Olanzapine-induced neuroleptic malignant syndrome

Neuroleptic Malignant Syndrome: No Longer Exclusively a “Neuroleptic” Phenomenon

Objective:

To review the literature concerning the incidence of neuroleptic malignant syndrome (NMS) associated with the use of atypical antipsychotics.

Data Sources:

Cases were identified through a search of MEDLINE (1986–March 2004) using the terms neuroleptic malignant syndrome, antipsychotic, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole.

Study Selection and Data Extraction:

Case reports of possible NMS secondary to second-generation antipsychotics were selected for review. Reports meeting the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for NMS were considered. Case reports in which 1 of the 2 major diagnostic criteria was met were also included in the analysis. Furthermore, at least one minor criterion was met. Case reports in which patients received traditional antipsychotics were excluded.

Data Synthesis:

NMS is a rare and sometimes fatal disease. Several theories exist as to how NMS develops, and an equally large amount of diagnostic criteria are available. However, the majority of available data are based on the first-generation neuroleptics and very few exist with regard to the second-generation antipsychotics.

Conclusions:

Although there are numerous case reports of NMS occurring secondary to the use of second-generation antipsychotics, the incidence has never been fully elucidated. While the reasons for this remain uncertain, not all cases of second-generation–induced NMS fulfill the diagnostic criteria established for traditional neuroleptics and therefore may not be reported as such.

Fever development in neuroleptic malignant syndrome during treatment with olanzapine and clozapine

Neuroleptic malignant syndrome (NMS) is the most dangerous life-threatening complication of antipsychotic medication. It's development is connected with the blockade of dopaminergic transmission (D2 receptors) in the nigrostriatal system of the brain. Fever is one of the main symptoms of this syndrome and it's elevation is due to the activation of the immune system. Numerous studies report that treatment with clozapine (doses 37.5-600 mg) or olanzapine (doses 10-25 mg) or the use of these drugs in polytherapy cause pyrexia between 37.8-40.6 °C. Additionally, levels of proinflammatory interleukins such as IL-6, IL-1,TNF-α were increased. The aim of this article is to describe how olanzapine and clozapine influence fever development in NMS, in relation to the dose of the drug taken by schizophrenic patients including changes in immunological system.

Olanzapine-induced hyperglycaemic coma and neuroleptic malignant syndrome: case report and review of literature

Although the relationship between antipsychotic medication, particularly second-generation antipsychotics (SGAs), and metabolic disturbance is increasingly accepted, there is an important, but little recognised, potential interaction between this and the other important serious adverse effect of neuroleptic malignant syndrome (NMS). We report a case of a 35-year old female who developed new onset type II diabetes mellitus with hyperosmolar hyperglycaemic coma and acute renal failure following treatment with a SGA for a first manic episode. The history is strongly suggestive of concurrent NMS. This case raises important questions about non-ketotic, hyperosmolar diabetic coma with antipsychotics, the possible association between hyperglycaemia and hyperthermia, and the direction of causality in this, the recognition of either syndrome when they co-exist and management issues in such patients. These questions are considered in the context of currently available literature.

Atypical neuroleptic malignant syndrome associated with risperidone treatment in two adolescents

Neuroleptic Malignant Syndrome (NMS) is a known, life threatening, side effect of classical antipsychotic drugs. We report two cases of 16 and 17 year old males, who suffered life-threatening "NMS-Like" syndromes in association with Risperidone treatment. Further controlled studies are needed.

Olanzapine-associated neuroleptic malignant syndrome: Is there an overlap with the serotonin syndrome?

Background

The neuroleptic malignant syndrome is a rare but serious condition mainly associated with antipsychotic medication. There are controversies as to whether "classical" forms of neuroleptic malignant syndrome can occur in patients given atypical antipsychotics. The serotonin syndrome is caused by drug-induced excess of intrasynaptic 5-hydroxytryptamine. The possible relationship between neuroleptic malignant syndrome and serotonin syndrome is at present in the focus of scientific interest.

Methods

This retrospective phenomenological study aims to examine the seventeen reported olanzapine – induced neuroleptic malignant syndrome cases under the light of possible overlap between neuroleptic malignant syndrome and serotonin syndrome clinical features.

Results

The serotonin syndrome clinical features most often reported in cases initially diagnosed as neuroleptic malignant syndrome are: fever (82%), mental status changes (82%) and diaphoresis (47%). Three out of the ten classical serotonin syndrome clinical features were concurrently observed in eleven (65%) patients and four clinical features were observed in seven (41%) patients.

Conclusion

The results of this study show that the clinical symptoms of olanzapine-induced neuroleptic malignant syndrome and serotonin syndrome are overlapping suggesting similarities in underlying pathophysiological mechanisms.

Olanzapine induced neuroleptic malignant syndrome--a case review

Neuroleptic malignant syndrome is the rarest and the most serious of the neuroleptic induced movement disorders. Although potent neuroleptics are more frequently associated with NMS, atypical antipsychotic drugs may also be a cause of NMS. Three databases were searched using the terms 'olanzapine' and 'neuroleptic' 'malignant syndrome'. Case reports were selected and reviewed from among all articles that fulfilled the search criteria. Twenty six cases were reviewed. Twenty cases fulfilled the criteria published by Sachdev et al. Olanzapine was the most probable cause of NMS in 16 cases. The absence of rigidity was described in only two of 16 highly probable olanzapine induced NMS cases, which is not as often as it is reported in clozapine associated NMS (36%). It was found that prior NMS is an important risk factor in NMS.

Neuroleptic malignant syndrome in an adolescent receiving olanzapine-lithium combination therapy

A 16-year-old boy developed fever, generalized rigidity, leukocytosis, and increased serum transaminase and creatine kinase levels while receiving treatment with olanzapine and lithium. When both drugs were discontinued, his fever and rigidity subsided and biochemical irregularities spontaneously returned to normal, without any complications. Classic neuroleptic malignant syndrome (NMS) was diagnosed. Concomitant administration of lithium with olanzapine may place patients at risk for NMS. Clinicians need to be aware of this rare but potentially fatal side effect in patients of all ages, and especially in adolescents receiving both drugs.

Neuroleptic malignant syndrome induced by atypical antipsychotics

A review of the English literature confirms that neuroleptic malignant syndrome (NMS) occurs with both traditional and atypical antipsychotic medications. Published reports of NMS induced by the traditional antipsychotics have given the practitioner valuable information on the prevention and treatment of this adverse effect. Case reports have also been published concerning NMS and clozapine, risperidone, olanzapine and quetiapine. By evaluating the case reports of atypical antipsychotic-induced NMS, valuable information may be obtained concerning similarities or differences from that induced by the traditional antipsychotics. The case reports of NMS with atypical antipsychotics were evaluated for diagnosis, age/sex of patient, risk factors, antipsychotic doses and duration of use, symptoms of NMS, and clinical course.

Antipsychotic treatment for late-life schizophrenia

The clinical characteristics of schizophrenia in older persons vary to some extent, depending on whether the onset of illness was earlier or later in life. Regardless of age of onset, antipsychotic medications are the mainstay of treatment. Age-related physiologic changes make older persons more sensitive to the therapeutic and toxic effects of antipsychotics. There is a paucity of controlled studies on the efficacy of antipsychotic medications in older persons with schizophrenia. Existing data suggest that atypical antipsychotics are at least as efficacious as and better tolerated than the conventional agents. In late-life schizophrenia, important adverse effects of antipsychotics include sedating, anticholinergic and cardiovascular effects, extrapyramidal symptoms, and tardive dyskinesia. Certain atypical antipsychotics are associated with a risk of metabolic changes as well as agranulocytosis. Clinical recommendations include a thorough diagnostic evaluation followed by treatment with low doses of atypical antipsychotics. Medication alone is likely to be less effective than when it is combined with an appropriate psychosocial intervention.

Olanzapine-associated neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is an uncommon but serious idiosyncratic reaction associated with antipsychotic medication. The purpose of this study was to reveal and analyze the clinical characteristics of the reported cases of NMS in patients given the novel antipsychotic olanzapine. A MEDLINE search related to olanzapine-induced NMS cases reported in the international literature was conducted. All cases were critically reviewed and examined against three different sets of NMS diagnostic criteria (DSM-IV, Addonizio, Levenson). The authors identified 17 cases of possible NMS associated with olanzapine. Ten of the reported NMS cases were definitely NMS meeting all three sets of criteria and three cases were probable NMS meeting two sets of criteria. Most of the patients exhibited a full-blown NMS. There were four definite NMS cases associated with olanzapine monotherapy. Three of them had concurrent serious physical illnesses and one had a previous NMS episode. Olanzapine can cause NMS, mainly in susceptible or predisposed patients.

Atypical neuroleptic malignant syndrome associated with olanzapine

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening adverse effect of antipsychotic agents. It generally is characterized by fever, altered mental status, rigidity, and autonomic dysfunction. A 53-year-old man developed NMS without rigidity while taking olanzapine. Such atypical cases may support either a spectrum concept of NMS or the theory that NMS secondary to atypical antipsychotics differs from that caused by conventional neuroleptics. More flexible diagnostic criteria than currently mandated by the the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision, may be warranted.

Failed challenge with quetiapine after neuroleptic malignant syndrome with conventional antipsychotics

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially life-threatening adverse effect associated with conventional antipsychotic agents. The syndrome is characterized by muscular rigidity, hyperpyrexia, altered consciousness, and autonomic dysfunction. Few cases of quetiapine-induced NMS have been reported. A 54-year-old man was unsuccessfully challenged with quetiapine after conventional antipsychotic-induced NMS.

Case control and family-based studies of tryptophan hydroxylase gene A218C polymorphism and suicidality in adolescents

The association of suicidality with polymorphism A218C in intron 7 of tryptophan hydroxylase (TPH) gene remains controversial. The aim of this study was to use family-based methods to examine this association in adolescents in order to eliminate the difficulty of sampling a control group from the same ethnic population. Eighty-eight inpatient adolescents who recently attempted suicide were assessed by structured interview for detailed clinical history, diagnoses, suicide intent, suicide risk, impulsivity, aggression, and depression. DNA samples were collected from all subjects, from both biological parents of 40 subjects and from one parent of 9 subjects; TPH allele frequencies were calculated and tested for association to phenotype, stratified by severity, using the haplotype relative risk (HRR) and transmission disequilibrium test (TDT) methods (n = 49). The frequencies were also compared for all the Jewish subjects (n = 84) to the known frequencies of these alleles in healthy Jewish populations. There was no significant allelic association of A218C polymorphism with suicidal behavior or other phenotypic measures according to the HRR method (chi-square = 0.094; P = 0.76), the TDT (chi-square = 0.258; P = 0.61), or association analysis to known population frequencies (chi-square = 1.667, P = 0.19 for Ashkenazi, and chi-square = 0.810, P = 0.37 for non-Ashkenazi). Analysis of variance with the Scheffè test demonstrated a significant difference between CC and AA genotypes in suicide risk and depression among the patients (n = 88). The findings suggest that polymorphism A218C has no major relevance to the pathogenesis of adolescent suicidal behavior, but may have a subtle effect on some related phenotypes.

Neuroleptic malignant syndrome during a change from haloperidol to risperidone

OBJECTIVE

To report a case of neuroleptic malignant syndrome (NMS) in a patient whose therapy was being switched from haloperidol to risperidone.

CASE REPORT

A 57-year-old African-American man, treated for schizophrenia with haloperidol for several years, developed NMS within 48 hours of the addition of low doses of risperidone and mirtazapine to his regimen. Symptoms, which included fever, generalized rigidity, and altered mental status, resolved after discontinuation of psychotropics, supportive management, and several weeks of treatment with bromocriptine and dantrolene. He was subsequently treated with olanzapine without adverse effects.

DISCUSSION

Several cases of NMS have been reported with risperidone, but none under these circumstances. NMS most likely occurred in this patient as a result of the additive dopamine 2 receptor blocking of haloperidol and risperidone. Sympathetic hyperactivity secondary to mirtazapine may also have been a contributing factor. If NMS may be induced by the simultaneous use of older, high-potency antipsychotics and newer, atypical antipsychotics such as risperidone, switching patients from older to newer antipsychotics may at times be difficult, since completely stopping one antipsychotic before starting the second may place patients at risk for psychotic relapse.

CONCLUSIONS

Clinicians should closely monitor patients receiving both haloperidol and risperidone or combinations of similar medications.

The pharmacology and toxicology of atypical antipsychotic agents

Recently, atypical antipsychotic agents have largely replaced traditional agents as first-line drugs for the treatment of schizophrenia. It is likely that atypical agents will soon account for the majority of poisonings from antipsychotic agents that present to health care facilities in the US. This article reviews the pharmacodynamics, pharmacokinetics, and toxicology of atypical antipsychotic drugs, chiefly clozapine, risperidone, olanzapine, and quetiapine. A descriptive summary of the human overdose experience with these agents is provided. Adverse effect and drug interaction data are reviewed. Based on the available pharmacodynamic, pharmacokinetic, and human overdose data, recommendations on management are provided.

Marked elevation of serum creatine kinase associated with olanzapine therapy

OBJECTIVE

To report a case of marked elevation of serum creatine kinase (CK) associated with olanzapine therapy.

CASE SUMMARY

A 39-year-old white Jewish schizophrenic man treated with olanzapine developed an elevated serum CK concentration with a peak concentration of 4000 IU/L (normal < 230). No other diagnostic criteria for neuroleptic malignant syndrome (NMS) were present. On discontinuation of the drug, serum CK concentrations returned to normal within eight days.

DISCUSSION

Olanzapine, like other atypical antipsychotic drugs, may cause muscle injury with concomitant elevations of serum CK of muscle origin. We suggest that in patients treated with olanzapine, CK concentrations should be checked on initiation of therapy, within the first 48 hours, and weekly thereafter for at least one month. In addition, patients with clinical signs suggestive of NMS should be monitored more carefully. For those patients with a history of NMS, or even of isolated serum CK elevation during antipsychotic therapy, follow-up should be stricter.

CONCLUSIONS

Marked elevation of serum CK may be a possible complication of olanzapine therapy.