Neuroleptic malignant syndrome after neuroleptic discontinuation

Neuroleptic Malignant Syndrome Improved with Intramuscular Administration of the Anticholinergic Agent, Biperiden

Anticholinergic drugs, such as biperiden, benztropine, and diphenhydramine, were used for neuroleptic malignant syndrome (NMS) in the 1980s and 1990s. However, they have not been recommended for pharmacotherapy in NMS since 2000, as they may prevent a decrease in body temperature by suppressing sweating. However, whether anticholinergic drugs actually exacerbate NMS remains unclear. This study highlights the usefulness of anticholinergic drugs, which are no longer attracting attention as current pharmacological treatments for NMS. I treated four NMS patients using anticholinergic drugs. Two patients were treated with biperiden alone, and the other two patients were treated with a combination of biperiden and other drugs, including dantrolene, amantadine, or diazepam. Intramuscular injection of biperiden improved muscle rigidity, tremors, dysphagia, and akinetic mutism. Psychiatrists are familiar with anticholinergic drugs as they are used for antipsychotic-induced akathisia and Parkinsonism. My study suggests that anticholinergic drugs, especially injectable formulations, can be a therapeutic option for NMS.

A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse

The process of stopping antipsychotics may be causally related to relapse, potentially linked to neuroadaptations that persist after cessation, including dopaminergic hypersensitivity. Therefore, the risk of relapse on cessation of antipsychotics may be minimized by more gradual tapering. There is converging evidence that suggests that adaptations to antipsychotic exposure can persist for months or years after stopping the medication-from animal studies, observation of tardive dyskinesia in patients, and the clustering of relapses in this time period after the cessation of antipsychotics. Furthermore, PET imaging demonstrates a hyperbolic relationship between doses of antipsychotic and D2 receptor blockade. We, therefore, suggest that when antipsychotics are reduced, it should be done gradually (over months or years) and in a hyperbolic manner (to reduce D2 blockade "evenly"): ie, reducing by one quarter (or one half) of the most recent dose of antipsychotic, equivalent approximately to a reduction of 5 (or 10) percentage points of its D2 blockade, sequentially (so that reductions become smaller and smaller in size as total dose decreases), at intervals of 3-6 months, titrated to individual tolerance. Some patients may prefer to taper at 10% or less of their most recent dose each month. This process might allow underlying adaptations time to resolve, possibly reducing the risk of relapse on discontinuation. Final doses before complete cessation may need to be as small as 1/40th a therapeutic dose to prevent a large decrease in D2 blockade when stopped. This proposal should be tested in randomized controlled trials.

Parkinsonism-hyperpyrexia Syndrome After Amantadine Withdrawal: Case Report and Review of the Literature

INTRODUCTION

Parkinsonism-hyperpyrexia syndrome (PHS) is a rare and potentially fatal complication of Parkinson disease (PD) characterized by a neuroleptic malignant-like syndrome due to abrupt discontinuation of antiparkinsonian medications.

CASE REPORT

A 79-year-old woman with late-stage PD presented at the hospital with neuropsychiatric and uncontrolled parkinsonian motor symptoms. Soon after the abrupt discontinuation of amantadine, the patient suddenly presented with global rigidity, global unresponsiveness, diaphoresis, tachycardia, recurrent hyperpyrexia, and a mildly elevated creatine kinase, which lead to the diagnosis of PHS. Amantadine was then reinitiated and her symptoms resolved within 10 days.

CONCLUSIONS

Amantadine is an antiparkinsonian medication scarcely associated with PHS. The few reported cases are further summarized and discussed in this article. This case highlights the importance of early recognition of PHS, which may be caused by changes in other antiparkinson agents such as amantadine, and the need to slowly titrate such agents.

Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development

The purpose of this article is to describe dependence and withdrawal phenomena related to CNS drugs discontinuation and to clarify issues related to the evaluation of clinical drug withdrawal and rebound as they relate to safety in new drug development. The article presents current understanding and definitions of drug dependence and withdrawal which are also relevant and important features of addiction, though not the same. Addiction, called substance use disorder in DSM-5, affects an individual’s brain and behaviour, represents uncontrollable drug abuse and inability to stop taking a drug regardless of the harm it causes. Characteristic withdrawal syndromes following abrupt discontinuation of CNS-active drugs from numerous drug classes are described. These include drugs both scheduled and non-scheduled in the Controlled Substances Act, which categorizes drugs in five schedules based on their relative abuse potentials and dependence liabilities and for regulatory purposes. Schedules 1 and 2 contain drugs identified as those with the highest abuse potential and strictest regulations. Less recognized aspects of drug withdrawal, such as rebound and protracted withdrawal syndromes for several drug classes are also addressed. Part I presents relevant definitions and describes clinical withdrawal and dependence phenomena. Part II reviews known withdrawal syndromes for the different drug classes, Part III describes rebound and Part IV describes protracted withdrawal syndromes. To our knowledge, this is the first compilation of withdrawal syndromes for CNS drugs. Part V provides details of evaluation of dependence and withdrawal in the clinical trials for CNS drugs, which includes general design recommendations, and several tools, such as withdrawal questionnaires and multiple scales that are helpful in the systematic evaluation of withdrawal. The limitations of different aspects of this method of dependence and withdrawal evaluation are also discussed.

"Brief" Aripiprazole-induced Neuroleptic Malignant Syndrome with Symptoms that Only Lasted a Few Hours

Neuroleptic malignant syndrome (NMS) with characteristic symptoms is a potentially lethal reaction to antipsychotic drugs. Atypical NMS usually lacks major symptoms and frequently occurs after treatment using atypical antipsychotics, such as aripiprazole. A 64-year-old man developed aripiprazole-induced NMS after surgery, and our early recognition of the NMS was based on high creatine kinase levels and low serum iron levels. His characteristic symptoms (a fever, rigidity, and altered mental status) were only present for a few hours and were resolved by aripiprazole discontinuation and supportive care. Aripiprazole-induced NMS can present with brief but major symptoms, and clinicians may overlook this "brief" appearance of NMS.

Neuroleptic Malignant Syndrome with Minimal Dose of Amisulpride

Amisulpride is an atypical antipsychotic drug, it helps in alleviation of symptoms of psychotic illnesses. Extrapyramidal features have been reported after taking amisulpride. Neuroleptic malignant syndrome (NMS) with amisulpride is rare, and have been reported earlier. In all the earlier reported cases patient received more than 150 mg of amisulpride. To the best of our knowledge we are reporting a case of NMS with very minimal dose of Amisulpride (50 mg) taken for very short period.

Neuroleptic Malignant Syndrome

Objective: To review evidence for the treatment of neuroleptic malignant syndrome (NMS) and to discuss how to rechallenge patients with neuroleptics when continued pharmacotherapy for chronic psychological illness is required. Data Sources: A PubMed search was conducted through March 2016 using available medical subject heading (MeSH) terms and keywords that included neuroleptic malignant syndrome, treatment, dantrolene, and bromocriptine. A manual search of article reference sections followed. Study Selection and Data Extraction: Case reports and case series in English that discussed NMS and atypical NMS treatment as well as neuroleptic rechallenge were included for review. Data Synthesis: The reported incidence of NMS was 0.02% to 0.03%, with a mortality rate of 5.6%. Current literature on NMS is primarily retrospective and emphasizes diagnostic criteria, causative agents, and potential pharmacotherapy. Details regarding timing of administration, dose, and duration of pharmacotherapy are inconsistently reported. Reported dosing strategies and outcomes have been summarized. Instances of rechallenge were infrequently reported but demonstrate that recurrence may happen at any time after NMS resolution. Recommendations regarding safe rechallenge are provided. Conclusion: NMS is a rare adverse drug reaction, with a complex pathophysiology and presentation. Timely diagnosis and discontinuation of antipsychotic therapy is the first-line treatment, followed by supportive care and pharmacotherapy. Antipsychotic rechallenge is often required and should be attempted only after a drug-free period and with a different agent, slowly titrated with close monitoring.

Second-generation antipsychotics and neuroleptic malignant syndrome: systematic review and case report analysis

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a rare, severe, idiosyncratic adverse reaction to antipsychotics. Second-generation antipsychotics (SGAs) were originally assumed to be free from the risk of causing NMS, however several cases of NMS induced by SGAs (SGA-NMS) have been reported.

OBJECTIVES

The aim of this study was to systematically review available studies and case reports on SGA-NMS and compare the presentation of NMS induced by different SGAs.

DATA SOURCES

Citations were retrieved from PubMed up to November 2013, and from reference lists of relevant citations.

STUDY ELIGIBILITY CRITERIA

Eligibility criteria included (a) primary studies reporting data on NMS, with at least 50 % of the sample receiving SGAs; or (b) case reports and case reviews reporting on NMS induced by SGA monotherapy, excluding those due to antipsychotic withdrawal.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standardized method for data extraction and coding was developed for the analysis of eligible case reports.

RESULTS

Six primary studies and 186 individual cases of NMS induced by SGAs were included. Primary studies suggest that SGA-NMS is characterized by lower incidence, lower clinical severity, and less frequent lethal outcome than NMS induced by first-generation antipsychotics. Systematic analysis of case reports suggests that even the most recently marketed antipsychotics are not free from the risk of inducing NMS. Furthermore, clozapine-, aripiprazole- and amisulpride-induced NMS can present with atypical features more frequently than other SGA-NMS, i.e. displaying less intense extrapyramidal symptoms or high fever.

LIMITATIONS

Case reports report non-systematic data, therefore analyses may be subject to bias.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Clinicians should be aware that NMS is virtually associated with all antipsychotics, including those most recently marketed. Although apparently less severe than NMS induced by older antipsychotics, SGA-NMS still represent a relevant clinical issue.

Antipsychotic discontinuation syndromes: a narrative review of the evidence and its integration into Australian mental health nursing textbooks

In light of the high number of people discontinuing antipsychotics each year, it is essential that nurses develop a robust understanding of all aspects of the discontinuation experience. While there is a large body of published work documenting post-discontinuation relapse rates, less is known about other aspects of the discontinuation experience. This paper presents the results of a narrative review of international studies of antipsychotic discontinuation syndromes and their relevance to nursing practice. Four key mental health nursing textbooks used in student nurse education in Australia are examined to assess how this evidence has been incorporated into clinical recommendations. This review finds that the evidence for discontinuation syndromes could be more widely disseminated and applied than it is at present. Strikingly, this evidence has not been incorporated into key mental health nursing textbooks in Australia at all. Slow integration into nursing published work may be influenced by a number of clinical and research uncertainties. We consider the impact of this silence on key nursing roles of psycho-education and adverse event monitoring during antipsychotic discontinuation periods. Further robust research should be conducted into discontinuation syndromes as a matter of urgency. Given the high number of consumers potentially impacted upon by discontinuation syndromes, nurse authors and educators should consider revising key nursing textbooks to include the currently available information about discontinuation syndromes.

Neuroleptic malignant syndrome induced by combination therapy with tetrabenazine and tiapride in a Japanese patient with Huntington's disease at the terminal stage of recurrent breast cancer

We herein describe the case of an 81-year-old Japanese woman with neuroleptic malignant syndrome that occurred 36 days after the initiation of combination therapy with tiapride (75 mg/day) and tetrabenazine (12.5 mg/day) for Huntington's disease. The patient had been treated with tiapride or tetrabenazine alone without any adverse effects before the administration of the combination therapy. She also had advanced breast cancer when the combination therapy was initiated. To the best of our knowledge, the occurrence of neuroleptic malignant syndrome due to combination therapy with tetrabenazine and tiapride has not been previously reported. Tetrabenazine should be administered very carefully in combination with other neuroleptic drugs, particularly in patients with a worsening general condition.

Challenges in pharmacologic management of the hospitalized patient with psychiatric comorbidity

BACKGROUND

Psychiatric comorbidity is common in the inpatient medical population. Hospitalists are frequently faced with decisions regarding the psychopharmacologic management of medically ill patients, yet receive limited psychiatric training. This review aims to assist the hospitalist in making an informed decision about the continuation of home psychotropic medications in the medically ill patient.

METHODS

A PubMed literature review was performed to obtain information on the effects of psychotropic medication discontinuation. In addition, the literature was reviewed regarding the potential challenges of psychotropic medication continuation.

RESULTS

A growing number of studies demonstrate high rates of relapse when medications are discontinued in patients suffering from mood disorders, schizophrenia, and anxiety disorders. Abrupt cessation of psychotropics is especially dangerous, leading to a greater chance of destabilization. Discontinuation syndromes, with prominent physical symptoms, may also result from sudden psychotropic cessation. Conversely, continuing home psychotropic medication may cause adverse effects due to drug-drug interactions or changing pharmacokinetics.

CONCLUSIONS

This review examines the risks of psychotropic discontinuation as well as the challenges of psychotropic continuation in the medically ill patient. When making complex psychopharmacologic decisions, hospitalists should employ all available resources, including pharmacists and consult-liaison psychiatrists. Ultimately, physicians and patients must make collaborative decisions, weighing the risks and benefits of psychiatric medications.

The effects of abrupt antipsychotic discontinuation in cognitively impaired older persons: a pilot study

BACKGROUND

Antipsychotic use for behavioural and psychological symptoms of dementia (BPSD) is controversial. Guidelines advise to reduce antipsychotics given the adverse effects and limited efficacy, to limit dose and treatment duration as well as to undertake discontinuation.

METHODS

A pilot study with 40 hospitalised geriatric cognitively impaired patients, in which the effects of abrupt antipsychotic discontinuation were investigated, using neuropsychiatric inventory (NPI) scores before and one month after discontinuation. Withdrawal symptoms were monitored thrice a day with a checklist during five consecutive days.

RESULTS

Participants (n = 40) had a mean age of 84 years (range 67-95) and 53% were male. The total mean baseline NPI score was 21 (SD 12) with predominantly behavioural rather than psychological disturbances. After abrupt discontinuation, mild withdrawal symptoms were observed in 72% of the patients, with frequencies of symptoms peaking on day 2 (53%) and day 3 (48%). After one month, 31 patients (85%) were still off antipsychotics and improved on the majority of NPI domains, with a total mean NPI score decreasing from 18 (SD 13) to 12 (SD 8, p = 0.003). In the relapse group, there was no deterioration associated with the abrupt discontinuation and subsequent resumption of therapy with a total mean NPI score decreasing from 31 (SD 12) at baseline to 27 (SD 8) at one-month follow-up (p = 0.345).

CONCLUSION

Abrupt antipsychotic discontinuation appears to be feasible in older individuals with BPSD. Systematically performed discontinuation efforts in clinical practice are needed to differentiate between patients where antipsychotics have no added value and patients where the benefits outweigh the risks.

Potential adverse effects of discontinuing psychotropic drugs. Part 3: Antipsychotic, dopaminergic, and mood-stabilizing drugs

Abrupt discontinuation of antipsychotic drugs in patients with schizophrenia is associated with earlier, and often more severe, illness episodes than are seen with gradual discontinuation. Antipsychotic drugs can cause various abnormal motor syndromes, but abruptly stopping them has been associated with the seemingly paradoxical development of similar motor syndromes, such as withdrawal dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome. Dopamine-releasing and dopamine-agonist drugs are used to treat some of the motor syndromes caused by antipsychotic drugs, but their abrupt discontinuation can also be associated with abnormal syndromes. When antipsychotic drugs, lithium, or certain anticonvulsant drugs are used for treatment of bipolar disorder, rapid versus gradual discontinuation is more likely to lead to greater mood instability and manic relapse. If necessary, these medications should be gradually tapered to minimize all types of adverse discontinuation effects. Patients should be educated about the possible adverse effects of abrupt medication discontinuation.

Neuroleptic malignant syndrome and its controversies

PURPOSE

Neuroleptic malignant syndrome (NMS) is a rare and life threatening condition usually defined as a complication of treatment with antipsychotics characterized by severe rigidity, tremor, fever, altered mental status, autonomic dysfunction, and elevated serum creatine phosphokinase and white blood cell count. The literature on this topic is rather extensive, but many aspects related to the syndrome are thought to be controversial. The aim of this paper, written with the clinician in mind, is to summarize some of the most prominent controversies that may have importance in usual clinical practice.

METHODS

The literature was searched for reviews, reports on the series of cases, individual case reports of NMS, and other clinically and theoretically important information.

RESULTS

There are controversies associated with virtually all important aspects of NMS. At the moment, it is not clear if this drug reaction is idiosyncratic or not, what diagnostic criteria are the most appropriate for usual clinical practice, and it seems that the estimated incidence is not in accordance with the number of treated patients. There are rather different approaches to the pathophysiological mechanisms, differential diagnosis, and treatment.

CONCLUSIONS

Some of the controversies related to NMS have an influence on our understanding of the condition and may have importance in clinical practice. There is a need for further research that should elucidate these controversies.

Probable case of neuroleptic malignant syndrome following administration of antituberculotic drugs in a chlorpromazine-treated patient

Neuroleptic malignant syndrome (NMS), a potentially fatal adverse reaction to neuroleptics, is known to occur more often in the initial stage of antipsychotic treatment. We describe a patient with chronic schizophrenia who, in a few days after the addition of antituberculotic drugs to his antipsychotic regimen, developed probable NMS without pyrexia. We reasoned that rifampin, a strong hepatic enzyme inducer, decreased the plasma chlorpromazine concentration of the patient, with the result of cholinergic hyperactivity and finally, the symptoms of NMS. Therefore, physicians should be aware of drug interactions and the likelihood of NMS, and consider antipsychotic dose adjustment when prescribing drugs that may influence pharmacokinetic properties of antipsychotics in a patient with schizophrenia receiving long-term antipsychotic treatment.

Fatal Neurotoxic Response to Neuroleptic Medications

Neuroleptic malignant syndrome (NMS) is a diagnosis of exclusion difficult to make due to a lack of pathognomonic features. Diagnosing NMS by postmortem examination becomes increasingly challenging when possible underlying brain pathology is obscured. The diagnosis is based on clinical history and laboratory findings. Autopsy and histologic findings, if any, usually are reflective of hyperthermia or complications (eg, aspiration pneumonia) of NMS. The authors describe a case of a 36-year-old Hispanic woman with a presumptive diagnosis of pseudoseizures, treated with various combinations of neuroleptic medications over a 6-week period prior to her sudden, unexpected, in-hospital death. Neuroleptic malignant syndrome is likely to have contributed to this patient's death. Confounding factors and medicolegal issues of a postmortem diagnosis of NMS are discussed.

Psychotropic discontinuation symptoms: a case of withdrawal neuroleptic malignant syndrome

INTRODUCTION

Although recent publications have focused on discontinuation symptoms of antidepressant medications, most classes of psychotropic drugs have been reported to have withdrawal symptoms. In light of the increased rate of psychotropic prescribing by primary care physicians, it is important for all physicians to be aware of psychotropic withdrawal symptoms.

CASE REPORT

We report on a patient who developed symptoms consistent with neuroleptic malignant syndrome after abrupt discontinuation of a variety of psychotropic medications.

METHODS

A MEDLINE search including both articles and letters to the editor was performed to identify symptoms reported in association with the discontinuation of psychotropic medications.

Diagnosis and treatment of viral encephalitis

Acute encephalitis constitutes a medical emergency. In most cases, the presence of focal neurological signs and focal seizures will distinguish encephalitis from encephalopathy. Acute disseminated encephalomyelitis is a non-infective inflammatory encephalitis that may require to be treated with steroids. Acute infective encephalitis is usually viral. Herpes simplex encephalitis (HSE) is the commonest sporadic acute viral encephalitis in the Western world. Magnetic resonance imaging of brain is the investigation of choice in HSE and the diagnosis may be confirmed by the polymerase chain reaction test for the virus in the cerebrospinal fluid. In this article, we review the diagnosis, investigations, and management of acute encephalitis. With few exceptions (for example, aciclovir for HSE), no specific therapy is available for most forms of viral encephalitis. Mortality and morbidity may be high and long term sequelae are known among survivors. The emergence of unusual forms of zoonotic encephalitis has posed an important public health problem. Vaccination and vector control measures are useful preventive strategies in certain arboviral and zoonotic encephalitis. However, we need better antiviral therapy to meet the challenge of acute viral encephalitis more effectively.

Addition of carbamazepine to long-term treatment with neuroleptics may induce neuroleptic malignant syndrome

BACKGROUND

Carbamazepine is an anticonvulsant, but also has an anti-manic effect, and recently it has been increasingly used in combination with neuroleptics. Nevertheless, there have been very few reports on the involvement of carbamazepine in the occurrence of neuroleptic malignant syndrome (NMS).

METHODS

A case of NMS occurring after addition of carbamazepine to long-term neuroleptic administration is described.

RESULTS

The patient had been treated with neuroleptics for about 30 years, and NMS developed when carbamazepine (400 mg/day) was added.

CONCLUSIONS

This case suggests that clinicians should consider the risk of NMS when carbamazepine is administered to patients undergoing long-term treatment with neuroleptics.