Neuroleptic malignant syndrome: evaluation of drug safety data from the AMSP program during 1993-2015

Serious adverse drug events associated with psychotropic treatment of bipolar or schizoaffective disorder: a 17-year follow-up on the LiSIE retrospective cohort study

Introduction

Mood stabilisers and other psychotropic drugs can lead to serious adverse drug events (ADEs). However, the incidence remains unknown. We aimed to (a) determine the incidence of serious ADEs in patients with bipolar or schizoaffective disorders, (b) explore the role of lithium exposure, and (c) describe the aetiology.

Methods

This study is part of the LiSIE (Lithium-Study into Effects and Side Effects) retrospective cohort study. Between 2001 and 2017, patients in the Swedish region of Norrbotten, with a diagnosis of bipolar or schizoaffective disorder, were screened for serious ADEs to psychotropic drugs, having resulted in critical, post-anaesthesia, or intensive care. We determined the incidence rate of serious ADEs/1,000 person-years (PY).

Results

In 1,521 patients, we identified 41 serious ADEs, yielding an incidence rate of 1.9 events per 1,000 PY. The incidence rate ratio (IRR) between ADEs with lithium present and causally implicated and ADEs without lithium exposure was significant at 2.59 (95% CI 1.20-5.51; p = 0.0094). The IRR of ADEs in patients <65 and ≥65 years was significant at 3.36 (95% CI 1.63-6.63; p = 0.0007). The most common ADEs were chronic lithium intoxication, oversedation, and cardiac/blood pressure-related events.

Discussion

Serious ADEs related to treatment of bipolar (BD) or schizoaffective disorder (SZD) were uncommon but not rare. Older individuals were particularly at risk. The risk was higher in individuals exposed to lithium. Serum lithium concentration should always be checked when patients present with new or unclear somatic symptoms. However, severe ADEs also occurred with other mood stabilisers and other psychotropic drugs.

When the fever will not stop, stop the pills! A case report

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a neurologic emergency potentially fatal. This rare side effect is most commonly associated with first-generation antipsychotics and less frequently with atypical or second-generation antipsychotics. The diagnosis relies on both clinical and laboratory criteria, with other organic and psychiatric conditions being ruled out.

CASE REPORT

A 39-year-old female patient, who is institutionalized and completely dependent, has a medical history of recurrent urinary infections and colonization by carbapenem-resistant Klebsiella pneumoniae. Her regular medication regimen included sertraline, valproic acid, quetiapine, risperidone, lorazepam, diazepam, haloperidol, baclofen, and fentanyl. The patient began experiencing dyspnea. Upon physical examination, she exhibited hypotension and a diminished vesicular murmur at the right base during pulmonary auscultation. Initially, after hospitalization, she developed high febrile peaks associated with hemodynamic instability, prompting the initiation of antibiotic treatment. Despite this, her fever persisted without an increase in blood inflammatory parameters, and she developed purulent sputum, necessitating antibiotherapy escalation. The seventh day of hospitalization showed no improvement in symptoms, suggesting NNMS as a differential diagnosis. All antipsychotic and sedative drugs, as well as antibiotherapy, were discontinued, after which the patient showed significant clinical improvement.

CONCLUSION

Antipsychotic agents are commonly employed to manage behavioral changes linked to various disorders. However, their severe side effects necessitate a high degree of vigilance, the cessation of all medications, and the implementation of supportive care measures. A prompt and accurate diagnosis of NMS is crucial to alleviating the severe, prolonged morbidity and potential mortality associated with this syndrome.

What clinical analysis of antipsychotic-induced catatonia and neuroleptic malignant syndrome tells us about the links between these two syndromes: A systematic review

OBJECTIVES

Antipsychotic-induced catatonia (AIC) and neuroleptic malignant syndrome (NMS) are life-threatening adverse reactions to antipsychotic medication. We conducted a systematic review of literature following the PRISMA statement guidelines to obtain a description of these syndromes (population, context of occurrence, antipsychotic agents implicated) and draw conclusions about their links.

METHODS

We searched Medline and Web of science databases from January 1951 to May 2019 (further restricted from 2000 to 2019) using search terms including "catatonia", "neuroleptic malignant syndrome" and "antipsychotic agents" for case reports, case series and analytic studies. After screening 4082 records, 410 full-text articles (describing 555 events) were assessed for eligibility. We included events of AIC and/or NMS according to Diagnostic and Statistical Manual (DSM) criteria and extracted data about patients' characteristics, context of occurrence, antipsychotic agent(s) involved and treatment outcomes.

RESULTS

We included 165 events (16 AIC, 129 NMS and 20 AIC + NMS) from 144 case reports and case series. The most reported diagnosis was schizophrenia. Comorbid pre-existing conditions such as central nervous system diseases and acute medical events were common. Most of the events (63.3 %) occurred during antipsychotic monotherapy. Second-generation antipsychotics (SGAs, 63.8 %) were overall more implicated than first-generation antipsychotics (FGAs, 36.2 %).

DISCUSSION

Our findings highlight that any antipsychotic medication, even SGA monotherapy prescribed at recommended dose, is at risk for these side effects. FGAs and polypharmacy seem to represent risk factors for malignant catatonia in AIC. The clinical overlap observed between AIC and NMS events in our review suggests a clinical continuum between catatonia and NMS.

Case report: Amisulpride therapy induced reversible elevation of creatine kinase-MB and bradycardia in schizophrenia

INTRODUCTION

Schizophrenia is regarded as one of the most severe, disabling, and costly mental illnesses. Hence, early effective prevention and treatment are critical to the prognosis of patients. Amisulpride, a first-line atypical antipsychotic medication that acts as a blocker of the D2 and D3 dopamine receptors, is used in varying doses for the treatment of both positive and negative symptoms of schizophrenia. Reversible amisulpride-induced elevation of the myocardial enzyme spectrum with bradycardia is a rare condition.

CASE PRESENTATION

We report a 26-year-old patient diagnosed with first-episode schizophrenia. This patient was treated with amisulpride (400 mg/d), but no clinical benefits were obtained. Meanwhile, amisulpride caused elevation of the myocardial enzyme spectrum with asymptomatic bradycardia. After stopping the medication, these parameters normalized.

CONCLUSION

We described a rare side reaction of amisulpride. Psychiatrists should take this side effect seriously in the clinical setting. The mechanism of this adverse reaction warrants further investigation and debate. When this side effect occurs during treatment, reducing the dosage of amisulpride and subsequently discontinuing medication, along with monitoring the electrocardiogram and serum myocardial enzymes, may be the most appropriate treatment protocol.

Malignant syndromes: current advances

Introduction: Many drugs are known to induce malignant syndromes. The most common malignant syndromes are induced by the use of antipsychotics and anesthetics and the withdrawal of anti-Parkinson drugs. As the clinical manifestations of antipsychotic malignant syndrome, Parkinson's disease hyperpyrexia syndrome and anesthetic-induced malignant syndrome are very similar, they are easily confused in the clinic.Areas covered: We reviewed articles published between 1960 and April 2021 describing malignant syndromes. This paper provides a detailed literature review of malignant syndromes and important guidance for the diagnosis and treatment of malignant syndromes to clinicians.Expert opinion: Although malignant syndromes are rare conditions with a low incidence, these conditions usually progress rapidly and can endanger patients' lives, meriting attention from clinicians. The typical clinical manifestations of malignant syndromes are hyperpyrexia, muscular rigidity, an altered mental status and increased levels of creatine kinase; however, the pathophysiology, treatment and prognosis of different malignant syndromes are quite different. Prompt diagnosis and treatment may significantly improve the prognosis of patients with malignant syndromes.

Serum osmolarity and blood viscosity as a potential explanation for the pathophysiology of neuroleptic malignant syndrome

Background: Neuroleptic malignant syndrome (NMS) is a rare but life-threatening side effect. NMS patients usually develop dehydration and fluid-electrolyte imbalance. In this study, we aimed to investigate serum osmolarity and blood viscosity in patients with NMS.Methods: This was a retrospective case-control study including 32 admissions of 27 patients with the diagnosis of NMS. As a control group, 31 non-NMS episodes of hospitalizations of the same patients were included.Results: Serum osmolarity of NMS group was 301.83 ± 20.27 mOsm/L and control group was 294.20 ± 5.92 mOsm/L. Serum osmolarity of NMS group was statistically significantly higher than the controls (p = .018). Whole blood viscosity (WBV) at high shear rate (HSR) value of NMS group was 16.17 ± 1.48 and control group was 16.50 ± 1.38 (p = .331). Regarding WBV at low shear rate (LSR) values, also no statistically significant difference was observed between groups. LSR values of NMS and control group were 39.86 ± 30.11 and 47.41 ± 28.43, respectively (p = .387).Conclusions: Our findings indicate that serum osmolarity of NMS group was statistically significantly higher than the controls. In terms of blood viscosity, there was no statistically significant difference between groups. Higher serum osmolarity in NMS patients than controls may be a reflection of a relative hemoconcentration in NMS.KEY POINTSNMS is usually associated with dehydration resulting in fluid-electrolyte imbalance.We compared the NMS episodes with non-NMS hospitalizations (as control group) of the same patients.Serum osmolarity was statistically significantly higher in NMS group than the controls.There was no statistically significant difference between groups in terms of blood viscosity.