When to hold / contraindications
- Suspected NMS (hot, stiff, altered mental status, autonomic instability)
- QTc > 500 ms or active torsades
- Severe hyperglycemia / DKA
- Severe orthostatic hypotension or recent fall with injury
- Pregnancy — discuss risk-benefit (third-trimester use can cause neonatal EPS/withdrawal)
- Severe agranulocytosis (rare)
Memory anchor
Atypicals (-pine, -done, -piprazole) = less EPS, more metabolic. Risperidone is the prolactin-raiser of the class. Track weight, glucose, lipids; not just symptoms.
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