Amisulpride Implicated in the Onset of Tardive Dyskinesia in a Man Who Previously Took Sulpiride Yu-Hsiang Lin, M.D

T.S.M.H Medical Nursing Journal Amisulpride implicated previously took sulpiride

Amisulpride implicated in the onset of tardive dyskinesia in a man who previously took sulpiride Yu-Hsiang Lin, M.D. 1 Kuanyi Tsai, M.D., M.S. 2,3 Frank Huang-chih Chou, M.D., M.S., Ph. D. 2,3 Department of Adult Psychiatry, Kai-Suan Psychiatric Hospital1; Department of Community Psychiatry, Kai-Suan Psychiatric Hospital2; Department of Nursing, Meiho Institute of Technology3 Both amisulpride and sulpiride are less associated with acute extrapyramidal symptoms. However, we report the case of a 52 year-old man with schizophrenia who received amisulpride due to the recurrence of acute psychotic symptoms. Despite improvement over positive symptoms, tardive dyskinesia developed soon after using amisulpride. The involuntary movements were slightly improved after amisulpride was cross-tapered to risperidone. Although lower risk of extrapyramidal symptoms is associated with amisulpride, there is still some risk of developing tardive dyskinesia.

Key words: Amisulpride, tardive dyskinesia, schizophrenia

Amisulpride is a highly selective

Introduction dopamine D2/D3 receptor antagonist. A meta-analysis of randomized controlled Tardive dyskinesia is characterized by trials showed that amisulpride was involuntary and irregular choreoathetoid significantly superior to typical movements. Traditionally, tardive antipsychotics in acute extrapyramidal dyskinesia was more often seen after typical effects (Leucht, Pitschel-Walz, Engel, & antipsychotic treatment. Atypical Kissling, 2002). Nevertheless, cases of antipsychotics are less commonly associated developing tardive dyskinesia after with inducing tardive dyskinesia. It has been receiving amisulpride as well as other reported that tardive dyskinesia disappears atypical antipsychotics have been reported after atypical antipsychotics treatment (Fountoulakis et al., 2006, Masdrakis et al., (Peritogiannis, Tsouli, Zafiris, Pappas, & 2007). Here, we present a case that Mavreas, 2006). However, some patients developed tardive dyskinesia soon after developed tardive dyskinesia after receiving receiving amisulpride. atypical antipsychotics.

Received: Mar, 13, 2009 Accepted: Apr, 27, 2009 Address correspondence and reprint requests to: Dr. Frank Huang-chih Chou Department of Community Psychiatry, Kai-Suan Psychiatric Hospital E-mail：[email protected] = 2009 Vol. 15 No. 2 135 T.S.M.H Medical Nursing Journal Amisulpride implicated previously took sulpiride

discharged with sulpiride 400mg daily. Case report In the following three years, he had fairly regular follow up at our hospital and This is the case of a 52 year-old found a part-time job as a security guard in unmarried man suffering from a parking lot. No obvious acute schizophrenia, and paranoia. He was raised extrapyramidal symptoms were noted when in a working-class family. He had a head receiving sulpiride. injury with concussion at the age of five. Nevertheless, despite regular Besides being isolated and introverted, he medication, he began to experience had frequent conflicts with his family in his delusions of persecution again with the teenage years. He graduated from a junior approaching presidential election in March high school in Taiwan. He began to drink 2008. He could sense that someone would about 2 beers per day at the age of 20. He assassinate him again. Hearing voices never married and lived on part-time jobs shouting at him, he could no longer do his and family support. job and felt horrible. He skipped the At the age of 48 (in 2004), he started medicine for several days and was brought to have delusions of persecution. At that to our hospital by his family. This was his time, someone attempted to assassinate second admission. The psychiatric President Chen (also the presidential symptoms were almost the same as candidate) in Taiwan. It was the first time diagnosed during his first admission. that he began to have the sense that Derogatory auditory hallucinations and someone wanted to kill him. He heard persecution delusions were noted. He said voices telling that killers were chasing him. everybody thought he was insane, but he He thought those men who had the opposite insisted that all these things were real. He political position would hurt him. With denied using any alcohol or illicit drugs in symptoms of poor sleep, wandering around, the past 3 years. Meanwhile, he agreed to self-talking and poor appetite for several join our amisulpride research and began to weeks, his mother brought him to the take amisulpride 400mg daily three days hospital, his first psychiatric admission. later. In the admission routine, the white Paranoid schizophrenia was diagnosed count and electrolyte were within normal according to the text revision of the 4th range. His aspartate aminotransferase and edition of Diagnostic and Statistical Manual alanine aminotransferase were 36 and 41 of Mental Disorders (DSM-IV-TR). After U/L, respectively. At first, the auditory treatment for a month, he was free from the hallucination rapidly improved. His positive delusion of being hunted. Then, he seldom symptoms responded well to amisulpride. had auditory hallucinations and less feeling He did not feel any kind of threat from the of being persecuted by others. He was environment just a few days after receiving

2009 Vol. 15 No. 2 136 T.S.M.H Medical Nursing Journal Amisulpride implicated previously took sulpiride amisulpride. He stopped saying someone been implicated in treating tardive would kill him and felt much ease at the dyskinesia (Truol, Von Hippel, Raape, & ward. Konig, 2002). Improvement of tardive Nevertheless, when his psychiatric dyskinesia following amisulpride treatment symptoms were improving, we noticed the was also reported (Peritogiannis et al., 2006). development of a slight involuntary A 48-week prospective study showed movements over his jaw. Three days later, risperidone might be beneficial for the involuntary chewing movement was pre-existing tardive dyskinesia (Bai et al., more obvious. Moreover, we found him 2005). Nevertheless, atypical antipsychotics standing with mild tilting backwards. No may develop tardive dyskinesia in some other localized tremors were found. Tardive cases. Although the real mechanism is still dyskinesia was impressed first and the unknown, it is believed that individual amisulpride dosage was tapered to 200mg atypical antipsychotic may vary in their daily but there was little impact. Oral propensity to cause tardive dyskinesia, involuntary movement was still obvious. which may be partly due to differences in

Therefore, we had no choice but to dopamine D2 receptor affinity (Bressan, discontinue amisulpride and began Jones, & Pilowsky, 2004). risperidone treatment 2mg daily. With the Amisulpride, an atypical antipsychotic, beginning of risperidone 2mg daily, the has selective actions at dopamine D2/D3 involuntary movements were not receptors. Recently, a meta-analysis of progressing. He was discharged as a result randomized controlled trials showed that of his improvement in positive psychiatric amisulpride was significantly superior to symptoms and tardive dyskinesia. One week typical antipsychotics in extrapyramidal side after discharge, he came back to our service. effects when amisulpride was given in low His oral involuntary movements, though, doses, 50-300 mg daily (Leucht et al., 2002). still persisted but did improve gradually. The annualized amisulpride-induced tardive Presently, he is keeping risperidone 2mg dyskinesia rate was 1.5% in a long-term daily for his psychiatric symptoms, although treatment of schizophrenia study (Rein & the improvement in tardive dyskinesia is L'Héritier, 1999). However, despite the limited. reduced extrapyramidal symptoms with amisulpride, two cases of Discussion amisulpride-induced tardive dyskinesia were reported in 2006 (Fountoulakis et al., Atypical antipsychotics were 2006) and 2007 (Masdrakis et al., 2007), considered to be less involved in tardive respectively. Here, we reported the case of a dyskinesia (Correll, Leucht, & Kane, 2004). 52 year-old male who developed tardive Moreover, secondary antipsychotics have dyskinesia, oral involuntary movement,

2009 Vol. 15 No. 2 137 T.S.M.H Medical Nursing Journal Amisulpride implicated previously took sulpiride after receiving amisulpride for several days. However, tardive dyskinesia and The most notable event is the development involuntary oral chewing movements of tardive dyskinesia soon after receiving occurred one week after amisulpride amisulpride in our case. Usually, it takes a treatment. long time to develop tardive dyskinesia after Since sulpiride and amisulpride are receiving antipsychotics. Therefore, we both pharmacologically less related to the wondered what triggered the tardive development of tardive dyskinesia, even in dyskinesia in our case. Was it simply due to some cases showing benefits over tardive using amisulpride? Was there a possibility dyskinesia, it is still likely to, in some way, of sulpiride-induced tardive dyskinesia after induce tardive dyskinesia in our case. It is discontinuing sulpiride? There may be a not easy to distinguish which medication third possibility that the fast onset of contributed to tardive dyskinesia in this amisulpride-induced tardive dyskinesia after patient. Although the patient took sulpiride long-term sulpiride treatment could be due for much longer and tardive dyskinesia to the similar pharmacologic structure. usually occurred long after antipsychotics Both sulpiride and amisulpride belong treatment, the patient developed tardive to the benzamide series. Sulpiride is a dyskinesia during amisulpride treatment. selective antagonist of dopamine D2 However, whether the same benzamide receptors. It does not block the dopamine series antipsychotics affect the development D1 receptors, except in high concentrations. of tardive dyskinesia remains unclear. Few Therefore, the selective action may do well cases show fast onset of tardive dyskinesia for tardive dyskinesia. Moreover, some after antipsyhoctics treatment. It occurs to cases even showed the disappearance of us that amisulpride which contributes to tardive dyskinesia after three months and, in tardive dyskinesia soon after several days some cases, the movements did not reappear using may be related to the previous after discontinuing sulpiride (Gerlach & medication, sulpiride, also a benzamide Casey, 1984). derivative. There may be some complex In our case, the patient took sulpiride mechanisms contributing to tardive for three and half years without developing dyskinesia. We need more evidence and any obvious extrapyramidal symptoms. better technology to determine the However, he had intermitted drugs 2 weeks underlying pathology. before this admission. (Unclear) After admission, we tried amisulpride to better Conclusion control his positive symptoms. Indeed, the With the prevalence of atypical delusion of persecution and auditory antipsychotics treatment, we should still hallucination improved several days after bear in mind the risk of tardive dyskinesia, amisulpride 400mg treatment (daily).

2009 Vol. 15 No. 2 138 T.S.M.H Medical Nursing Journal Amisulpride implicated previously took sulpiride though some studies show improvements of Amisulpride-induced tardive tardive dyskinesia by atypical antipsychotics dyskinesia. Schizophrenia research, 88(1-3), 232-234. treatment. Amisulpride is not an exception. 5. Gerlach, J., & Casey, D. E. (1984). The earlier we notice the involuntary Sulpiride in tardive dyskinesia. Acta movements due to tardive dyskinesia, the psychiatrica Scandinavica better we can switch to other atypical Supplementum, 311, 93-102. 6. Leucht, S., Pitschel-Walz, G., Engel, R. antipsychotic therapy. Moreover, studies on R., & Kissling, W. (2002). the risk of tardive dyskinesia with secondary Amisulpride, an unusual "atypical" generation antipsychotics are limited. antipsychotic: a meta-analysis of Long-term study is needed to determine the randomized controlled trials. The American journal of psychiatry, 159(2), risk of tardive dyskinesia in patients treated 180-190. with secondary generation antipsychotics. 7. Masdrakis, V. G., Papadimitriou, G. N., Papageorgiou, C., Kouzoupis, A., References Giailoglou, D., & Soldatos, C. R. (2007). Development of tardive 1. Bai, Y. M., Yu, S. C., Chen, J. Y., Lin, dyskinesia in a patient taking C. Y., Chou, P., & Lin, C. C. (2005). amisulpride. Progress in Risperidone for pre-existing severe neuro-psychopharmacology & tardive dyskinesia: a 48-week biological psychiatry, 31(2), 586-587. prospective follow-up study. 8. Peritogiannis, V., Tsouli, S., Zafiris, S., International clinical Pappas, D., & Mavreas, V. (2006). psychopharmacology, 20(2), 79-85. Improvement of tardive dyskinesia 2. Bressan, R. A., Jones, H. M., & following amisulpride treatment. Pilowsky, L. S. (2004). Atypical Progress in antipsychotic drugs and tardive neuro-psychopharmacology & dyskinesia: relevance of D2 receptor biological psychiatry, 30(4), 748-750. affinity. Journal of 9. Rein, W., & L'Héritier, C. (1999). psychopharmacology, 18(1), 124-127. Treatment-emergent tardive dyskinesia 3. Correll, C. U., Leucht, S., & Kane, J. in the long-term treatment of M. (2004). Lower risk for tardive schizophrenia: A comparison of dyskinesia associated with amisulpride and haloperidol. European second-generation antipsychotics: a Neuropsychopharmacology, systematic review of 1-year studies. 9(Supplement 5), 282. The American journal of psychiatry, 10. Truol, S., Von Hippel, C., Raape, J., & 161(3), 414-425. Konig, F. (2002). Improvement of 4. Fountoulakis, K. N., Panagiotidis, P., tardive dyskinesia after treatment with Siamouli, M., Kantartzis, S., Mavridis, olanzapine. Psychiatrische Praxis, T., Iacovides, A., et al. (2006). 29(6), 315-7.

2009 Vol. 15 No. 2 139 T.S.M.H Medical Nursing Journal Amisulpride implicated previously took sulpiride

Amisulpride 導至一位之前服用 sulpride 的男性產生遲發性運動不能

林裕翔1 蔡冠逸2,3 周煌智1,3 高雄市立凱旋醫院成人精神科1、高雄市立凱旋醫院社區精神科2 美和技術學院護理系3

Amisulpride 及 sulpiride 是比較不會引起急性錐體外症狀的藥物，然而我們報告一個 52 歲的男性妄想型精神分裂病人，他因為反覆的急性精神症狀發作而接受 amisulpride，雖然活性症狀的改善，但遲發性運動不能在接受該藥後不久就發生。不自主運動在改成 risperdone 後有些微改善，因此，雖然 amisulpride 是比較不會產生椎體外症狀，它依然有可能產生遲發性運動不能的危險性存在。

關鍵詞：: Amisulpride、遲發性運動不能、精神分裂病

收文日期：98 年 3 月 13 接受日期：98 年 4 月 27 通訊作者：周煌智醫師高雄市凱旋二路 130 號高雄市立凱旋醫院成人精神科

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