Risperidone, commonly prescribed for psychosis, is well known to cause orthostatic hypotension but
prolonged hypotension is rare and associated with overdose. Its excretion is dependent on the enzyme
CYP2D6 whose activity varies as per individual phenotype. Maximum therapeutic levels are achieved
at 2 h of administration of the drug. We hereby described a 55-year-old female with Acromegaly and
pituitary macroadenoma who experienced sudden hypotension and shock which led us to sequentially
rule out apoplexy, secondary adrenal insufficiency and cardiac causes amongst others. The plausible
end culprit for the cause of hypotension was a conundrum and found to be single dose of risperidone
2mg. The Naranjo Adverse Drug Reaction Probability Assessment Scale scored 6, indicating a probable
relation between the drug and the reaction. This case underscores the importance of considering first-
dose hypotension, even with a low dose of risperidone and highlights the necessity for clinician
awareness.