DOCSLIB.ORG

Extrapyramidal Symptoms During Long-Term Treatment with Antipsychotics

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Extrapyramidal Symptoms During Long-Term Treatment with Antipsychotics ELSEVIER SYMPOSIUM Extrapyramidal Symptoms during Long-Term Treatment with Antipsychotics Special Focus on Clozapine and 01 and 02 Dopamine Antagonists Jes Gerlach, M.D., Henrik Lublin, M.D., and Linda Peacock, M.D. In schizophrenic patients in maintenance treatment, The low level of EPS with clozapine may be linked to the clozapine, compared to classic neuroleptics, induces special receptor-binding profile of this drug: during relatively few extrapyramidal syndromes (EPS), especially treatment with therapeutic doses of clozapine, the level of less akathisia and tremor and usually no dystonia or D2 receptor blockade is too low (40% to 50% occupancy by rigidity. In patients with dyskinetic movements (acute or positron emission tomography) to induce EPS, and the D1 tardive) induced by other neuroleptics, clozapine may receptor blockade (also 40% to 50% occupancy) has a lower reduce or even remove dyskinesia or permit it to disappear. EPS potential than D2 blockade. This binding profile may at It cannot, however, be excluded that clozapine can induce the same time contribute to the special antipsychotic properties dyskinesia in extremely rare cases, but it seems more likely of clozapine. Other receptor affinities may contribute to the that this is due to previous treatment with classic beneficial effect of clozapine in EPS and schizophrenia. neuroleptics. The earlier clozapine is started, the less chance [Neuropsychopharmacology 14:35S-39S, 1996] of development of dyskinesia. KEY WORDS: Clozapine; Dopamine receptors; EPS; described in the literature (for reviews, see Casey 1991; Parkinsonism; Tardive dyskinesia Barnes and Edwards 1993), and several rating scales are available for their evaluation (Kane et al. 1992; Gerlach Neuroleptic-induced extrapyramidal syndromes (EPS) et al. 1993). can be divided into four main categories: akathisia, dys­ Extrapyramidal syndromes can be distressing and tonia, dyskinesia, and parkinsonism. These are the clas­ disabling and are a major cause of poor compliance sic EPS, which can be related to neuroleptic treatment with treatment, which in turn has implications for re­ and seen during and/ or following treatment. These lapse, hospitalization, and morbidity. They cause suffer­ syndromes may also occur spontaneously, independent ing for both patients and relatives and limit possibilities of neuroleptic treatment, due to high age and/ or dis­ for development and activities. At times they may ease. The syndromes are all well known and thoroughly counteract the therapeutic effect of neuroleptics and de­ ter social integration. Finally, EPS entail the risk of be­ From the Research Institute of Biological Psychiatry, St. Hans coming irreversible and thereby a concrete expression Hospital, Roskilde, Denmark. of neuroleptics' ability to produce permanent brain Address correspondence to: Jes Gerlach, M.D., St. Hans Hospital, Department P, DK-4000 Roskilde, Denmark. damage. This article was presented at the integrated symposium "A New With this background it is important to try to under­ Understanding: Neurobiological Basis and Long-Term Outcome of stand the pathophysiologic mechanisms underlying these Schizophrenia" chaired by Herbert Y. Meltzer and Leif H. Lind­ strom at the CINP Congress, June 28, 1994, in Washington, D. C. EPS and to limit their development as far as possible. 1 Clozapine is available under the trade names Clozaril and Leponex. Clozapine1 causes fewer EPS than traditional neuro- NEUROPSYCHOPHARMACOLOGY 1996-VOL. 14, NO. 35 © 1996 American College of Neuropsychopharmacology Published by Elsevier Science Inc. 0893-133X I 96 /$15 .00 655 Avenue of the Americas, New York, NY 10010 SSDI 0893-133X(95)00203-0 36S J. Gerlach et al. NEUROPSYCHOPHARMACOLOGY 1996-VOL. 14, NO. 3S leptics. Whereas EPS may be seen in at least 75% of pa­ do not otherwise show typical parkinsonian features. tients treated with traditional neuroleptics, they have Tremor was seen in 3% of clozapine-treated patients been found to be relatively rare in clozapine-treated pa­ versus 11 % of control patients, and rigidity in 0% ver­ tients (about 5%) (Casey 1989; Fitton and Heel 1990). sus 19%. However, the prevalence is still not clear, and especially No acute dystonia was seen in any of the groups, but the EPS profile during long-term maintenance treat­ 13 of the control patients reported recent dystonic symp­ ment with clozapine has been insufficiently evaluated. toms versus O in the clozapine-treated group. Further­ The purpose of this study is to briefly discuss: (1) more, 10 control patients displayed splaying of one or EPS in chronic schizophrenic patients during long-term more fingers in fixed positions (probably a localized, antipsychotic treatment with clozapine versus tradi­ mild form of dystonia) compared to one in the cloza­ tional neuroleptics, and (2) based on studies in nonhu­ pine group. Only one case of dystonia-dyskinesia has man primates, the possibility of reducing the risk of been reported in the literature (Thomas et al. 1993). EPS by means of D1 antagonists and combined D1 and Fourteen percent of the clozapine treated patients D2 receptor antagonists. and 40% of the controls had subjective akathisia (p < .001), whereas 7% of clozapine treated patients and 29% of the controls were found to have objective akathisia EPS DURING MAINTENANCE TREATMENT (p < .001). WITH CLOZAPINE VERSUS TRADITIONAL As can be seen from Figure 1, 33 patients had dyski­ NEUROLEPTICS nesia before clozapine (evaluated from the charts). This number decreased to 15 patients during the median In a retrospective-prospective study (Peacock et al. 5-year clozapine treatment period (evaluated blind 1996), 100 chronic schizophrenic patients on clozapine from video). The corresponding figures for the control and 100 patients on classic neuroleptics (flupenthixol, group were 19 and 16, an apparently lower reduction perphenazine, and zuclopenthixol, the three most fre­ (p < .07). quently used classic neuroleptics in Denmark) were ex­ Fourteen clozapine-treated patients whose charts did amined for EPS and other side-effects (only the EPS not contain information about previous dyskinesia data are discussed here). The indications for using cloz­ showed dyskinesia at the time of evaluation versus 41 apine were: therapeutic resistance 47 patients; EPS vul­ in the control group (p < .001). In these cases, the nerability 11; both 42. present drug may have induced the syndrome, but the The two groups had received their present neurolep­ syndrome may also have been present in a latent form tic for similar periods of time: clozapine patients for a at the start of the treatment or not mentioned in the median of 5 years (range 0.3 to 19) and control patients charts. Under all circumstances, these observations sug­ for 5 years (0.3 to 24). However, the clozapine patients gest that clozapine permits dyskinesia to disappear to a had previously received traditional neuroleptics for 9 higher degree than classic neuroleptics, and it especially years (0.5 to 31). The total length of neuroleptic treat­ induces fewer new cases. ment was similar for the two groups. In conclusion, this study strongly indicates that cloz­ The median daily dose of clozapine was 400 mg (100 apine has a lower potential to induce both acute and to 1200) versus 9 mg (flupenthixol), 24 mg (perphena­ tardive EPS. zine), and 20 mg (zuclopenthixol) for the control group (corresponding to haloperidol 8 to 10 mg). Concomitant medication included benzodiazepines (clozapine pa­ D1 AND D2 RECEPTOR MECHANISMS IN THE tients 33% versus controls 26%), anticholinergics (6% DEVELOPMENT OF EPS versus 63%) and antidepressants (16% versus 3%). The EPS were evaluated blind (by means of a video) Studies from different nonhuman primate centers indi­ with the St. Hans Rating Scale for extrapyramidal syn­ cate that, although D1 antagonists can produce EPS, dromes (Gerlach et al. 1993). these are more benign than those induced by D2 antago­ Clozapine treated patients showed less parkinsonian nists. The following observations from studies in Cebus signs than control patients. A total of 33 out of 100 cloza­ monkeys must be emphasized: pine-treated patients (33%) showed some signs of par­ kinsonism as compared to 61 % of the control group (in 1. D1 antagonists produce dystonia when given in low spite of anticholinergics in 63% of the control patients). single doses to animals pretreated with D2 antago­ In both cases, bradykinesia was the predominant fea­ nists (Kistrup and Gerlach 1987; Peacock et al. 1990) ture, as is common in neuroleptic-treated patients. In the and when given in high single doses to drug-naive case of clozapine, however, it can be discussed whether animals (Casey 1992). the bradykinesia/ slow movements are due to a true 2. However, tolerance to dystonia is seen during pro­ parkinsonism, as the patients often are hypotonic and longed treatment, implying that no dystonia is seen NEUROPSYCHOPHARMACOLOGY 1996-VOL. 14, t\O. 3S EPS during Neuroleptic Treatment 37S so.--------------,,----------------, Dyskinesia Dyskinesia disappearance induction 40 · ..,_ 0 m20 .0 E z:::::l 10 0 Clozapine Control Clozapine Control M Before present drug • During present drug Figure 1. Dyskinesia disappearance and potential induction during long-term treatment (median 5 years) with clozapine (N = 100) versus classic neuroleptics (N = 100). The clozapine patients had previously been treated with classical neurolep­ tics for median 9 years. Difference with respect to disappearance: p < .07; with respect to
Load more

Recommended publications
  • Acute Extrapyramidal Symptoms Following Abrupt Discontinuation of Propranolol
    Medical Journal of the Volume 14 Islamic Republic of Iran Number 3 Fall 1379 November 2000 ACUTE EXTRAPYRAMIDAL SYMPTOMS FOLLOWING ABRUPT DISCONTINUATION OF PROPRANOLOL A. ALAVIAN GHAVANINI From the Center Jor Research Consultation, School oj Medicine, Shiraz University ojMedical Sciences, Shiraz, I.R. Iran. ABSTRACT A case of acute extrapyramidal manifestations consisting of dystonia and akathisia following abrupt discontinuation of propranolol is reported. She re­ sponded well to oral propranolol and intramuscular diazepam. Extrapyramidal symptoms have commonly been associated with acute or chronic administration of neuroleptic drugs. There have been reports of a substantial number of cases with similar clinical characteristics associated with tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors. Al­ though it is known that beta-adrenoceptor antagonists are effective in the treat­ ment of extrapyramidal symptoms, especially akathisia, there has been no previ­ ous report of such symptoms induced by abrupt withdrawal of these drugs. Al­ though she had been on low dose amitriptyline and had discontinued this medica­ tion long before, prolonged use of amitriptyline may have had a predisposing role in the development of these symptoms. MJIRL Vol. 14, No.3, 305-306, 2000. Keywords: Propranolol; Extrapyramidal symptoms; Beta-adrenoceptor antagonists. INTRODUCTION She described a feeling of "being pulled down by gravity." She had never experienced such symptoms before. Thor­ Extrapyramidal symptoms include acute dystonias, ough physical examination with special focus on the ner­ akathisia, Parkinson's syndrome, and tardive dyskinesia. vous system was unremarkable except for the involuntary These symptoms are common manifestations of neurolep­ contraction of jaw muscles and a fine tremor in her ex­ tic drugs.
    [Show full text]
  • Prevalence of Extrapyramidal Side Effects in Patients on Antipsychotics Drugs at a Tertiary Care Center
    f Ps al o ych rn ia u tr o y J Kirgaval et al., J Psychiatry 2017, 20:5 Journal of Psychiatry DOI: 10.4172/2378-5756.1000419 ISSN: 2378-5756 Research Article Open Access Prevalence of Extrapyramidal Side Effects in Patients on Antipsychotics Drugs at a Tertiary Care Center5 Ramprasad Santhanakrishna Kirgaval1*, Srinivas Revanakar2 and Chidanand Srirangapattna2 1Department of Psychiatry, Shimoga Institute of Medical Sciences, Shimoga, Karnataka, India 2Department of Pharmacology, Shimoga Institute of Medical Sciences, Shimoga, Karnataka, India Abstract Background: Antipsychotic drugs are associated with adverse effects that can lead to poor medication adherence, stigma, distress and impaired quality of life. Among the various side effects of anti-psychotics extra pyramidal symptoms constitute one of the important side effects interfering with the compliance of the patients towards medication. Objective: Evaluation of extrapyramidal side effects by AIMS in patients who are on antipsychotics. Results: The extrapyramidal symptoms were more commonly seen in males (62.85%), the age of incidence of maximum in the age group of 34.28, Maximum was seen among the patients on the Risperidone (45.7%), Involvement of the extremities was common (42.85%) and 64.28% of individuals had moderate severity and 54.28% of individuals were aware of the extrapyramidal symptoms which provided mild distress. Conclusion: Extrapyramidal symptoms are one of the commonest side effect of the antipsychotics interfering with compliance of the patients towards adherence to medications, thereby decreasing the efficacy. Keywords: Extrapyramidal symptoms; Compliance; Antipsychotics; positive symptom of the psychosis but have some serious limitations AIMS. such as lack of efficacy against negative symptoms and adverse effects like extrapyramidal symptoms [7].
    [Show full text]
  • Modern Antipsychotic Drugs: a Critical Overview
    Review Synthèse Modern antipsychotic drugs: a critical overview David M. Gardner, Ross J. Baldessarini, Paul Waraich Abstract mine was based primarily on the finding that dopamine ago- nists produced or worsened psychosis and that antagonists CONVENTIONAL ANTIPSYCHOTIC DRUGS, used for a half century to treat were clinically effective against psychotic and manic symp- a range of major psychiatric disorders, are being replaced in clini- 5 toms. Blocking dopamine D2 receptors may be a critical or cal practice by modern “atypical” antipsychotics, including ari- even sufficient neuropharmacologic action of most clinically piprazole, clozapine, olanzapine, quetiapine, risperidone and effective antipsychotic drugs, especially against hallucina- ziprasidone among others. As a class, the newer drugs have been promoted as being broadly clinically superior, but the evidence for tions and delusions, but it is not necessarily the only mecha- this is problematic. In this brief critical overview, we consider the nism for antipsychotic activity. Moreover, this activity, and pharmacology, therapeutic effectiveness, tolerability, adverse ef- subsequent pharmacocentric and circular speculations about fects and costs of individual modern agents versus older antipsy- altered dopaminergic function, have not led to a better un- chotic drugs. Because of typically minor differences between derstanding of the pathophysiology or causes of the several agents in clinical effectiveness and tolerability, and because of still idiopathic psychotic disorders, nor have they provided a growing concerns about potential adverse long-term health conse- non-empirical, theoretical basis for the design or discovery quences of some modern agents, it is reasonable to consider both of improved treatments for psychotic disorders. older and newer drugs for clinical use, and it is important to inform The neuropharmacodynamics of specific modern anti- patients of relative benefits, risks and costs of specific choices.
    [Show full text]
  • At-A-Glance: Psychotropic Drug Information for Children and Adolescents
    At-A-Glance: Psychotropic Drug Information for Children and Adolescents Pediatric Dosage/ Drug Generic FDA Approval Serum Level Name Age/Indication when applicable Warnings and Precautions/Black Box Warnings Combination Antipsychotic/Antidepressant fluoxetine & 18 and older N/A: Pediatric Black Box Warning for fluoxetine/olanzapine olanzapine dosing is currently combination formula (marketed as Symbyax): Usage unavailable or not increased the risk of suicidal thinking and behaviors in applicable for this children and adolescents with major depressive disorder drug. and other psychiatric disorders. Other precautions for fluoxetine/olanzapine combination: Possibly unsafe during lactation. Avoid abrupt withdrawal. Antipsychotic Medications *Precautions which apply to all atypical or second generation antipsychotics (SGA): Neuroleptic Malignant Syndrome/Tardive Dyskinesia/ Hyperglycemia/ Diabetes Mellitus/ Weight Gain/ Akathisia/Dyslipidemia †Precautions which apply to all typical or first generation antipsychotics (FGA): Extrapyramidal symptoms/Tardive Dyskinesia aripiprazole * (SGA) 10 and older for 2-10 mg/kg/day Black Box Warning for aripiprazole: Not approved for bipolar disorder, depression in under age 18. Increased risk of suicidal manic, or mixed thinking and behavior in short-term studies in children episodes; 13 to 17 and adolescents with major depressive disorder and for schizophrenia other psychiatric conditions. and bipolar; 6 to 17 for irritability associated with autistic disorder asenapine* 18 and older N/A Black Box Warning for asenapine: Not approved for dementia-related psychosis. Increased mortality risk for elderly dementia patients due to cardiovascular or infectious events. chlorpromazine† 18 and older 0.25 mg/kg tid Other precautions for chlorpromazine: May alter cardiac (FGA) conduction; sedation; Neuroleptic Malignant Syndrome; weight gain. Use caution with renal disease, seizure disorders, and respiratory disease and in acute illness.
    [Show full text]
  • Venlafaxine-Induced Acute Dystonia
    Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2015;28:374-377 Case Report / Olgu Sunumu DOI: 10.5350/DAJPN2015280410 Venlafaxine-Induced Acute Ipek Sonmez1, Ferdi Kosger2 1Assoc. Prof. Dr., Near East University, Dystonia: a Case Report Faculty of Medicine, Department of Psychiatry, Nicosia - Turkish Republic of Northern Cyprus 2Assist. Prof. Dr., Eskisehir Osmangazi University, Faculty of Medicine, Eskisehir - Turkey ABSTRACT Venlafaxine-induced acute dystonia: a case report Although mechanisms underlying neuroleptic-induced extrapyramidal symptoms have been well researched, extrapyramidal symptoms associated with antidepressants are understudied. Research conducted to date is more concerned with selective serotonin reuptake inhibitors. Recognized risk factors for extrapyramidal symptoms associated with antidepressants are advancing age, female sex, and pharmacokinetic interaction of concurrently used drugs with CYP2D6 inhibition effect. This case is presented to emphasize that the occurrence of extrapyramidal symptoms, which are clinically important side effects requiring intervention, may be related with venlafaxine, a serotonin noradrenaline reuptake inhibitor. Address reprint requests to / Yazışma adresi: Dystonia, extrapyramidal syndrome, venlafaxine Keywords: Assoc. Prof. Dr. Ipek Sonmez Near East University, Faculty of Medicine, ÖZET Department of Psychiatry, Nicosia, Turkish Venlafaksin kullanımına bağlı akut distoni: Olgu sunumu Republic of Northern Cyprus Antipsikotiklere bağlı ekstrapiramidal sendromlar iyi araştırılmış olmasına rağmen, antidepresanlara bağlı Phone / Telefon: +90-392-675-1000 ekstrapiramidal sendromlar yeterince incelenmemiştir. Bugüne kadar yapılan araştırmalar daha çok Seçici E-mail address / Elektronik posta adresi: Serotonin Gerialım İnhibitörleri ile ilgilidir. Antidepresan kullanımına bağlı ekstrapiramidal sendrom gelişimi için [email protected] tanımlanmış risk faktörleri ileri yaş, kadın cinsiyet ve eş zamanlı kullanılan ilaçların CYP2D6 inhibisyonu Date of receipt / Geliş tarihi: etkileşimidir.
    [Show full text]
  • Tardive Dyskinesia
    Task Force Reports This is the eighteenth in a series of reports approved by the Board of Trustees of the American Psychiatric Association to give wider dissemination to the findings of APA's many commissions, committees, and task forces that are called upon to evaluate the state of the art in a problem area of current concern to the profession, to related disciplines, and to the public. The findings, opinions, and conclusions of the report do not necessarily represent the views of the officers, trustees, or all members of the Association. Each report, however, does represent the thoughtful judgment and findings of the task force of experts who composed it. These reports are considered a substantive contribution to the ongoing analysis and evaluation of problems, programs, issues, and practices in a given area of concern. Alan A. Stone, M.D. President, APA, 1979-80 Library of Congress Catalogue No. 80-65372 Copyright 1980 by the American Psychiatric Association 1400 K Street, N.W., Washington, D.C. 20005 Printed in U.S.A. 2nd Printing October, 1983 TARDIVE DYSKINESIA Report of the American Psychiatric Association Task Force on Late Neurological Effects of Antipsychotic Drugs Ross J. Baldessarini, M.D., Chairperson Jonathan O. Cole, M.D. John M. Davis, M.D. George Gardos, M.D., Consultant Sheldon H. Preskorn, M.D., Falk Fellow George M. Simpson, M.D. Daniel Tarsy, M.D., Invited Neurologist Approved for Publication by the Council on Research and Development John M. Davis, M.D., Chairperson Charles Gaitz, M.D. Edward Joel Sachar, M.D. George Winokur, M.D.
    [Show full text]
  • Selective Serotonin Reuptake Inhibitors and Adverse Effects: a Narrative Review
    Review Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review Amber N. Edinoff 1,*, Haseeb A. Akuly 1 , Tony A. Hanna 1, Carolina O. Ochoa 2, Shelby J. Patti 2, Yahya A. Ghaffar 2, Alan D. Kaye 3, Omar Viswanath 4,5,6, Ivan Urits 3,7 , Andrea G. Boyer 8, Elyse M. Cornett 3 and Adam M. Kaye 9 1 Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, Shreveport, LA 71103, USA; [email protected] (H.A.A.); [email protected] (T.A.H.) 2 School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; [email protected] (C.O.O.); [email protected] (S.J.P.); [email protected] (Y.A.G.) 3 Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; [email protected] (A.D.K.); [email protected] (I.U.); [email protected] (E.M.C.) 4 College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; [email protected] 5 Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE 68124, USA 6 Valley Anesthesiology and Pain Consultants—Envision Physician Services, Phoenix, AZ 85004, USA 7 Southcoast Physicians Group Pain Medicine, Southcoast Health, Wareham, MA 02571, USA 8 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29464, USA; [email protected] 9 Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA; [email protected] * Correspondence: [email protected]; Tel.: +1-(318)-675-8969 Citation: Edinoff, A.N.; Akuly, H.A.; Hanna, T.A.; Ochoa, C.O.; Patti, S.J.; Abstract: Depression is the most prevalent psychiatric disorder in the world, affecting 4.4% of the Ghaffar, Y.A.; Kaye, A.D.; Viswanath, global population.
    [Show full text]
  • The Continuing Problem of Extrapyramidal Symptoms: Strategies for Avoidance and Effective Treatment
    Jes Gerlach The Continuing Problem of Extrapyramidal Symptoms: Strategies for Avoidance and Effective Treatment Jes Gerlach, M.D. © CopyrightAntipsychotic agents 2000 remain thePhysicians most effective treatment Postgraduate for both acute and chronic Press, schizophre- Inc. nia. However, conventional antipsychotic agents are frequently associated with significant side effects including, perhaps most notably, extrapyramidal symptoms (EPS). The emergence of EPS can signifi- cantly compromise patient compliance with treatment and can have profound effects on long-term treatment outcomes. Providing effective symptom relief with minimal side effects and without induc- ing EPS is, therefore, a primary goal in the treatment of schizophrenia. Atypical antipsychotic agents are now regarded as first-line therapies for the treatment of schizophrenia because of their lower pro- pensity to induce EPS compared with conventional antipsychotics, and evidence exists that these agents are associated with a lower relapse rate, which perhaps reflects an improvement in patient com- pliance. (J Clin Psychiatry 1999;60[suppl 23]:20–24) ntipsychotic agents remain theOne most personal effective treat-copy may beProviding printed effective symptom relief without inducing Ament for acute and chronic schizophrenia. However, EPS is, therefore, a primary goal in the treatment of the association of the conventional agents with neurologic schizophrenia. The main characteristics of antipsychotic- adverse effects—extrapyramidal symptoms (EPS)—can associated EPS are outlined in this article, followed by limit their usefulness. EPS are abnormalities in the co- a discussion of the place of the atypical antipsychotics ordination and integration of body movements and can (clozapine, risperidone, olanzapine, and quetiapine), with be painful and disfiguring. Clinically, it may be useful to their generally lower propensity to induce EPS, in the divide these symptoms into those which most often appear treatment of schizophrenia.
    [Show full text]
  • 548 Trimipramine for Refractory Panic Attacks
    LETTERS TO THE EDITOR duced because of psychiatric symptoms, such as auditory provides significant rapid antipanic effects with minimal hallucinations and diarrhea. On the 12th day of per- side effects at a low dose. Tricyclic drugs are less widely ospirone treatment, Mr. A suddenly became confused used than selective serotonin reuptake inhibitors (SSRIs) and obtunded with severe muscle rigidity. When he was because tricyclic drugs generally have more severe adverse admitted to a psychiatry department, he had a high fe- effects at the higher doses required for effective treatment ver, tachycardia, and severe extrapyramidal symptoms. Laboratory tests showed an elevation of creatine phos- of panic disorders (2). This is a case report about a man with phokinase (33,878 IU/liter) and leukocyte levels a 20-year history of panic disorders who was unresponsive (30.9×109/liter). A urine analysis showed myoglobinuria. to all agents tried, with the exception of imipramine, which A brain computerized tomography scan showed no re- was discontinued because of side effects. Tripramine at 50 markable change, and the possibility of infectious dis- mg/day induced remission of the panic attacks without ad- ease was excluded. verse effects. Mr. A had a fulminant neuroleptic malignant syndrome complicated with rhabdomyolysis and acute renal failure. Mr. A, a 41-year-old white man, had suffered from On the third day of admission, he was transferred to an in- panic attacks since age 21. According to Mr. A, the medi- tensive care unit. He received dantrolene treatment and cations tried to no avail (either were ineffective or were hemodialysis.
    [Show full text]
  • Protriptyline Hcl Tablets, USP
    PROTRIPTYLINE HYDROCHLORIDE- protriptyline hydrochloride tablet, film coated Sigmapharm Laboratories, LLC ---------- Protriptyline HCl Tablets, USP Suicidality and Antidepressant Drugs Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of protriptyline hydrochloride or any other antidepressant in a child, adolescent, or young adult must balance this risk with the clinical need. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 and older. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Protriptyline hydrochloride is not approved for use in pediatric patients. (See Warnings: Clinical Worsening and Suicide Risk, PRECAUTIONS: Information for Patients, and Precautions: Pediatric Use) DESCRIPTION Protriptyline HCl is N-methyl-5H dibenzo [a,d]-cycloheptene-5-propanamine hydrochloride. Its molecular formula is C 19H 21N•HCl and its structural formula is: Protriptyline HCl, dibenzocycloheptene derivative, has a molecular weight of 299.84. It is a white to yellowish powder that is freely soluble in water and soluble in dilute HCl. Protriptyline HCl is supplied as 5 mg or 10 mg film-coated tablets.
    [Show full text]
  • ANTIPSYCHOTICS in General Practice
    Prescribing ATYPICAL ANTIPSYCHOTICS in general practice 14 | BPJ | Issue 40 Prescribing of atypical antipsychotics is increasing Key concepts Antipsychotic medicines are classified as “typical” or ■ Use of atypical antipsychotics, such as “atypical”. Typical antipsychotics, also known as traditional quetiapine and olanzapine, is increasing and or first-generation antipsychotics, include haloperidol and in many cases, they are being prescribed chlorpromazine. Atypical antipsychotics, also known as “off-label” – this is a worrying trend due to their second generation antipsychotics, include quetiapine, potential to cause harm risperidone and olanzapine. Both types of antipsychotics ■ Atypical antipsychotics should only be used act in a similar way by blocking receptors in the dopamine for specific indications and used with caution, pathway, but atypical antipsychotics are less likely to especially in elderly people and young adults cause the extrapyramidal adverse effects associated ■ Atypical antipsychotics are indicated for with the older typical antipsychotics. However, atypical the treatment of schizophrenia and related antipsychotics, along with typical antipsychotics, are disorders and in some circumstances to treat associated with serious adverse effects, such as diabetes the behavioural and psychological symptoms 1 mellitus, stroke and cardiac death. associated with dementia (risperidone only) ■ Antipsychotics are not a first-line treatment for Antipsychotics are indicated for the treatment of anxiety and are not recommended for post- schizophrenia and related disorders and in some traumatic stress disorder or insomnia circumstances to treat the behavioural and psychological symptoms associated with dementia (risperidone only). International experience shows that antipsychotics are being increasingly used for off-label conditions (e.g. anxiety, insomnia).2, 3 The use of atypical antipsychotics has been increasing in New Zealand (Figure 1) and it is likely that off-label use is a factor in this increase.
    [Show full text]
  • Dystonia”[Mesh] OR Dystonia[Tiab] OR “Torticollis”[Mesh] OR Torticollis[Tiab]
    eAppendix 1: Search Strategy The PubMed search strategy employed the following terms (yielded 910 hits on 3/28/17): (“Dystonia”[Mesh] OR dystonia[tiab] OR “Torticollis”[Mesh] OR torticollis[tiab] OR wryneck[tiab] OR "Psychomotor Agitation"[Mesh] OR “psychomotor agitation”[tiab] OR restlessness[tiab] OR akathisia[tiab] OR "Akathisia, Drug-Induced"[Mesh] OR “drug-induced akathisia”[tiab] OR “tardive akathisia”[tiab] OR “Hypokinesia”[Mesh] OR hypokinesia[tiab] OR hypodynamia[tiab] OR bradykinesia[tiab] OR “Tardive Dyskinesia”[Mesh] OR “tardive dyskinesia”[tiab] OR "Drug-Related Side Effects and Adverse Reactions"[Mesh] OR “adverse drug event”[tiab] OR “adverse drug reaction”[tiab] OR “drug side effect”[tiab] OR "Treatment Outcome"[Mesh] OR “treatment outcome”[tiab]) AND ("Diphenhydramine"[Mesh] OR Diphenhydramine[tiab] OR "Histamine H1 Antagonists"[Mesh] OR “Histamine H1 Antagonists”[tiab] OR "Histamine H1 Antagonists" [Pharmacological Action] OR "Benztropine"[Mesh] OR benztropine[tiab]) AND ("Dopamine D2 Receptor Antagonists"[Mesh] OR “dopamine D2 antagonists”[tiab] OR "Dopamine D2 Receptor Antagonists" [Pharmacological Action] OR "Antiemetics"[Mesh] OR antiemetics[tiab] OR "Antiemetics" [Pharmacological Action] OR "Metoclopramide"[Mesh] OR metoclopramide[tiab] OR "Prochlorperazine"[Mesh] OR prochlorperazine[tiab] OR “Chlorpromazine” [MeSH] OR chlorpromazine[tiab] OR "Cholinergic Antagonists"[Mesh] OR “cholinergic antagonists”[tiab] OR "Cholinergic Antagonists" [Pharmacological Action] OR "Droperidol"[Mesh] OR droperidol[tiab]) The Cochrane search strategy employed the following terms (yielded 143 hits on 3/24/17): 1. (search terms 1 to 7): Dystonia, hypokinesia, extrapyramidal rigidity, psychomotor agitation, movement disorders, Drug-Related Side Effects and Adverse Reactions, treatment outcome 2. (search terms 8 to 10) Diphenhydramine, Histamine H1 Antagonists, Benztropine 3. (search terms 11 to 17) Dopamine D2 Receptor Antagonists, Antiemetics, Metoclopramide, Prochlorperazine, Chlorpromazine, Cholinergic Antagonists, Droperidol 4.
    [Show full text]