Acute dystonia

Injectable dosage form can be given intramuscularly for relief of acute dystonia. 

Van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ 1999 319(7210) 623-626. 

Acute dystonias occur immediately after neuroleptization and are manifested by motor impairments, particularly in the head, neck, and shoulder region. After several days to months, a parkinsonian syndrome (pseudoparkinsonism) or akathisia (motor restlessness) may develop. All these disturbances can be treated by administration of antiparkin-son drugs of the anticholinergic type, such as biperiden (i.e., in acute dystonia). As a rule, these disturbances disappear after withdrawal of neuroleptic medication. Tardive dyskinesia may become evident after chronic neuroleptization for several years, particularly when the drug is discontinued. It is due to hypersensitivity of the dopamine receptor system and can be exacerbated by administration of anticholinergics. 

Two extrapyramidal conditions, acute dystonia and akathisia, occur early during treatment, while parkinsonism tends to evolve gradually over days to weeks. All three reactions occur most commonly with the high-potency antipsychotics (Table 34.1) and are related to high Dz-receptor occupancy. Acute dystonia, which occurs in about 5% of patients on antipsychotic therapy, consists of uncontrollable movements and distortions of the face, head, and neck. It can be treated with centrally acting an-timuscarinic agents, such as benztropine, while antipsychotic therapy is temporarily discontinued. When this reaction subsides, the anticholinergic can be withdrawn. 

Extrapyramidal symptoms appear to be dose-related and typically occur in the first few days of therapy. Marked drowsiness and lethargy, excessive salivation, and fixed stare occur frequently Less common reactions include severe akathisia (motor restlessness) and acute dystonias (such as torticollis, opisthotonos, and oculogyric crisis). 

Acute dystonias are typically seen in the first few days to weeks of treatment and can occur with even limited exposure (e.g., children treated with a single dose of prochlorperazine for nausea). Although dystonias may disappear spontaneously, they should be treated aggressively, as they are often painful and upsetting to the patient. Rarely, laryngeal dystonias may seriously compromise respiration. Occasionally, an acute dystonic reaction is resistant to standard treatment but may respond to parenteral diazepam, caffeine sodium benzoate, or barbiturate-induced sleep. 

Gagrat D, Hamilton J, Belmaker RH. Intravenous diazepam in the treatment of neuroleptic-induced acute dystonia and akathisia. Am J Psychiatry 1978 135 1232-1233. 

As in adults, the main acute untoward effects of high-potency, typical antipsychotics are extrapyramidal symptoms (EPS) syndromes, particularly acute dystonia, and sedation (167). Parkinsonism is rare in preschool-aged children but does occur in school-aged children and adolescents. 

Adolescent boys may be more vulnerable to acute dystonia than adults. Although these adverse effects can be treated with anticholinergic agents, dose reduction should also be considered. For acute dystonia, diphenhydramine (25 to 50 mg) may be given orally or intramuscularly, as can equivalent doses of benztropine (1 to 2 mg/day). Diphenhydramine has both sedative and anticholinergic properties, with the former being helpful in calming the patient whereas the latter reverses the reaction itself. 

These alkaloids contain pyrrole or modified pyrrole, e.g. pyrrolidine, ring system. The simplest example of this class is nicotine. A pyrrolidine ring is the central structure of the amino acids proline and hydroxyproline. These alkaloids are also found in many drug preparations, e.g. procyclidine hydrochloride, which is an antichohnergic drug mainly used for the treatment of drug-induced Parkinsonism, akathisia and acute dystonia. 

Acute dystonia is sudden and severe muscular spasm which can infrequently be life threatening. 

This chapter will describe some of the most common, reversible, drug-induced neurological reactions acute dystonia acute akathisia parkinsonism and a broad, ill-defined category called dysphoria. All of them tend to begin early in treatment but can start later on as well. Chapters 4 and 5 will review the sometimes delayed and often persistent adverse reactions, including irreversible forms of akathisia and dystonia. 

SSRIs cause a wide range of neurological impairments. Spigset (1999) found the following neurological reports in order of frequency parethesias, headache, dizziness, tremor, seizures, acute dystonia, dyskinesia, muscle cramps, muscle weakness, parkinsonism, muscle stiffness, akathisia, myoclonus, extrapyramidal reactions, increased muscle tone, and migraine. There have been reports of irreversible tardive dyskinesia caused by SSRIs (see subsequent section). 

Reccoppa, L., Welch, W. A., 8c Ware, M. R. (1990, November). Acute dystonia and fluoxetine. Journal of Clinical Psychiatry, 51, 487. 

Acute dystonia has been described in association with fluvoxamine (SEDA-18, 20). 

Acute dystonia has been described during the first days of paroxetine treatment (SEDA-17, 19). 

Acute dystonia is a recognized complication of treatment with antipsychotic drugs and it can also occur with SSRIs and the anxiolytic drug buspirone. 

Detweiler MB, Harpold GJ. Bupropion-induced acute dystonia. Ann Pharmacother 2002 36(2) 251-4. 

In a double-blind, placebo-controlled, dose-response trial, 270 acutely agitated patients were randomized to receive 1-3 intramuscular injections of olanzapine (2.5, 5, 7.5, or 10 mg), haloperidol (7.5 mg), or placebo within 24 hours (60). Olanzapine had a dose-related effect in reducing agitation olanzapine was better than placebo but not better than haloperidol the most frequently reported adverse event was hypotension, which occurred with olanzapine (n = 7) but not haloperidol or placebo. Acute dystonias did not occur in patients given olanzapine or placebo but occurred in two patients given haloperidol. 

A comprehensive review has strongly advocated immediate intravenous administration of anticholinergic drugs to relieve acute dystonia. 

Acute dystonia occurred during spiramycin therapy in a patient who was being treated with neuroleptic drugs (368). 

Brody AL. Acute dystonia induced by rapid increase in risperidone dosage. J Clin Psychopharmacol 1996 16(6) 461-2. 

Landry P, Cournoyer J. Acute dystonia with olanzapine. J Clin Psychiatry 1998 59(7) 384. 

Bernard JM, Le Roux D, Pereon Y. Acute dystonia during sevoflurane induction. Anesthesiology 1999 90(4) 1215-6. 

Patients taking olanzapine reported a low incidence of dystonias, which may be about 0.3% (SEDA-22, 56). In the light of two new cases of acute dystonia associated with olanzapine in patients with previous history of dystonia or parkinsonism related to antipsychotic treatment, comparative figures have been reported. Acute dystonia occurred in 1.4% of patients who took olanzapine, compared with 5.0-6.3% of those taking haloperidol (84). 

Two patients developed acute dystonias while taking the lowest therapeutic dose of olanzapine (5 mg/day) (85), and tardive dyskinesia and tardive dystonia have also been reported. 

Alevizos B, Papageorgiou C, Christodoulou GN. Acute dystonia caused by low dosage of olanzapine. J Neuropsychiatry Clin Neurosci 2003 15 241. 

Cocaine has been associated with movement disorders, such as acute dystonias, choreoathetosis, and akathisia. Chronic pancerebellar dysfunction occurred in a cocaine user with schizophrenia treated with risperidone (129). 

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