Neuroleptic Malignant Syndrome management

Which drug may be useful in the management of the neuroleptic malignant syndrome, although it can worsen the symptoms of schizophrenia ... 

Repeated high i.m. doses over several days are inadvisable inasmuch as most patients do not require such aggressive intervention, and this strategy may increase the risk for severe EPS and the neuroleptic malignant syndrome (NMS). Finally, it is preferable to switch patients to oral treatment as quickly as possible to manage the remainder of an acute episode. 

Immediate discontinuation of the antipsychotic and the use of bromocriptine when needed to manage symptoms if a neuroleptic malignant syndrome develops... 

A rare, but potentially fatal idiosyncratic adverse effect is neuroleptic malignant syndrome. This can occur with any antipsychotic drug. The symptoms are rigidity, hyperthermia, autonomic lability, and reduced level of consciousness. Massively elevated levels of creatinine kinase are usually found. Prior to 1984, the mortality rate was around 25% but improved early recognition has considerably reduced this. Management is cessation of antipsychotics, appropriate conservative measures and dantrolene if necessary for muscle rigidity. 

Velamoor VR. Neuroleptic malignant syndrome. Recognition, prevention and management. Drug Saf 1998 19(l) 73-82. 

A patient with schizoaffective disorder, who developed risperidone-related neuroleptic malignant syndrome, responded satisfactorily to supportive management and vitamin E plus vitamin B6 (111). 

Tiapride appears to be useful in alcohol withdrawal as an alternative to the benzodiazepines (2). It facilitates the management of ethanol withdrawal, but its use in patients at risk of severe reactions in acute withdrawal should be accompanied by adjunctive therapy for hallucinosis and seizures. Since it may prove difficult to identify such patients and since there is also a small risk of the neuroleptic malignant syndrome (particularly with parenteral administration), the usefulness of tiapride in this setting is likely to be limited. The potential risk of tardive dyskinesia at the dosage used in alcoholic patients following detoxification (300 mg/day) requires evaluation and necessitates medical supervision. It is unlikely to produce problems of dependence or abuse. 

In one patient who took 900 mg of phenelzine, there was a marked excess of nrinary and plasma catecholamines, analogous to pheochromocjdoma, and the patient was successfully managed with alpha-adrenoceptor antagonists (44). In another patient, who probably took about 2000 mg of phenelzine, hyperpyrexia was prominent and responded to dantrolene sodium (45). The authors noted clinical similarities to malignant hyperpyrexia and neuroleptic malignant syndrome. 

Management of fulminant hypermetabolism of skeletal muscle because of malignant hyperthermia crisis. Treatment of neuroleptic malignant syndrome, relief induced pain in patients with muscular of exercise-dystrophy, treatment of flexor spasms... 

The typical antipsychotic drugs (e.g., chlorpromazine, thioridazine, fluphenazine, and haloperidol) act primarily as DA antagonists, blocking Dj receptors. Side effects include the induction of pseudo-Parkinsonism, akathisia, and/or acute dystonic effects. Their use and symptom management are discussed, as are other adverse effects including toxicity, tardive dyskinesia, and neuroleptic malignant syndrome. 

Susman VL. Clinical management of neuroleptic malignant syndrome. Psychiatric Q 2001 72 325-336. 

Dantrolene is not likely to be effective for hyperthennia caused by conditions other than muscular hyperactivity, such as increased metabolic rate (eg, salicylate or dinitrophenol poisoning), neuroleptic malignant syndrome (NMS), impaired heat dissipation (eg, anticholinergic syndrome), or environment exposure (heat stroke). However, there is anecdotal evidence (case reports or case-control studies) of benefit for the management of NMS, MAO inhibitor (phenelzine poisoning)-induced hyperthermia, muscle rigidity from baclofen withdrawal, hypertonicity from carbon monoxide poisoning, tetanus, and black widow spider envenomation. 

Ward - most psychosis management decisions are made in team ward rounds, but you ll often be alone if and when neuroleptic malignant syndrome strikes (Ch.67)... 

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