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