[Akathisia. A frequent adverse effect in treatment with neuroleptics]

Neuroleptics are employed in the treatment of psychotic states but also in the treatment of anxiety states, as anti-emetics, in the treatment of pain and for anaesthesia. In approximately 20% of the patients, side effect in the form of akathisia are observed. Akathisia caused by neuroleptics may be difficult to diagnose as the symptoms are non-specific with anxiety, restlessness and agitation. Treatment consisted previously of anticholinergics but investigations have been published which demonstrate good effects of non-specifically acting beta-receptor blocking agents. On the basis of a review of the literature, the development of akathisia caused by neuroleptics is described, the symptoms and differential diagnoses involved and the therapeutic possibilities, are described.

Serum iron and transferrin in acute neuroleptic induced akathisia

Thirty acute psychiatric patients were examined prospectively at the beginning of neuroleptic treatment for acute psychotic symptoms and on average 16 days later. Two alternative hypotheses were examined: 1) neuroleptic treatment affects the levels of serum iron and transferrin; 2) acute akathisia developing during the initial few weeks of treatment is associated with low levels of serum iron and transferrin, either initially or at follow up or both. Serum iron levels did not change on repeat measurement, while there was a small, but significant decrease of serum transferrin. There was a significantly greater decrease in iron and transferrin levels in patients with akathisia on follow up compared with non-akathisics. In addition, akathisia ratings were highly correlated with serum transferrin levels on follow up.

Fetal phenytoin exposure, hypoplastic nails, and jitteriness

In a prospective study infants born to mothers with epilepsy (n = 61) were found to have an unexpectedly high incidence of congenital anomalies (26/61, 43%) and neonatal conditions (26/61, 43%) compared with controls (0/62, and 6/62, 10%, respectively). There were two neonatal deaths in the study group but none among the controls. Hypoplasia of the finger or toenails was a common congenital anomaly in those infants whose mothers had received phenytoin alone or in combination with other anticonvulsant drugs (11 of 40, 28%). The mean serum phenytoin concentration was higher among mothers of infants with hypoplastic nails than among those with normal nails. Jitteriness was a common neonatal condition affecting infants of epileptic mothers (11 of 61, 18%) but not controls The mean cord serum phenytoin concentrations were similar among jittery and non-jittery infants. At follow up (after excluding one infant with Down's syndrome from the study group) the infants seemed to have developed normally, though one had serious learning difficulties at school. We suggest that hypoplasia of the nails is related to high maternal serum concentrations of phenytoin, and though 18% of infants born to epileptic mothers were jittery compared with no control infants this may not be the result of withdrawal of the drug in all cases.

Clinical variants of tardive dyskinesia in Japan

Involuntary movement disorders were investigated in a psychiatric hospital in Japan. The prevalence of tardive dyskinesia was 9.9% and four clinical variants of tardive dyskinesia could be classified. Of the 716 patients, tardive dystonia was identified in 15 cases, tardive akathisia in one, respiratory dyskinesia in two and rabbit syndrome in 17. The existence of tardive forms for acute dystonic reactions and akathisia suggests that any type of acute extrapyramidal symptoms can have a tardive form.

Efficacy and safety of morning versus evening fluoxetine administration

A total of 120 patients who met DSM-III criteria for unipolar major depressive episode were equally randomized to fluoxetine a.m. or fluoxetine p.m. treatment groups, such that 30 patients were in each group at each of two sites. Patients received 20 to 80 mg of fluoxetine every day for 5 weeks; the dose was based on clinical response. Highly significant within-treatment improvement was reflected by changes in mean scores on the Hamilton Rating Scale for Depression (total score and factors), the Raskin Depression Scale, the Covi Anxiety Scale, the Clinical Global Impressions Scale for Severity, and the Clinical Global Impressions Scale for Improvement. No significant differences occurred between the a.m. and p.m. groups for any efficacy variable. Evaluation of adverse events and vital signs indicated no clinically significant differences between the two treatment groups. The data indicate that fluoxetine is equally efficacious and well tolerated regardless of the time of day it is administered and suggest that fluoxetine may be administered at either time of day without affecting clinical course.

Lack of efficacy of d-propranolol in neuroleptic-induced akathisia

d-Propranolol lacks clinically significant beta-adrenergic receptor blocking properties, but has the same membrane stabilizing effects as racemic (d,l) propranolol. To assess the role of beta-blockade versus membrane stabilization or other shared nonspecific effects in the therapeutic action of propranolol in neuroleptic-induced akathisia (NIA) we treated 11 patients with NIA in a crossover, double-blind study of d-propranolol versus placebo. Akathisia scores were unchanged after both d-propranolol and placebo. Eight patients were subsequently treated in a nonblind manner with racemic propranolol, with a significant reduction in akathisia scores. These findings suggest that beta-blockade, not membrane stabilization or other shared nonspecific effects, contributes to the efficacy of propranolol in NIA.

Clinical illness associated with a commercial tick and flea product in dogs and cats

A commercial flea and tick product containing 9.0% fenvalerate for use in dogs and cats was suspected of causing illness. An acute toxicity study was performed in 10 dogs and 10 cats exposed to the product orally (po) and dermally at differing doses. Samples were obtained for DEET and fenvalerate analysis. Oral dosing of dogs and cats produced severe clinical illness at doses as low as 0.66% of a can (7 ounce spray can)/kg body weight. Dermal application of the product resulted in minor clinical abnormalities in dogs. Oral exposure at 0.5% can/kg body weight resulted in severe illness, and dermal application caused severe illness or death in cats at 20% and 40% of a can/kg body weight. The cats receiving 10% of a can/kg body weight dermally became depressed for several hours but recovered uneventfully. Serum DEET concentrations closely paralleled the clinical signs observed in the animals. Serum concentrations of DEET above 20 ppm were considered diagnostic for intoxication. Urine concentrations of DEET above 1 ppm and tissue (liver, bile, and kidney) concentrations of DEET above 10 ppm were supportive of poisoning; values near 100 ppm were diagnostic for fatal poisoning.

Toxic neonatal effects following maternal clomipramine therapy

Clomipramine is a chlorinated tricyclic antidepressant commonly used in the treatment of depression (1). The drug is widely prescribed in Europe and Canada and has been recently approved for use in the USA. Its safety during pregnancy and breastfeeding, however, has not been fully established. Very few reports on its effect on the fetus and neonate have been published (2,3). We report a case of a mother treated with clomipramine during pregnancy, and the side effects observed in the infant. The correlation between plasma clomipramine concentrations in the baby's blood and clinical effects are described. Subsequently, we present the pregnancy outcome of five prospectively collected cases.

Acute drug-induced akathisia is not associated with low serum iron status

The iron status of 50 consecutively admitted psychiatric patients due to be started on neuroleptic medication was examined. Fifteen of the patients developed akathisia in the 2 weeks of follow-up. The patients did not differ significantly from the 35 non-akathisic patients in serum iron and transferrin levels and haemoglobin values. The findings do not support the postulated association between low serum iron status and acute neuroleptic-induced akathisia.

Effects of remoxipride on measures of psychological performance in healthy volunteers

The acute psychomotor effects after oral doses of 30, 60 and 120 mg remoxipride, a new selective D2 receptor blocker, and placebo were investigated in a double-blind crossover study in 11 healthy male volunteers. Two out of the first three subjects given 120 mg remoxipride experienced marked akathisia, and therefore no subsequent subjects were given this dose. There were no other clearly drug-related adverse effects reported below 120 mg, although restlessness was reported at 60 mg. Remoxipride was associated with increases in error scores on a continuous attention task and on auditory vigilance, and with a reduction in critical flicker frequency, suggesting a decrease in arousal level. There were no significant changes in psychomotor measures such as choice reaction time, decision making time, or body sway. Subjective assessments using visual analogue scales showed a slight dose-related increase in drowsiness, while the calm-excited scale showed a small change in the excited direction with 30 mg only. The peak effects were at 4-6 h after drug intake, which was later than expected from previous pharmacokinetic data. These results indicate that remoxipride may have a slight depressant effect in the dose-range used. The pattern of changes is consistent with current theories on the role of dopamine in attention and arousal, and with the effects of other neuroleptics. It differs, however, from tranquilisers such as the benzodiazepines, which show a more global pattern of effects.

Safety of long-term neuroleptanxiolysis with fluspirilene 1.5 mg per week

In recent years concern has been frequently expressed that a long-term treatment with fluspirilene 1.5 mg/week might induce tardive dyskinesia, yet there are no empirical data from controlled studies available. In 11 private practices 276 patients under long-term treatment with either fluspirilene or benzodiazepines for reasons of anxiety or psychoneurotic or psychosomatic disorders were investigated by an independent and specially trained physician from our hospital with regard to symptoms to tardive dyskinesia, parkinsonism, and akathisia. Of these patients, 155 had received fluspirilene 1.5 mg/week with a mean duration of treatment of 17.5 months (s = 13.3), and 121 had received benzodiazepines with a mean duration of treatment of 45.7 months (s = 44.6). The mean total scores of the AIMS, the Simpson Angus Scale, and an akathisia scale did not differ significantly between the two groups. In the fluspirilene group a positive correlation of age and psychotropic comedication with the total scores of the AIMS and the akathisia scale could be found, but there was no correlation between duration or continuity of treatment with fluspirilene and symptoms of tardive dyskinesia. In each of the two groups 10 patients (6.9% of the fluspirilene group and 8.3% of the benzodiazepine group) showed abnormal involuntary movements, which corresponds to the incidence of spontaneous dyskinesia. The results of this study do not indicate an increase in tardive dyskinesia for patients with a mean duration of treatment with fluspirilene 1.5 mg/week of 18 months.

Akathisia, motility, and locomotion in healthy volunteers

Apomorphine (10 micrograms/kg subcutaneously with oral domperidone 10 mg), oral sultopride (50 mg), and placebos were given to nine normal volunteers, using a Latin-square design and double-blind procedures. A battery of tests was applied before the dose, and after the dose after time lapses of 15, 45, 90, 105, 120, and 180 min. Spatiotemporal and dynamic gait parameters, gait stability, and modulations remained unchanged with all three treatments. Apomorphine induced repeated yawning in all subjects. Akathisia was observed in four of nine subjects with sultopride. Sultopride was associated with drowsiness and sleepiness on visual analog scales. Akathisia may be related to decreased dopaminergic activity in the prefrontal cortex and mesocortical dopamine system blockade. The imbalance between mesocortical and nigrostriatal dopaminergic systems might explain the fact that sultopride in our experiment modified spontaneous behavior but not volitional behavior. Thus, it is possible to discriminate between two types of increased motor activity, and motility must be distinguished from locomotor activity.

The relationship between blood perphenazine levels, early resolution of psychotic symptoms, and side effects

Serum perphenazine concentrations and early resolution of psychosis were examined to determine if blood level monitoring could be used to maximize drug efficacy while limiting extrapyramidal side effects (EPS). Sixty-six acutely psychotic inpatients were given perphenazine 0.5 mg/kg/day for 10 days, and their response was rated blind to blood level. Although 36 of 66 patients showed resolution of psychosis, neither perphenazine nor N-dealkylated perphenazine levels were related to global response or to Brief Psychiatric Rating Scale (BPRS) totals. Improvement in two individual BPRS items (hallucinations and conceptual disorganization) was related to serum perphenazine levels and suggestive of a lower therapeutic threshold of 0.8 ng/mL. Perphenazine level was not correlated with EPS; but benztropine, given only if required for serious EPS, was more likely to be used when perphenazine levels were elevated. The data suggest that higher perphenazine levels were no more effective than moderate levels but that higher levels may be associated with increased EPS; the data also suggest that individual symptoms rather than global response were associated with a lower therapeutic perphenazine threshold.

Fluphenazine dose, clinical response, and extrapyramidal symptoms during acute treatment

Fifty-three patients with acute exacerbations of Research Diagnostic Criteria schizophrenic, schizoaffective (mainly schizophrenic), and other nonaffective psychoses completed 24 or 28 days of treatment with randomized, fixed, double-blind doses of 10, 20, or 30 mg of oral fluphenazine hydrochloride daily. In the sample as a whole, improvement was not predicted by dose but was negatively related to duration of illness and of lifetime hospitalization, and to the presence of akathisia during the study (which was unrelated to chronicity). But among patients showing 40% or greater improvement in positive symptoms, percent improvement was predicted by dose and dose per kilogram of body weight; this was not the case for negative symptoms. Severity of acute extrapyramidal symptoms (excluding acute dystonia, dyskinesia, and akathisia) was significantly correlated with dosage per kilogram. Doses greater than 0.2 mg/kg per day were associated with greater clinical improvement but also with a high incidence of extrapyramidal symptoms; doses over 0.3 mg/kg per day were associated with more severe extrapyramidal symptoms. These preliminary results suggest that there is a linear relationship between fluphenazine dosage and acute outcome, and that this relationship is observed in patients whose conditions improve to a criterion level. It is suggested that the nonresponder group may include many patients in whom dose is not relevant because they are unable (for a variety of reasons) to respond to the study treatment conditions; excluding them from analysis may allow a significant dose-response relationship to be observed. Akathisia deserves further study as a possible predictor of nonresponse.

[Hoigné's syndrome or pseudo-anaphylactic reaction to procaine penicillin G: a still current classic]

In this journal in 1959 R. Hoigné described the first cases of pseudo-anaphylactic reactions induced by intramuscular administration of procaine penicillin G. This complication, characterized by acute psychological and neurological manifestations, is still of current interest since recently three cases of Hoigné's syndrome were diagnosed at the University Hospital of Geneva. This entity deserves consideration because it must be differentiated from authentic anaphylactic shock due to penicillin. The distinction is important from a therapeutic viewpoint since Hoigné's syndrome allows continuation of treatment, whereas it is absolutely contraindicated in anaphylactic shock.

Electroconvulsive therapy emergence agitation and succinylcholine dose

In this prospective study, five patients who had repeatedly shown troublesome restless emergence agitation after each of 20 sessions of electroconvulsive therapy (ECT) with a succinylcholine dose about .7 mg/kg showed no agitation after 15 ECT sessions in which the succinylcholine dose was increased to about 1.0 mg/kg. The probability that the pattern of response to higher succinylcholine dose resulted from random processes is less than .005. This provides evidence that patients predisposed to emergence agitation are sensitive to seizure-induced metabolic changes in skeletal muscle tissue and that the likelihood of emergence agitation rises with the ratio of skeletal muscle mass to succinylcholine dose. Because ECT-inducted serum lactate elevations are blocked by succinylcholine, emergence agitation might be essentially the same phenomenon as lactate-induced panic.