EXTRAPYRAMIDAL SIDE EFFECTS
Raj Mohan has recently been on an increased regime of anti-psychotics for Schizophrenia. The following complications are associated with combined use of more than one anti-psychotic, EXCEPT:
| A |
Neuroleptic Malignant Syndrome |
|
| B |
Renal Tubular Necrosis |
|
| C |
Paralytic illeus |
|
| D |
QTc Prolongation in ECG |
Raj Mohan has recently been on an increased regime of anti-psychotics for Schizophrenia. The following complications are associated with combined use of more than one anti-psychotic, EXCEPT:
| A |
Neuroleptic Malignant Syndrome |
|
| B |
Renal Tubular Necrosis |
|
| C |
Paralytic illeus |
|
| D |
QTc Prolongation in ECG |
Neuroleptic Malignant Syndrome, Paralytic illeus, QTc Prolongation in ECG, Seizures (GTC) and Sudden death from Arrythmias are recognised complications of polydrug therapy in psychosis.
Most of the side effects are a result of cumulative side effects of individual drugs. Renal toxicity is not a common side effect of antipsychotics and hence the option can be eliminated.
Ref: Maudley prescribing guidelines, 10th Edition
A 26-year-old man with schizophrenia and tardive dyskinesia. Which is the most appropriate pharmacotherapeutic agent?
| A |
Clozapine |
|
| B |
Valproic acid |
|
| C |
Haloperidol |
|
| D |
Paroxetine |
A 26-year-old man with schizophrenia and tardive dyskinesia. Which is the most appropriate pharmacotherapeutic agent?
| A |
Clozapine |
|
| B |
Valproic acid |
|
| C |
Haloperidol |
|
| D |
Paroxetine |
Valproic acid is an anticonvulsant used as a mood stabilizer. It is found useful in the treatment of mania in a bipolar disorder.
It has also been valuable in the treatment of rapid cycling bipolar patients.
Paroxetine is an example of a selective serotonin reuptake inhibitor (SSRI), which is a newer form of antidepressant.
The SSRis are being found to be as effective as the tricyclic antidepressants.
Haloperidol is an example of a neuroleptic or antipsychotic medication useful in the management of acute psychosis, as well as long-term care. Clozapine is a newer atypical antipsychotic medication.
It is not associated with tardive dyskinesia as are the older neuroleptics.
This makes it a drug of choice for individuals who have developed signs of tardive dyskinesia after using other neuroleptics.
Problems with agranulocytosis prevent clozapine from being used as a “first line” neuroleptic.
Ref: Meltzer H.Y., Bobo W.V., Heckers S.H., Fatemi H.S. (2008). Chapter 16. Schizophrenia. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds),CURRENT Diagnosis & Treatment: Psychiatry, 2e.
Adverse effect of clozapine:
| A |
Hypertension |
|
| B |
Sialorrhea |
|
| C |
Extrapyramidal S/E |
|
| D |
Neuroleptic malignant syndrome |
Adverse effect of clozapine:
| A |
Hypertension |
|
| B |
Sialorrhea |
|
| C |
Extrapyramidal S/E |
|
| D |
Neuroleptic malignant syndrome |
B i.e. Sialorrhea
A patient with acute psychosis, who is on haloperidol 20mg/day for last 2 days, has an episode characterized by tongue protrusion, oculogyric crisis, stiffness and abnormal posture of limbs and trunk without loss of consciousness for last 20 minutes before presenting to casualty. This improved within a few minutes after administration of diphenhydramine HC1. The most likely diagnosis is:
| A |
Acute dystonia |
|
| B |
Akathisia |
|
| C |
Tardive dyskinesia |
|
| D |
Neuroleptic malignant syndrome |
A patient with acute psychosis, who is on haloperidol 20mg/day for last 2 days, has an episode characterized by tongue protrusion, oculogyric crisis, stiffness and abnormal posture of limbs and trunk without loss of consciousness for last 20 minutes before presenting to casualty. This improved within a few minutes after administration of diphenhydramine HC1. The most likely diagnosis is:
| A |
Acute dystonia |
|
| B |
Akathisia |
|
| C |
Tardive dyskinesia |
|
| D |
Neuroleptic malignant syndrome |
A i.e. Acute dystonia
A 30-year-old man who was recently started on haloperidol 30mg/day developed hyperpyrexia, muscle rigidity, akinesia, mutism, sweating, tachycardia and increased blood pressure. The investigations showed increased VVBC count, increased creatinine phosphokinase. There is no history of any other drug intake or any signs of infection. The most likely diagnosis is:
| A |
Drug overdose |
|
| B |
Neuroleptic malignant syndrome |
|
| C |
Drug induce Parkinsonism |
|
| D |
Tardive dyskinesia |
A 30-year-old man who was recently started on haloperidol 30mg/day developed hyperpyrexia, muscle rigidity, akinesia, mutism, sweating, tachycardia and increased blood pressure. The investigations showed increased VVBC count, increased creatinine phosphokinase. There is no history of any other drug intake or any signs of infection. The most likely diagnosis is:
| A |
Drug overdose |
|
| B |
Neuroleptic malignant syndrome |
|
| C |
Drug induce Parkinsonism |
|
| D |
Tardive dyskinesia |
B i.e. Neuroleptic malignant syndrome
A 31 year old male, with mood disorder, on 30 mg of haloperidol and 100 mg of lithium, is brought to the hospital emergency room with history of acute onset of fever, excessive sweating, confusion, rigidity of limbs and decreased communication for a day. Examination reveals tachycardia and labile blood pressure and investigations reveal increased CPK enzyme levels and lecocytosis. He is likely to have developed.
| A |
Lithium toxicity |
|
| B |
Tardive dyskinesia |
|
| C |
Neuroleptic malignant syndrome |
|
| D |
Hypertensive encephalopathy |
A 31 year old male, with mood disorder, on 30 mg of haloperidol and 100 mg of lithium, is brought to the hospital emergency room with history of acute onset of fever, excessive sweating, confusion, rigidity of limbs and decreased communication for a day. Examination reveals tachycardia and labile blood pressure and investigations reveal increased CPK enzyme levels and lecocytosis. He is likely to have developed.
| A |
Lithium toxicity |
|
| B |
Tardive dyskinesia |
|
| C |
Neuroleptic malignant syndrome |
|
| D |
Hypertensive encephalopathy |
C i.e. Neuroleptic malignant syndrome
Extrapyramidal side-effect least seen with ‑
| A |
Clozapine |
|
| B |
Haloperidol |
|
| C |
Thioridazine |
|
| D |
Fluphenozine |
Extrapyramidal side-effect least seen with ‑
| A |
Clozapine |
|
| B |
Haloperidol |
|
| C |
Thioridazine |
|
| D |
Fluphenozine |
Ans. is ‘a’ i.e., Clozapine
o Antipsychotics with no extrapyramidal effects.
1. Clozapine 2. Aripiprazole 3. Quetiapine
o Amongst typical antipsychotics, thioridazone has least extrapyramidal effects.
Which drug is the most useful in treating an episode of antipsychotic induced acute dystonia ‑
| A |
Lorazepam |
|
| B |
Haloperidol |
|
| C |
Promethazine |
|
| D |
Phenobarbitone |
Which drug is the most useful in treating an episode of antipsychotic induced acute dystonia ‑
| A |
Lorazepam |
|
| B |
Haloperidol |
|
| C |
Promethazine |
|
| D |
Phenobarbitone |
Ans. is ‘c’ i.e., Promethazine
o Antihistaminics have central anticholinergic property (e.g. promethazine) and central anticholinergic is the drug of choice for acute dystonia.
A female suffering from psychosis, taking phenothiazines now complains of sudden onset of high grade fever, muscle rigidity and altered sensorium. The diagnosis is –
| A |
Malignant hyperthermia |
|
| B |
Neuroleptic malignant syndrome |
|
| C |
Tardive dyskinesia |
|
| D |
Akathesia |
A female suffering from psychosis, taking phenothiazines now complains of sudden onset of high grade fever, muscle rigidity and altered sensorium. The diagnosis is –
| A |
Malignant hyperthermia |
|
| B |
Neuroleptic malignant syndrome |
|
| C |
Tardive dyskinesia |
|
| D |
Akathesia |
Ans. is ‘b’ i.e., Neuroleptic malignant syndrome
o History of intake of antipsychotic drugs and high grade fever, muscle rigidity, altered sensorium suggests Neuroleptic Malignant Syndrome.
A 40 year old adult man on medication for psychiatric illness for the last 2 weeks, suddenly develops marked rigidity, immobility, fever, fluetuating BP and heart rate. Most likely diagnosis ‑
| A |
Akathisia |
|
| B |
Parkinsonism |
|
| C |
Malignant neuroleptic syndrome |
|
| D |
Catatonic schizophrenia |
A 40 year old adult man on medication for psychiatric illness for the last 2 weeks, suddenly develops marked rigidity, immobility, fever, fluetuating BP and heart rate. Most likely diagnosis ‑
| A |
Akathisia |
|
| B |
Parkinsonism |
|
| C |
Malignant neuroleptic syndrome |
|
| D |
Catatonic schizophrenia |
Ans. is ‘c’ i.e., Malignant neuroleptic syndrome
Hyperthermia is seen in :
| A |
Malignant neuroleptic syndrome |
|
| B |
Cannabis poisoning |
|
| C |
Opium intoxication |
|
| D |
Hypothyroidism |
Hyperthermia is seen in :
| A |
Malignant neuroleptic syndrome |
|
| B |
Cannabis poisoning |
|
| C |
Opium intoxication |
|
| D |
Hypothyroidism |
Answer is A (Malignant neuroleptic syndrome) :
‘Malignant Neuroleptic Syndrome is an important cause of Hyperthermia Syndromes’ – Harrisons
Causes of Hyperthermia
- Heat Stroke
- Exertional : Exercise in higher-than-normal heat and/or humidity
- Nonexertional : Anticholinergics, including antihistamines; antiparkinsonian drugs; diuretics; phenothiazines
- Drug Induced Hyperthermia
- Amphetamines, cocaine, phencyclidine (PCP), methylendioxymethamphetamine (MDMA; “ectasy”), lysergic acid diethylamide(LSD), salicylates, lithium, anticholinergics, sympathomimetics
- Neuroleptic Malignant Syndrome
- Phenothiazines, butyrophenones, including haloperidol and bromoperidol; fluoxetine; loxapine; tricyclic dibenzodiazepines; metoclopramide; domperidone; thiothixene; molindone; withdrawal of dopaminergic agents
- Serotonin Syndrome
- Selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), trycyclic antidepressants
- Malignant Hyperthermia
- Inhalational anesthetics, succinylcholine
- Endocraniopathy
- Thyrotoxocosis, pheochromocytoma
- Central Nervous System Damage—
- Cerebral hemorrhage, status epilepticus, hypothalamic injury
Antidepressant drug that can cause neuroleptic malignant syndrome and tardive dyskinesia is:
March 2009
| A |
Amineptin |
|
| B |
Carbamazepine |
|
| C |
Amoxapine |
|
| D |
Trazodone |
Antidepressant drug that can cause neuroleptic malignant syndrome and tardive dyskinesia is:
March 2009
| A |
Amineptin |
|
| B |
Carbamazepine |
|
| C |
Amoxapine |
|
| D |
Trazodone |
Ans. C: Amoxapine
One of major metabolites of amoxapine, 7-hydroxyamoxapine, has a dopamine receptor blocking effect, making this drug a common cause of neuroleptic malignant syndrome.
Amoxapine is also associated with acute extrapyramidal symptoms and tardive dyskinesia.
Amongst the following, extrapyramidal side effect is commonest with which drug :
September 2006
| A |
Thioradizine |
|
| B |
haloperidol |
|
| C |
Clozapine |
|
| D |
Ziprasidone |
Amongst the following, extrapyramidal side effect is commonest with which drug :
September 2006
| A |
Thioradizine |
|
| B |
haloperidol |
|
| C |
Clozapine |
|
| D |
Ziprasidone |
Ans. B: Haloperidol
Extrapyramidal disturbances are the major dose limiting side effects of neuroleptics; more prominent with high potency drugs like fluphenazine, haloperidol, pimozide etc., least with thioridazine, clozapine, and all other atypical antipsychotics, except high doses of risperidone.
Which of the following extrapyramidal effect is seen on chronic use of antipsychotic ‑
| A |
Dystonia |
|
| B |
Akathisia |
|
| C |
Tardive dyskinesia |
|
| D |
Parkinsonism |
Which of the following extrapyramidal effect is seen on chronic use of antipsychotic ‑
| A |
Dystonia |
|
| B |
Akathisia |
|
| C |
Tardive dyskinesia |
|
| D |
Parkinsonism |
Ans. is `c’ i.e., Tardive dyskinesia
Antidepressant causing Tardive dyskinesia is ‑
| A |
MAO inhibitors |
|
| B |
Mianserin |
|
| C |
Imipramine |
|
| D |
Amoxapine |
Antidepressant causing Tardive dyskinesia is ‑
| A |
MAO inhibitors |
|
| B |
Mianserin |
|
| C |
Imipramine |
|
| D |
Amoxapine |
Ans. is ‘d’ i.e., Amoxapine
- Amoxapine is the only antidepressant which blocks D2 receptors along with inhibition of NA reuptake → has mixed antidepressant + neurolepic property.
- Due to blockade of D, receptors it causes extrapyramidal side effects -4 Parkinsonism, Tardive dyskinesia, Akathesia, neuropeptic malignant syndrome.
Drug effective in Tardive dyskinesia
| A |
Central anticholinergic |
|
| B |
Dantroline |
|
| C |
Succinylcholine |
|
| D |
Terabenazine |
Drug effective in Tardive dyskinesia
| A |
Central anticholinergic |
|
| B |
Dantroline |
|
| C |
Succinylcholine |
|
| D |
Terabenazine |
Ans. is ‘d’ i.e., Tetrabenazine
[Ref: Clinical Pharmacology Ip. 108; www.ncb.nlm.nih.gov)
- There is currently no satisfactory treatment for tardive dyskinesia other than discontinuation of drug.
- Tetrabenazine (TBZ) is currently considered as a first line and most effective medication for treatment of persistent and disabling tardive dyskinesia.
- Reserpine is an alternative to tetrabenazine.
