Fluphenazine

Full spectrum: acute dystonia, akathisia, parkinsonism, tardive dyskinesia. High D2 occupancy is the mechanism. Risk is comparable to haloperidol. Monitor with standardized assessment tools. With the decanoate formulation, EPS management is complicated by the inability to rapidly reduce drug levels, side effects must be managed through the current injection cycle while the plan is adjusted for the next.

Involuntary choreiform movements, most commonly orofacial (lip-smacking, tongue protrusion, jaw movements). Risk increases with cumulative duration and dose of D2 blockade. FGAs carry higher TD risk than SGAs. Screen with AIMS at baseline and periodically. TD may be irreversible in some cases even after the offending medication is stopped. VMAT2 inhibitors (valbenazine, deutetrabenazine) are FDA-approved for treatment.

D2 blockade in the tuberoinfundibular pathway removes dopamine's tonic inhibition of prolactin release. Clinical consequences: galactorrhea, amenorrhea, sexual dysfunction, gynecomastia, and with prolonged hyperprolactinemia, potential effects on bone mineral density. Monitor symptoms; check prolactin level if symptomatic.

Same risk as all antipsychotics. Presents with severe rigidity, hyperthermia, altered mental status, and autonomic instability. With the decanoate formulation, NMS may have a more prolonged course because the depot cannot be removed. Requires ICU management with extended monitoring.

High-potency FGAs produce less H1-mediated sedation than chlorpromazine or SGAs like quetiapine and olanzapine. Some patients still experience sedation, particularly at higher doses or early in treatment.

Less alpha-1 blockade than chlorpromazine. Still possible, particularly in elderly patients or with concurrent antihypertensives.

FGAs generally produce less weight gain than olanzapine, quetiapine, or clozapine. Fluphenazine is relatively weight-neutral compared to the metabolically problematic SGAs. Metabolic monitoring is still reasonable but metabolic risk is not the primary concern with this medication.

Phenothiazine class effect. Counsel patients about sun exposure. Blue-gray skin discoloration has been reported with long-term phenothiazine use (rare).

Pain, induration, or nodule formation at the injection site. Proper injection technique (gluteal muscle, rotation of sites) reduces risk. Rarely clinically significant.