Case report of withdrawal syndrome after olanzapine discontinuation

Reducing the Risk of Withdrawal Symptoms and Relapse Following Clozapine Discontinuation-Is It Feasible to Develop Evidence-Based Guidelines?

Clozapine is the only antipsychotic that is effective in treatment-resistant schizophrenia. However, in certain clinical situations, such as the emergence of serious adverse effects, it is necessary to discontinue clozapine. Stopping clozapine treatment poses a particular challenge due to the risk of psychotic relapse, as well as the development of withdrawal symptoms. Despite these challenges for the clinician, there is currently no formal guidance on how to safely to discontinue clozapine. We assessed the feasibility of developing evidence-based recommendations for (1) minimizing the risk of withdrawal symptoms, (2) managing withdrawal phenomena, and (3) commencing alternatives treatment when clozapine is discontinued. We then evaluated the recommendations against the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. We produced 19 recommendations. The majority of these recommendation were evidence-based, although the strength of some recommendations was limited by a reliance of studies of medium to low quality. We discuss next steps in the refinement and validation of an evidence-based guideline for stopping clozapine and identify key outstanding questions.

Late-Onset Dystonia With Low-Dose Olanzapine in an Older Person: A Case Report

Drug-induced dystonias are rare but can occur with second-generation antipsychotics. They are usually dose-related and occur soon after dose initiation. This case describes the development of dystonia after two years of olanzapine 5 mg daily in an older person with Alzheimer's dementia. The dystonia resolved after diphenhydramine treatment on day two of hospitalization, but then the patient became delirious, which was treated with lorazepam on day three. Six days after admission, she developed tremors and rigidity that self-resolved. Her dystonia resolved after 11 days. The recurrence of symptoms during the hospitalization may have been a result of the progression of her dementia. This is the first known case of a patient developing dystonia after chronic use of low-dose olanzapine. This was not characterized as tardive dystonia because the dystonia was resolved with anticholinergic medication. This case illustrates the difficulty of using anticholinergics to treat dystonias in older people, which can precipitate delirium. Choosing an alternative antipsychotic with less extrapyramidal symptom risk is challenging as she had previous trials with quetiapine and risperidone. Clozapine was deemed an unfavorable alternative, as laboratory monitoring would be burdensome. Olanzapine-induced dystonias can develop anytime during therapy. Families must balance the desire for mood stabilization with antipsychotics side effects.

Clozapine discontinuation withdrawal symptoms in schizophrenia

Clozapine is an atypical antipsychotic used in treatment-resistant schizophrenia. Whilst clozapine is highly effective, there are some clinical scenarios, such as the emergence of severe side effects, that necessitate its discontinuation. There is an emerging literature suggesting that discontinuing antipsychotics, in particular clozapine, can cause an array of withdrawal symptoms. We review the evidence for the existence of clozapine-induced withdrawal symptoms, and in particular focus on withdrawal-associated psychosis, cholinergic rebound, catatonia and serotonergic discontinuation symptoms. To date, there has been surprisingly little clinical guidance on how to minimise the likeliness of withdrawal symptoms in patients who are stopped on clozapine abruptly or gradually. We discuss the key outstanding questions in this area and why there is a need for guidance on the management of withdrawal symptoms associated with clozapine discontinuation.

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.

Reversible Hyperkinetic Movement Disorder Related to Quetiapine Withdrawal: A Case Report

Quetiapine is used in treatment of schizophrenia, schizoaffective and bipolar disorders as well as psychosis in Parkinson's disease (PD) patients. Neurological side effects are not uncommon with this drug. However, there is limited knowledge about quetiapine withdrawal extra-pyramidal side effects. More recently quetiapine is used for sleep disorders and behaviour abnormalities in PD and its related syndrome. Therefore withdrawal dyskinesias may become more widely observed in the future, and patients need to be warned against sudden discontinuation of the drug. We present a rare case of Quetiapine withdrawal and discussing his bizarre abnormal movement.

Practical guidelines for the use of new generation antipsychotic drugs (except clozapine) in adult individuals with intellectual disabilities

New generation antipsychotic (NGA) drugs introduced to the US market after clozapine (aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone) are frequently used in individuals with intellectual disabilities (ID). However, there is very limited research to fully establish evidence-based or personalized medicine approaches for their use in this population. These guidelines take a pragmatic approach to establishing frameworks for their use by utilizing the prescribing information and reviewing the available literature on other relevant neuropsychiatric disorders. In the absence of expert consensus guidance and well-controlled comparison trials, we present a set of guidelines to inform initiation, dosing and monitoring of use in adults. Further, in these guidelines we provide practical information on drug-drug interactions and adverse drug reactions, and a brief review of discontinuation syndromes, potential for abuse, use during pregnancy and cost considerations. We also provide drug utilization review forms for each NGA to facilitate implementation of these guidelines, these guidelines provide a practical and necessary resource for practitioners treating psychiatric disorders and challenging behaviors in adult individuals with ID.

Olanzapine treatment decreases the density of muscarinic M2 receptors in the dorsal vagal complex of rats

In this study, we investigated the effects of antipsychotic drugs, olanzapine and haloperidol, on the density of the muscarinic M2 receptors in the dorsal vagal complex (DVC) and hypoglossal nucleus (HN). Female Sprague Dawley rats were treated with olanzapine, haloperidol or vehicle (control) for 1 (short-term) or 12 weeks (long-term). Quantitative autoradiography was used to investigate the M2 receptor density in the DVC and HN using a muscarinic antagonist [(3)H] AF-DX384. Olanzapine, but not haloperidol, treatment induced a significant decrease in the binding density of M2 receptors in the DVC compared to control groups. Although the HN showed a higher density of [(3)H] AF-DX384 binding than the DVC, treatment with both olanzapine and haloperidol did not induce any significant changes in [(3)H] AF-DX384 binding in the HN. These results suggest that olanzapine-induced body weight gain may be associated with functional changes in the muscarinic neurotransmission in the DVC.

Switching atypical antipsychotics: a review

BACKGROUND

Atypical antipsychotics are increasingly used in the treatment of diverse psychiatric disorders; however, there is little information on the 'why, when, and how' of switching between the different atypical antipsychotics currently available.

OBJECTIVE

To review the data on switching and atypical antipsychotics.

METHODS

A literature search was initially conducted using the key words followed by a search of relevant articles including conference abstracts; relevant pharmaceutical companies were also contacted.

RESULTS

Clinical trial data are limited in terms of parameters measured, and case reports describe specific problems. Few studies are based on real world populations of psychiatric patients over the long-term. Careful patient and drug selections matched to a carefully supervised and appropriate cross titration based upon the pharmacodynamic and pharmacokinetic properties of all of the drugs involved is important to avoid potential complications such as re-emergence or worsening of psychosis and withdrawal, rebound, and emergent phenomena including new or uncovered side-effects. Psychoeducation and involvement of patients and caregivers in the process are also necessary for a successful switch.

CONCLUSION

Despite the prevalence of switching in real world clinical practice, there is a paucity of data to guide clinicians with respect to effective and safe strategies. There are no criteria defining a successful switch. With the increasing range and formulations of atypical antipsychotics available, there is a rationale for their early use to avoid the practical problems associated with switching from conventional antipsychotics as well as the opportunity to maintain patients on an optimal atypical antipsychotic monotherapy.