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Reversible Worsening of Psychosis Due to Benzydamine in a Schizoaffective Young Girl Who Is Already Under Treatment with Antipsychotics

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Reversible Worsening of Psychosis Due to Benzydamine in a Schizoaffective Young Girl Who Is Already Under Treatment with Antipsychotics Olgu Sunumlar› / Case Reports Reversible Worsening of Psychosis Due to Benzydamine in a Schizoaffective Young Girl Who is Already under Treatment with Antipsychotics Mehmet Kerem Doksat ÖZET: ABSTRACT: Antipsikotiklerle tedavi alt›nda olan flizoaffek- Reversible worsening of psychosis due to tif bir genç k›zda benzidamin kullan›lmas›na benzydamine in a schizoaffective young girl ba¤l› olarak geliflen reversibl psikoz kötülefl- who is already under treatment with mesi antipsychotics Ülkemizde Tantum, Tanflex, Benzidan gibi isimlerle sat›lan Benzydamine, available as the hydrochloride form, is an benzidamid hidroklorid, antienflamatuar ve analjezik ola- anti-inflammatory drug providing both rapid and rak s›kl›kla kullan›lan bir ilâçt›r. 500 ilâ 3000 mg gibi oral extended pain relief in many painful inflammatory dozlarda “deliran” (kafa bulucu) etkisi görülür; yarat›c›l›¤› conditions. In oral dosages of 500 mg to 3000 mg it is a artt›r›c› hallüsinozise (ego-distonik hallüsinasyonlara) ve “deliriant” and CNS stimulant, popular in Poland and Brazil. öforiye yol açt›¤› için, Polonya ve Brezilya’da s›kl›kla kulla- In Brazil it is so popular that many people use it for n›lmaktad›r. Yüksek dozlarda panoya, a¤›z kurulu¤u ve recreational purposes. A person in a “benzydamine trip” konvülsiyonlar görülebilir ve 2000–3000 mg dozlar›nda may experience a feeling of well-being, euphoria and in merkezî sinir sistemini uyar›c› etkisi belirginleflir. Bu “trip- higher doses hallucinations, paranoia, dry mouth and ler” bilerek veya kazaen al›nan yüksek dozlardan sonra or- convulsions may also be experienced. In dosages of 750 taya ç›k›p, ilâç kesilince 2 ilâ 3 günde kendili¤inden düzelir. mg to 2000-3000 mg benzydamine is a hallucinogen and Günde 40 mg sitalopram, 80 mg ziprasidon ve hafif akatizi CNS stimulant. These “triply” effects may be observed in için verilen 6 mg biperiden ile üç senedir hemen tamamen poisoning or accidental or “on purpose” overdose cases düzelmifl durumdaki bir genç k›z hastamda basit bir orto- also, hallucinosis (i.e. ego-dystonic hallucinations) is typical pedik sorun için gitti¤i ortopedistin yazd›¤› Tantum Draje in such cases and generally remits spontaneously in 2 to 3 (50 mg) günde üç kez kulland›ktan hemen sonra hallüsino- days after cessation of the drug even in children. zis, disfori ve paranoid ideasyon geliflip, ilâc› 5. gün kestik- I report a 22 years-old schizoaffective patient under almost ten sonra 5 günde tekrar normâl hâline döndü. Nörolojik complete remission with citalopram 40 mg, ziprasidone 80 muayenesinde, ayr›nt›l› laboratuar tetkiklerinde hiçbir mg and biperiden 2 mg tid for mild akathisia. She was anormâllik bulunmad›. almost symptom-free for three years. She had a leg injury Araflt›rabildi¤im kadar›yla, zâten psikotik olup da ilâç teda- and an orthopedist prescribed Tantum pills 50 mg tid after visi alt›nda bulunan bir hastada, klinik dozlarda dahi hallü- meals. On the second day she was hallucinated with MD, Professor of Psychiatry, ‹Ü Cerrahpafla sinozis geliflen ilk vak’a takdimi budur. Gerçekte ise bu so- complete insight (i.e., hallucinosis), dysphoric and slightly T›p Fakültesi, Psikiyatri Anabilim Dal›, runun daha s›k oldu¤unu ve bu ilâc› yazmadan önce, han- paranoid; like her initial complaints. She used the drug for ‹stanbul-Türkiye gi daldan olursa olsun, hekimlerin geçmifl veya hâlen mev- totally 5 days. When I examined her on the 6th day, she was Yaz›flma Adresi / Address reprint requests to: cut bir psikiyatrik sorunu, bilhassa psikozu sorgulamalar› vigil; her orientation and judgment were intact, excluding Mehmet Kerem Doksat, ‹Ü Cerrahpafla T›p gerekti¤ini düflünüyorum. the diagnosis of delirium. There was nothing abnormal in Fakültesi, Psikiyatri Anabilim Dal›, Duygudurum Bozukluklar› Birimi Baflkan›. KM her neurological examination and laboratory testing Pafla, 34303. ‹stanbul-Türkiye Anahtar sözcükler: Benzydamine, hallüsinozis, ilâçla including CBC, liver, kidney and thyroid functions. We indüklenen psikoz, madde suiistimali quitted benzydamine and did nothing else except waiting Telefon / Phone: +90-212-240-1603 for the course. It took her 5 days to become symptom-free Faks / Fax: +90-212-219-2174 Klinik Psikofarmakoloji Bülteni 2009;19:279-284 again. She had no recurrent complaint or persisting hallucinosis. Although there is no previously published Elektronik posta adresi / E-mail address: information about this hallucinogenic and deteriorating [email protected], [email protected] effect of benzydamine in a psychotic young person, Kabul tarihi / Date of acceptance: physicians including orthopedist, dermatologists etc 10 May›s 2009 / May 10, 2009 planning to prescribe benzydamine to their patients should concern and must take at least a brief anamnesis for Ba¤›nt› beyan›: previous or ongoing psychotic disorder. M.K.D.: Çok say›da ilaç firmas›ndan bilimsel aktiviteleri karfl›l›¤› honorarium kabul etmifltir. Key words: Benzydamine, hallucinosis, drug induced psychosis, substance abuse Declaration of interest: M.K.D.: Received honoraria for scientific activities from various pharmaceutical Bulletin of Clinical Psychopharmacology 2009;19:279-284 companies. INTRODUCTION form, is a anti-inflammatory drug with local anesthetic and analgesic properties providing both rapid and Benzydamine [3-(1-benzyl-1H-indazol-3-yloxy)-N,N- extended pain relief as well as a significant anti- dimethylpropan-1-amine] (marketed as Tantum, Tanflex, inflammatory treatment for the painful inflammatory and Benzidan in Turkey), available as the hydrochloride conditions of the mouth and throat. It selectively binds to Klinik Psikofarmakoloji Bülteni, Cilt: 19, Say›: 3, 2009 / Bulletin of Clinical Psychopharmacology, Vol: 19, N.: 3, 2009 - www.psikofarmakoloji.org 279 Reversible worsening of psychosis due to benzydamine in a schizoaffective young girl who is already under treatment with antipsychotics inflamed tissues as a weak prostaglandin synthetase lipooxygenase, and is not ulcerogenic. inhibitor is thought to be virtually free of any adverse It is available in a mouth wash named Tantum Verde systemic effects. It may be used alone or as an adjunct to across Europe. In the UK it is sold by 3M under the trade other therapy giving the possibility of increased name Difflam, as Difflam Spray, Difflam Oral Rinse and therapeutic effect with little risk of interaction (1). It is Difflam Cream. Its high cost (about £7 a bottle) makes it well absorbed after oral intake and effective blood level is less attractive than the cheaper method of gargling aspirin. reached in 1 hour, lasting up to 4-6 hours. It is relatively In Australia it is available from 3M as Difflam-C Alcohol less-protein bound than other non-steroid anti- & Color Free Solution, Difflam 3% Gel, Difflam Extra inflammatory agents (15-20%), which increases the Strength Gel 5%, Difflam-C Solution, Difflam Solution drug’s bioavailability. It is more concentrated in inflamed (including Difflam Throat Spray), Difflam Cream and tissues than normal tissues; elimination half-life is about Difflam Lozenges. It is sold in Eastern Europe without 24 hours, excreted by liver and kidneys partially prescription as Tantum Rosa - a vaginal antiseptic and unchanged, and partially as metabolized. anti-inflammatory, containing 0.14 g of benzydamine It is also a systemic anti-inflammatory drug which is hydrochloride to be reconstituted with clean water to a widely available and used topically for the treatment of 0.1% (1 mg/mL) solution for vaginal enema/instillation. the mouth, as a gel for application to inflamed joints and In Brazil it is sold by prescription under the name vaginal problems, and as a pill for systemic use. Its “Benflogin”, with each box containing 20 pills (50mg physicochemical properties and pharmacological each). In Pakistan it is sold by prescription under the name activities differ markedly from those of the aspirin-line Tantum Capsule (50mg). It is available in a cream and gel non-steroidal anti-inflammatory drugs; i.e. it is a weak named Tantum Fort across Egypt by EIPICo. It is base unlike the aspirin-like drugs which are acids or available with prescription as a mouthwash named Novo- metabolized to acids, and a major contrast with the Benzydamine (Novopharm) in Canada. In Turkey, like aspirin-like drugs is that benzydamine is a weak inhibitor many other medications, it is cheap and sold over the of the synthesis of prostaglandins but it has several counter in all pharmacies as Tantum, Tanflex, and properties which may contribute to its anti-inflammatory Benzidan; which make it a very easily reachable, activity. These properties include inhibition of the consumable, and abusable drug! synthesis of the inflammatory cytokine, tumor necrosis Main indications are in odontostomatology, gingivitis, factor-alpha (EC(50), 25 micromoles/L). Inhibition of the stomatitis, glossitis, aphthous ulcers, dental surgery and oxidative burst of neutrophils occurs under some oral ulceration due to radiation therapy; in conditions at concentrations of 30 to 100 micromoles/L, otorhinolaryngology pharyngitis, tonsillitis, post- all are concentrations which may be produced within oral tonsillectomy, and radiation or intubation mucositis, in tissues after local application. A further activity of general inflammatory diseases, bruising, tendonitis, benzydamine is a general activity known as membrane bursitis, burns etc. Oral dose is 0.7-1 mg/kg (50 mg) tid stabilization which is demonstrated by several actions after meals; if required, 1 additional pill may be added; including inhibition of granule release from neutrophils at maximum daily dose is four pills a day, with mean therapy concentrations ranging from 3 to 30 micromoles/L and duration of 5 to 15 days (3). stabilization of lysosomes. Lack of knowledge of the Benzydamine is well tolerated. Occasionally oral tissue tissue concentrations of benzydamine limit the chance of numbness or stinging sensations may occur. Benzydamine making a reasonable correlation between its in vitro and in may be abused recreationally. In oral dosages of 500 mg to vivo pharmacological activities. The concentration of 3000 mg it is a “deliriant” and CNS stimulant, popular in benzydamine in the mouthwash is 4 micromoles/L but the Poland and Brazil.
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