Hypothermia induced by risperidone and olanzapine in a patient with Prader-Willi syndrome

Successful Treatment of Risperidone-Induced Hypothermia With Aripiprazole: A Brief Case Report and a Literature Review

Hypothermia, a potentially fatal condition, can result from various internal causes, including certain medications. Antipsychotics, in particular, are associated with hypothermia, typically emerging 7-10 days after dosage adjustments. Here, we report the case of a 68-year-old male with a history of cerebral palsy, bipolar disorder, and paranoid schizophrenia who was admitted due to poor oral intake and was found to have persistent hypothermia despite active external rewarming. After substituting risperidone with aripiprazole, his temperature normalized, and he experienced no further hypothermic episodes.  Antipsychotic-induced hypothermia should be considered in patients on these medications who present with non-specific symptoms. Regular monitoring of temperature and vital signs is crucial for early detection and management.

Severe hypothermia, bradycardia and cardiac arrest in association with risperidone

Antipsychotic medications, including risperidone, are widely used in the treatment of psychiatric disorders, including schizophrenia. While hyperthermia is an establish adverse effect of these medications, less is known about the rare occurrence of hypothermia. We present two patients who developed hypothermia, bradycardia and cardiac arrest in association with risperidone. We briefly review previously similarly reported cases.

The risk factors, frequency and diagnosis of atypical antipsychotic drug-induced hypothermia: practical advice for doctors

Hypothermia is unpredictable and life-threatening adverse effect of atypical antipsychotic drug (APD) treatment, which has been little described. The aim of this article is to increase the awareness that hypothermia induced by APD drugs is more common than the current published case reports may suggest, and risk factors increase its development. Moreover, valuable guidelines regarding how to detect the early stages of hypothermia in clinical practice are included. A literature search for reports on APD-induced hypothermia in PubMed, Academic Search Complete, Medline Complete and eHealthMe databases was conducted. The literature search apart from eHealthMe database resulted in 524 articles, which included 34 case reports. Hypothermia was mostly induced by olanzapine (14) and risperidone (10). However, the data from Food and Drug Administration reports revealed several dozen more cases of APD-induced hypothermia (591case reports) compared with the published case reports (e.g. olanzapine-262 and risperidone-161). Hypothermia, mostly mild (61% of cases), has developed mainly in men (71%) having schizophrenia, a few hours after commencement of treatment or in the presence of risk factors. Owing to the increased risk of hypothermia development during APD treatment, doctors should routinely measure body temperature of patients, especially during the first days of the therapy. Early diagnosis of hypothermia and appropriate treatment may prevent death.

Mild Hypothermia in a Child with Low-Dose Risperidone

Abstract. Risperidone is a widely used, second-generation antipsychotic approved for treating schizophrenia as well as for treating aggression in children and adolescents with mental retardation. The substance has a well-established risk profile including alterations of body temperature. Apart from hyperthermia with and without full-blown malignant neuroleptic syndrome, low body temperatures (hypothermia) have also been reported anecdotally, usually appearing in the context of comedication. Here, we report a case of hypothermia associated with a low-dose risperidone monotherapy in a child.

Hypothermia due to Antipsychotic Medication: A Systematic Review

BACKGROUND

Hypothermia is a rare, but potentially fatal adverse effect of antipsychotic drug (APD) use. Although the opposite condition, hyperthermia, has been researched extensively in the context of the malignant antipsychotic syndrome, little is known about hypothermia due to APDs.

OBJECTIVE

This study aimed to review the literature on hypothermia in the context of APD use, and formulate implications for research and clinical care.

METHODS

A systematic search was made in PubMed and Ovid Medline.

RESULTS

The literature search yielded 433 articles, including 57 original case descriptions of hypothermia developed during APD use with non-toxic plasma levels. All cases together indicate that the risk of developing hypothermia is highest during the 7 days following initiation, or increase in dosage, of APDs, especially in the presence of additional predisposing factors, such as advanced age, exposure to cold, adjuvant use of benzodiazepines, and (subclinical) hypothyroidism. In addition, data derived from drug-monitoring agencies suggest that the prevalence of APD-related hypothermia is at least 10 times higher than suggested by the literature.

CONCLUSION

We conclude that health-care professionals need to monitor the body temperature of patients starting with (an increased dose of) APDs for a duration of 7-10 days to prevent hypothermia, especially in the presence of multiple risk factors. Moreover, systematic studies are needed to establish the actual prevalence of APD-related hypothermia as well as the relative risk for individual APDs.

Prolonged hypothermia due to olanzapine in the setting of renal failure: a case report and review of the literature

Temperature dysregulation is an infrequent but previously documented adverse effect of antipsychotic medications. The majority of documented cases involve durations of hypothermia of less than 24 h. We present the case of a patient on therapeutic olanzapine for bipolar disease with dehydration from gastroenteritis leading to acute kidney injury in the setting of stage III chronic kidney disease, who presented with severe hypothermia of 31.2°C (88.2°F). He required active rewarming in the intensive care unit for a total of 9 days. This is the second case report of prolonged hypothermia from olanzapine in the setting of kidney disease. Clinicians should be aware that patients with renal dysfunction may be at increased risk for prolonged hypothermia from olanzapine.

[Hypothermia under olanzapine treatment: clinical case series and review of current literature]

BACKGROUND

Antipsychotic drugs may lead to hypothermia as well as hyperthermia. Although known for decades and clinically highly relevant, the mechanisms by which antipsychotic drugs alter thermoregulatory processes in the human body are still far from being fully understood. In clinical practice, much attention is paid to antipsychotic drug-induced elevation of body core temperature as observed in the neuroleptic malignant syndrome (NMS). But also hypothermia is a clinically highly relevant adverse reaction to antipsychotic drugs.

MATERIAL AND METHODS

Here we report a case series of three patients who developed severe hypothermia after administration of olanzapine. A review of the current literature is given with a focus on risk factors for the development of antipsychotic drug-induced hypothermia and its pathophysiologic mechanisms.

RESULTS

A 51-year-old female patient suffering from catatonic schizophrenia, cachectic nutritional condition and hypothyroidism developed severe hypothermia of 30.0°C body core temperature after administration of 30 mg olanzapine per day under comedication with lorazepam and L-thyroxine. A 48-year-old female patient with catatonic schizophrenia showed hypothermia of 31.0°C (rectal measurement) after single-dose administration of olanzapine 10 mg orally and a total of 3 mg lorazepam (1-1-1 mg). The third case report describes a 69-year-old male patient with acute delusional disorder exhibiting hypothermia of 33.0°C (rectal measurement) in combination with a reversible atrioventricular block grade III without any further comedication.

CONCLUSION

A review of the current literature reveals that thermoregulatory disturbances as sequelae of antipsychotic drug administration depend on individual disposition as well as various independent risk factors such as environmental temperature, somatic comorbidities, endocrinological abnormalities (e.g. hypothyroidism) and structural damage of the brain. A complex interaction of dopaminergic regulatory mechanisms in the ventral hypothalamus and peripheral vaso- and sudomotor adjustments seems to be causative. Hypothermia following antipsychotic drug administration represents a serious adverse drug reaction and a potentially life-threatening event.

Use of Typical Antipsychotics Predicts Recurrent Hypothermia for Institutionalised Psychiatric Patients

Objective

To find out the predicting factors of early recurrent hypothermia in patients from a mental institute and the role of use of antipsychotics.

Design

Retrospective cohort study.

Setting

Accident and emergency department of a regional public hospital in Hong Kong.

Method

All adult patients transferred from a mental hospital to the study centre presenting with hypothermia from 1st January 2002 to 31st December 2009 were included. Demographic data, medical history, drug history, patient's mobility status, and the ambient temperature of the presenting date were collected as predicting variable and analyzed using Wei, Lin and Weissfeld model, with time to the next hypothermia as outcome variable.

Results

Forty eight patients with 96 hypothermia episodes were included. The use of typical antipsychotics was associated with a significantly shorter median time to the next hypothermia episode (50.2 to 21 months) (p=0.005 by log rank test). In the Wei, Lin and Weissfeld model, use of typical antipsychotics was the sole significant predicting factor for early recurrent hypothermia (p<0.0001), with hazard ratio of 2.89 (95% CI 1.64-5.10).

Conclusion

Use of typical antipsychotics is the only significant predictor of early recurrence of hypothermia in institutionalised psychiatric patients.

Hypothermia associated with antipsychotic drug use: a clinical case series and review of current literature

Hypothermia as an adverse reaction of antipsychotic drug use represents a potentially life-threatening complication. However, the mechanisms by which antipsychotic drugs alter thermoregulatory processes in the human body are far from being fully understood. Here we present a case series of 5 patients developing severe hypothermia after administration of olanzapine and benperidol. Controlled by a network of neural structures, body temperature is physiologically regulated in far more narrow boundaries than are other vital functions, and its homeostasis is critical for survival. The preoptic region in the ventral hypothalamus is assumed to act as a coordinating center that is endowed with thermosensory units that constantly compare actual body temperature with target values and initiate regulatory and compensatory mechanisms in case of mismatch. Hypothermia risk seems to increase in the first days after initiation of antipsychotic drug therapy or increases in the daily dose. Schizophrenic patients bear a higher risk than nonschizophrenic patients treated with antipsychotic drugs (such as patients with dementia or depression). Antipsychotic drugs with strong 5-HT2 antagonism seem to be more frequently associated with hypothermia. These cases demonstrate the clinical relevance of hypothermia as an adverse reaction to antipsychotic treatment and the importance of careful monitoring of body temperature.

An unusual case of hypothermia associated with therapeutic doses of olanzapine: a case report

Introduction

We report a case of a 42-year-old man who had symptomatic hypothermia as a result of taking olanzapine for paranoid schizophrenia. According to published data, only a few cases of hypothermia associated with olanzapine have been reported since its introduction into clinical use.

Case presentation

A 42-year-old Sri Lankan man with schizophrenia who was being treated with a therapeutic dose of olanzapine presented with reduced level of consciousness. He had a core temperature of 32°C and was bradycardic. At the time of admission, the electrocardiogram showed sinus bradycardia with J waves. He did not have any risk factors for developing hypothermia except the use of olanzapine. There was improvement in his clinical condition with reversal of electrocardiogram changes following gradual rewarming and the omission of olanzapine.

Conclusion

Hypothermia induced by antipsychotic medications is not uncommon, but olanzapine-induced hypothermia is rare and occurrence has been reported during initiation or increasing the dose. But here the patient developed hypothermia without dose adjustment.

Hypothermia following antipsychotic drug use

Objective

Hypothermia is an adverse drug reaction (ADR) of antipsychotic drug (APD) use. Risk factors for hypothermia in ADP users are unknown. We studied which risk factors for hypothermia can be identified based on case reports.

Method

Case reports of hypothermia in APD-users found in PUBMED or EMBASE were searched for risk factors. The WHO international database for Adverse Drug Reactions was searched for reports of hypothermia and APD use.

Results

The literature search resulted in 32 articles containing 43 case reports. In the WHO database, 480 reports were registered of patients developing hypothermia during the use of APDs which almost equals the number of reports for hyperthermia associated with APD use (n = 524). Hypothermia risk seems to be increased in the first days following start or dose increase of APs. APs with strong 5-HT2 antagonism seem to be more involved in hypothermia; 55% of hypothermia reports are for atypical antipsychotics. Schizophrenia was the most prevalent diagnosis in the case reports.

Conclusion

Especially in admitted patients who are not able to control their own environment or physical status, frequent measurements of body temperature (with a thermometer that can measure low body temperatures) must be performed in order to detect developing hypothermia.

No effect of dietary fat on short-term weight gain in mice treated with atypical antipsychotic drugs

RATIONALE

Atypical antipsychotic drugs (AAD) induce significant weight gain in female C57BL/6J mice. The effect of dietary fat on weight gain and serum lipids in this model is unknown.

OBJECTIVES

Test the hypothesis that the obesigenic effects of these drugs are greater in the presence of a high-fat diet.

METHODS

Female C57BL/6J mice were treated with atypical antipsychotics for 3 weeks and fed either a low-fat or high-fat diet (4.6 vs 15.6% fat by wt). Food intake (FI), body weight (BW), body composition, and serum lipids were measured during treatment with optimized doses of olanzapine, quetiapine, and risperidone. Energy intake (EI) and feed efficiency (FE) were calculated. Group differences in change were analyzed via repeated measures analysis of variance (ANOVA). Serum lipid concentrations, EI and FE were compared using two-way ANOVA.

RESULTS

AAD-treated mice gained significantly more weight than controls after 3 weeks (P<0.001). Treatment and diet had significant effects on FI and EI over time (P<0.001). AAD-treated mice had significantly higher FE than controls (P<0.05); however, there was no significant drug by diet interaction (P=0.65). Risperidone low-fat mice gained significantly more absolute fat mass than placebo low-fat mice (P<0.05). All treatment groups, except quetiapine low-fat and olanzapine high-fat, gained significantly more absolute lean mass than placebo controls (P<0.05). Cholesterol levels were significantly lower in quetiapine and risperidone than placebo (P<0.05). Risperidone low-fat mice had significantly higher triglyceride levels than placebo and risperidone high-fat mice (P<0.05).

CONCLUSIONS

A high-fat diet does not increase AAD-induced BW gain in female mice during a 3-week treatment period.

A case of risperidone-induced hypothermia

Risperidone is one of the second-generation antipsychotics (SGAs). Use of SGAs or so-called atypical antipsychotics is becoming more frequent because they are more efficacious and safer than typical antipsychotics. This is due to their ability to occupy some other receptors as well as dopamine type 2 (D(2)) receptors in the brain. Risperidone has more affinity for serotonin type 2 (5-HT(2)) than for D(2) receptors. This accounts for its better treatment of negative symptoms of schizophrenia and fewer extrapyramidal side effects when compared with typical antipsychotics. Common side effects associated with risperidone include extrapyramidal symptoms, dizziness, nausea, weight gain, sleep disturbance, and sexual dysfunction. We describe here a case of risperidone-induced hypothermia. Body temperature is regulated by the preoptic anterior hypothalamus with involvement of dopamine, serotonin, norepinephrine, and alpha-adrenergic receptors. Experimental data suggest that stimulation of 5-HT(2) and dopamine receptors can increase the body temperature. Additional clinical evidence indicates potent antagonists of 5-HT(2) are more likely to cause hypothermia. Risperidone has higher potency for occupying 5-HT(2) than D(2) receptors.

Osborn waves in the electrocardiogram, hypothermia not due to exposure, and death due to diabetic ketoacidosis

Hypothermia usually occurs because a patient has been exposed to a cold environment; however, a number of nonenvironmental conditions may produce hypothermia. This report relates the clinical course of a patient whose hypothermia was due to severe diabetic ketoacidosis. In addition, we review the causes of hypothermia and Osborn waves beyond exposure to cold temperature. Hypothermia due to diabetic ketoacidosis is an uncommon complication of a common disease that carries with it clinically significant consequences. Accordingly, we believe that all clinicians should be aware of this potential complication of diabetic ketoacidosis and should be able to recognize the importance of the electrocardiogram in such patients.

[Severe intoxication probably from olanzapine (Zyprexa). Beneficial effect of glucagon]

We report the case of a 43-year-old schizophrenic who sustained, after 12 days of treatment including olanzapine (20 mg.day-1), carbamazepine, levomepromazine and alprazolan, a severe shock with bradycardia (HR: 40 b.min-1), circulatory collapse (SAP: 60 mmHg), hypothermia (T: 27 degrees C), coma and disseminated intravascular coagulation. A significant improvement was obtained with high doses of intravenous glucagon, whereas the normalization of central temperature, atropine, adrenaline and volume loading had been inefficient. Olanzapine, alone of associated with other psychotropics, could cause severe circulatory collapse with hypothermia and coma responding to a treatment including glucagon.