nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 NEUROLEPTIC MALIGNANT SYNDROME, ELECTROCONVULSIVE THERAPY AND OTHER TREATMENTS JASSIN M. JOURIA, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract Neuroleptic Malignant Syndrome is both rare and potentially fatal. Health clinicians need to recognize signs and symptoms and ask the right questions to make an accurate diagnosis and begin treatment. While this condition is not entirely understood, its symptoms are recognizable and typically easily resolved with little or no long-term impact to the patient when caught early. A treatment and management plan must be implemented. Pharmacotherapy has not been consistently effective in all case reports of neuroleptic malignant syndrome. In contrast, electroconvulsive therapy may be effective. A key step in the management of neuroleptic malignant syndrome is the initiation of supportive medical therapy.
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NEUROLEPTIC MALIGNANT SYNDROME ...(NMS) is not homogeneous, but rather, the clinical signs or symptoms are rather heterogeneous, making diagnosis difficult, especially in the early
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TREATMENTS JASSIN M. JOURIA, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of
educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
Abstract
Neuroleptic Malignant Syndrome is both rare and potentially fatal. Health
clinicians need to recognize signs and symptoms and ask the right questions to
make an accurate diagnosis and begin treatment. While this condition is not
entirely understood, its symptoms are recognizable and typically easily resolved
with little or no long-term impact to the patient when caught early. A treatment
and management plan must be implemented. Pharmacotherapy has not been
consistently effective in all case reports of neuroleptic malignant syndrome. In
contrast, electroconvulsive therapy may be effective. A key step in the
management of neuroleptic malignant syndrome is the initiation of supportive
1. Patients typically develop neuroleptic malignant syndrome
a. one month after cessation of a causative drug. b. one month after exposure to a causative drug. c. two weeks after exposure to a causative drug. d. within hours or days after exposure to a causative drug.
2. True or False: Neuroleptic malignant syndrome in hospitalized
patients is considered a neurologic emergency as a delay in treatment or withholding of therapeutic measures can potentially lead to serious morbidity or death.
a. True b. False
3. Aggressive ______________ is often required, especially if highly
elevated creatine phosphokinase (CPK) levels threaten to damage the kidneys.
a. electroconvulsive therapy b. hydration c. body cooling d. dose escalation
4. Patients with NMS may be at increased risk of morbidity due to
a. renal failure. b. disseminated intravascular coagulation (DIC). c. deep venous thrombosis. d. All of the above
5. Bromocriptine mesylate, a dopamine agonist,
a. is used to treat neuroleptic malignant syndrome (NMS). b. is contraindicated in treating NMS. c. is used to treat hypotension. d. may be used to treat NMS but it cannot be administered with
enhancement of the GABAergic system. The cerebrospinal fluid (CSF) level of
gamma-aminobutyric acid (GABA) is significantly decreased in the active phase
and the GABAergic system is considered hypofunctioning in NMS.2
Reducing the recovery time with benzodiazepine treatment may be related to the
effects of these drugs on GABAergic hypofunction. In a patient with severe NMS
and rhabdomyolysis, high-dose lorazepam and diazepam may be prescribed for
treatment. In addition, a clinician may administer the antipsychotic olanzapine 5
days after NMS resolution, which is quicker than some reports delaying
antipsychotic treatment until approximately 2 weeks following the NMS
resolution.
Supportive treatment, including antipyretic medications such as non-steroidal
anti-inflammatory drugs or acetaminophen, and external cooling are frequently
administered. Endovascular cooling has been reported in an NMS patient.
Case Study 2: Male Patient, Age 34
A male patient with history of Type 2 diabetes mellitus on oral hypoglycemic agents was hospitalized twice with symptoms of ketosis. He was treated with Insulin, intravenous fluids, and supportive therapy. He was discharged on twice daily dosing of insulin. Poor drug compliance, poor motivation regarding diabetes care, and psychomotor agitation were noted during hospitalization. Psychiatry consultation was sought for behavioral abnormalities. On psychiatry evaluation, the patient was diagnosed to have mental retardation with psychotic features. He was started on the antipsychotic risperidone, at a dose of 1 mg twice daily.
One week after starting on antipsychotics, he presented with extrapyramidal symptoms of dystonia, parkinsonian gait, fine tremors, high spiking fever, altered sensorium, and muscle rigidity. He was hospitalized and started on supportive therapy. Blood counts, urine microscopy, and renal function were normal except for low sodium. Creatine phosphokinase (CPK) was ordered in view of muscle rigidity that was very high (1543). A diagnosis of NMS was made and imaging and lumbar puncture were deferred as the initial reports were suggestive of NMS.
Risperidone was stopped immediately, and he was treated with lorazepam, trihexyphenidyl, paracetamol, and intravenous fluids in consultation with psychiatrist. Within 48 h of hospitalization, his symptoms improved and CPK level gradually came down. The patient was afebrile on the 3rd day and his glycemic
control improved. Family was informed of the diagnosis and the need for close monitoring of his glycemic control. Psychiatrists decided not to restart antipsychotic drugs. His behavioral abnormalities were to be managed with counseling sessions. He was discharged without further complications.
Treatment depends on the severity of symptoms. Patients who are hemodynamically unstable are to be transferred to higher centers for intensive monitoring. Mild cases can be managed at the secondary care setting in consultation with a psychiatrist.
Supportive therapy involves discontinuation of antipsychotic agents, correction of electrolyte imbalances, nutritional deficiencies and monitoring of airway, breathing, and circulation. Specific dopaminergic agents such as bromocriptine, dantrolene, and electroconvulsive therapy as an option are considered for more severe cases by psychiatrists. Iron deficiency should be corrected as low iron levels may aggravate movement disorders.
Complete resolution of symptoms takes around 2 days to 2 weeks. Symptoms
may last for a month in patients being administered depot preparations.
Restarting antipsychotics in patients with history of NMS if needed is done on
consultation with psychiatry. Depot preparations are generally not
recommended, however, a 2-week interval is to be considered between recovery
and restarting antipsychotic agents. No complications with anesthesia have been
reported in post-NMS patients.31
Other Pharmacologic Approaches
Amantadine may be used due to its dopaminergic and anticholinergic
pharmacologic effects. It has been used successfully in some NMS
cases. Apomorphine is being considered but it is still not an optimal choice
because it is not supported by major evidence.
Levodopa, combined with the carbidopa (dopadecarboxylase inhibitor), has also
been reported to be effective in reversing hyperthermia.18 Treatment may have
to be continued for several days. Minor tranquilizers such as benzodiazepines are
a good choice for treating agitation and catatonia.
Complete recovery of symptoms was reported in 25 (63%) of the cases, and
partial recovery was noted in 11 (28%).25
Case Study 1: Female (Age 42)
A 42-year-old female with paranoid schizophrenia was treated with perphenazine at 16 mg daily, initially started at 2mg daily and gradually increased. Additionally, she was administered risperidone 6mg daily.
Patient developed clinical signs and symptoms of neuroleptic malignant syndrome (NMS), including an elevated creatinine kinase level to 3766/L, tachycardia, increased muscle tone, diaphoresis, dysphagia, incontinence, labile blood pressure, and severe confusion. Initially, she was treated with intravenous fluids and supportive care while her risperidone and perphenazine were discontinued. After her medications were discontinued, she developed paranoid persecutory delusions with loss of concentration. She also was discovered to have bilateral pulmonary embolism. She was started on enoxaparin and warfarin.
The patient's NMS showed a progressive increase in symptoms in spite of discontinuing her medications, so ECT was tried. Bitemporal ECT with a MECTA-type device using 1.0 milliseconds pulse width and 30 to 50 joule was applied three times a week for a total of eight sessions. Sodium thiopental and succinylcholine were used as anesthesia. After the second session of ECT, the patient's tachycardia decreased and she started to communicate. Following the fourth ECT, she was able to spend half of the day out of bed. The symptoms of NMS were resolved totally by the eighth session. No serious adverse event was observed with ECT and the acute postictal confusional states that did occur subsided within 20 to 30 minutes. Electrocardiogram, blood pressure, and pulse rates stayed within normal limits during the ECT sessions. After the last ECT application, the CK level was measured as 98U/L. Along with the improvement in NMS, we observed significant reductions in her psychotic symptoms.
The choice of ECT in this case was made to provide an emergent intervention to a complicated case of severe NMS and pulmonary embolism. The reported mortality rate of NMS is broadly reported to be 4 to 20%. ECT was selected in this case for a rapid treatment rather than reliance upon pharmacology.
Electroconvulsive therapy may be considered for treatment of neuroleptic
malignant syndrome (NMS) when autonomic stability has been re-established,
and there is inadequate response to pharmaceutical measures or
nonpharmacological treatment is required for continuing comorbid psychiatric
Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 1. Patients typically develop neuroleptic malignant syndrome
a. one month after cessation of a causative drug. b. one month after exposure to a causative drug. c. two weeks after exposure to a causative drug. d. within hours or days after exposure to a causative drug.
2. True or False: Neuroleptic malignant syndrome in hospitalized
patients is considered a neurologic emergency as a delay in treatment or withholding of therapeutic measures can potentially lead to serious morbidity or death.
a. True b. False
3. Aggressive ______________ is often required, especially if highly
elevated creatine phosphokinase (CPK) levels threaten to damage the kidneys.
a. electroconvulsive therapy b. hydration c. body cooling d. dose escalation
4. Patients with NMS may be at increased risk of morbidity due to
a. renal failure. b. disseminated intravascular coagulation (DIC). c. deep venous thrombosis. d. All of the above
5. Bromocriptine mesylate, a dopamine agonist,
a. is used to treat neuroleptic malignant syndrome (NMS). b. is contraindicated in treating NMS. c. is used to treat hypotension.
d. may be used to treat NMS but it cannot be administered with dantrolene.
6. Anticholinergic drugs, such as _______________, usually do not
reduce the rigidity of neuroleptic malignant syndrome (NMS) and do not affect hyperthermia.
a. carbidopa b. levodopa c. benzatropine d. amantadine hydrochloride
7. Fluctuation in the level of a patient’s consciousness is accompanied
with an impaired deglutory reflex leads to an increased risk for _______________, which is associated with a significant mortality rate.
a. hypothermia b. aspiration pneumonia c. muscle rigidity d. dementia
8. Using ____________ may be ineffective because hyperthermia in
neuroleptic malignant syndrome is not mediated by pyrogens.
a. cooled IV fluids b. cooling blankets c. antipyretics d. ice packs
9. When recognized early and treated aggressively, the following may
be said about neuroleptic malignant syndrome (NMS):
a. it is still often fatal. b. it is manageable but not curable. c. a majority of patients will recover completely between 2 and 14 days. d. a majority of patients will partially recover.
10. True or False: The use of dantrolene, bromocriptine, and biperiden
to treat NMS is the recommended, first-line of treatment option accepted by the medical community.
11. Because of its efficacy in anesthetic-induced ________________,
the muscle relaxant dantrolene has been used in the treatment of neuroleptic malignant syndrome (NMS).
a. multiple sclerosis b. central nervous system infections c. malignant hyperthermia d. dementia
12. Dantrolene should not be co-administered with ________________,
as cardiovascular collapse can occur.
a. calcium channel blockers b. dopamine agonists c. benzodiazepines d. All of the above
13. True or False: Pharmacotherapy has been consistently effective in
all case reports of neuroleptic malignant syndrome (NMS).
a. True b. False
14. Electroconvulsive therapy (ECT) may be effective to treat
neuroleptic malignant syndrome (NMS) if symptoms
a. are manageable and idiopathic malignant catatonia is excluded. b. are refractory to supportive care and pharmacotherapy. c. of persistent residual catatonia are not present. d. of parkinsonism are not present.
15. A neuroleptic malignant syndrome (NMS) patient’s response to
electroconvulsive therapy (ECT) treatment may be predicted based upon
a. the patient’s age. b. the sex of the patient (males were more responsive). c. the patient’s psychiatric diagnosis. d. None of the above
16. A typical electroconvulsive therapy (ECT) regimen for acute
neuroleptic malignant syndrome (NMS) would include
a. no more than 4 treatments. b. only single-electrode placement. c. six to 10 treatments with bilateral electrode placement. d. no more than 6 treatments.
17. Electroconvulsive therapy (ECT) can be helpful in a high percentage
of cases in which patients
a. fall into a coma. b. become catatonic. c. have Malignant Catatonia (MC). d. All of the above
18. Which of the following statements concerning electroconvulsive
therapy (ECT) in treating neuroleptic malignant syndrome (NMS) is/are true?
a. ECT controls symptoms of NMS but does not reduce its mortality rate. b. ECT can be potentially lifesaving in severe cases. c. There are no hazards associated with the use of ECT. d. All of the above
19. Which of the following is NOT a hazard associated with
electroconvulsive therapy (ECT) used to treat neuroleptic malignant syndrome (NMS)?
a. Acute lethal catatonia (ALC) b. Ventricular fibrillation c. Cardiac arrest d. Uncontrolled spontaneous seizures.
20. True or False: Electroconvulsive therapy (ECT) reduces the mortality
associated with neuroleptic malignant syndrome (NMS) by approximately 50 percent.
21. In cases that used electroconvulsive therapy (ECT) as the primary
treatment of neuroleptic malignant syndrome (NMS), the partial recovery rate was
a. approximately one-half of patients treated. b. seen in 75% of patients treated. c. approximately one-fourth of patients treated. d. seen in less than 10% of patients treated.
22. In electroconvulsive therapy (ECT) for severe neuroleptic malignant
syndrome (NMS) cases with a high risk of complications, ____________________ is the primary disorder.
a. catatonia (muscle rigidity) b. acute lethal catatonia (ALC) c. dysphoria with psychotic features d. euphoria with psychotic features
23. Which of the following statements best describes the use of
anesthetic agents in neuroleptic malignant syndrome (NMS) patients?
a. anesthetic agents are never feasible in NMS patients. b. succinylcholine is used in some cases. c. anesthetic agents may be used but succinylcholine is contraindicated. d. succinylcholine may be used but it always results in laboratory
abnormalities. 24. ________________ is effective in the treatment of neuroleptic
malignant syndrome (NMS) by enhancement of the GABAergic system.
a. Dantrolene b. Succinylcholine c. Bromocriptine mesylate d. Diazepam
25. True or False: The cerebrospinal fluid (CSF) level of gamma-
aminobutyric acid (GABA) is significantly decreased in the active phase and the GABAergic system is considered hypofunctioning in neuroleptic malignant syndrome (NMS).
CORRECT ANSWERS: 1. Patients typically develop neuroleptic malignant syndrome
d. within hours or days after exposure to a causative drug. “Patients typically develop NMS within hours or days after exposure to a causative drug, with most exhibiting symptoms within 2 weeks and nearly all within 30 days.”
2. True or False: Neuroleptic malignant syndrome in hospitalized
patients is considered a neurologic emergency as a delay in treatment or withholding of therapeutic measures can potentially lead to serious morbidity or death.
a. True “Neuroleptic malignant syndrome in hospitalized patients is considered a neurologic emergency as a delay in treatment or withholding of therapeutic measures can potentially lead to serious morbidity or death.”
3. Aggressive ______________ is often required, especially if highly
elevated creatine phosphokinase (CPK) levels threaten to damage the kidneys.
b. hydration “Importantly, aggressive hydration is often required, especially if highly elevated CPK levels threaten to damage the kidneys. Metabolic abnormalities may need to be corrected, and bicarbonate loading should be considered in some cases as it may be beneficial in preventing renal failure.”
4. Patients with NMS may be at increased risk of morbidity due to
a. renal failure. b. disseminated intravascular coagulation (DIC). c. deep venous thrombosis. d. All of the above [correct answer]
“Patients with NMS may be at increased risk of morbidity due to renal failure, disseminated intravascular coagulation (DIC) secondary to rhabdomyolysis, deep venous thrombosis and...”
a. is used to treat neuroleptic malignant syndrome (NMS). “Bromocriptine mesylate, a dopamine agonist, is also used to treat NMS...”
6. Anticholinergic drugs, such as _______________, usually do not
reduce the rigidity of NMS and do not affect hyperthermia.
c. benzatropine “Anticholinergic drugs, such as benzatropine, usually do not reduce the rigidity of NMS and do not affect hyperthermia.”
7. Fluctuation in the level of a patient’s consciousness is accompanied
with an impaired deglutory reflex leads to an increased risk for _______________, which is associated with a significant mortality rate.
b. aspiration pneumonia “Also, it is very important to keep in mind that fluctuation in the level of consciousness is accompanied with an impaired deglutory reflex, and therefore, increased risk for aspiration pneumonia, which is associated with a significant mortality rate.”
8. Using ____________ may be ineffective because hyperthermia in
neuroleptic malignant syndrome is not mediated by pyrogens.
c. antipyretics “Hyperthermia should be treated with cooling blankets, ice packs, cooled intravenous (IV) fluids, and antipyretics, although some researchers believe antipyretics are ineffective because hyperthermia in NMS is not mediated by pyrogens.”
9. When recognized early and treated aggressively, the following may be said about neuroleptic malignant syndrome (NMS):
c. a majority of patients will recover completely between 2 and 14 days. “When recognized early and treated aggressively, NMS is usually not fatal and a majority of patients will recover completely between 2 and 14 days.”
10. True or False: The use of dantrolene, bromocriptine, and biperiden
to treat NMS is universally recommended by the medical community and the gold standard as initial treatment.
b. False “The three main drug options for treating NMS are dantrolene, bromocriptine, and biperiden; however, the use of these drugs to treat NMS is a controversial topic. In the case of biperiden, it has been suspected as a cause of NMS.”
11. Because of its efficacy in anesthetic-induced ________________,
the muscle relaxant dantrolene has been used in the treatment of neuroleptic malignant syndrome (NMS).
c. malignant hyperthermia “Because of its efficacy in anesthetic-induced malignant hyperthermia, the muscle relaxant dantrolene has been used in the treatment of NMS....”
12. Dantrolene should not be co-administered with ________________,
as cardiovascular collapse can occur.
a. calcium channel blockers “Dantrolene can be combined with benzodiazepines or dopamine agonists, but it should not be co-administered with calcium channel blockers, as cardiovascular collapse can occur.”
13. True or False: Pharmacotherapy has been consistently effective in all case reports of neuroleptic malignant syndrome (NMS).
b. False “Pharmacotherapy has not been consistently effective in all case reports of NMS. Moreover, drug effects are usually observed early and are unlikely to occur after the first few days of treatment.”
14. Electroconvulsive therapy (ECT) may be effective to treat
neuroleptic malignant syndrome (NMS) if symptoms
b. are refractory to supportive care and pharmacotherapy. “In contrast, electroconvulsive therapy (ECT) may be effective if symptoms are refractory to supportive care and pharmacotherapy even late in the course of NMS,...”
15. A neuroleptic malignant syndrome (NMS) patient’s response to
electroconvulsive therapy (ECT) treatment may be predicted based upon
a. the patient’s age. b. the sex of the patient (males were more responsive). c. the patient’s psychiatric diagnosis. d. None of the above [correct answer]
“While some researchers have found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments.21 Treatment response to ECT was not predicted by age, sex, psychiatric diagnosis, or any particular features of NMS.”
16. A typical electroconvulsive therapy (ECT) regimen for acute
neuroleptic malignant syndrome (NMS) would include
c. six to 10 treatments with bilateral electrode placement. “A typical ECT regimen for acute NMS would include 6 to 10 treatments with bilateral electrode placement.”
17. Electroconvulsive therapy (ECT) can be helpful in a high percentage of cases in which patients
a. fall into a coma. b. become catatonic. c. have Malignant Catatonia (MC). d. All of the above [correct answer]
“If a patient should fall into a coma or become catatonic, there is research to suggest that ECT can be helpful in a high percentage of cases. It can also be helpful if a patient with NMS also has Malignant Catatonia (MC).”
18. Which of the following statements concerning electroconvulsive
therapy (ECT) in treating neuroleptic malignant syndrome (NMS) is/are true?
b. ECT can be potentially lifesaving in severe cases. “ECT reduces the mortality of NMS by approximately half.... When pharmacological treatments fail to control the NMS disorder, ECT can be potentially lifesaving in severe cases. However, ECT for NMS is not without hazard and has been associated with ventricular fibrillation, cardiac arrest and uncontrolled spontaneous seizures.”
19. Which of the following is NOT a hazard associated with
electroconvulsive therapy (ECT) used to treat neuroleptic malignant syndrome (NMS)?
a. Acute lethal catatonia (ALC) “However, ECT for NMS is not without hazard and has been associated with ventricular fibrillation, cardiac arrest and uncontrolled spontaneous seizures. ECT is sometimes used to control psychiatric symptoms while neuroleptics may be contraindicated.... Because ECT effectively treats acute lethal catatonia (ALC), it stands to reason that ECT might effectively reverse skeletal muscle rigidity in NMS.”
20. True or False: Electroconvulsive therapy (ECT) reduces the mortality associated with neuroleptic malignant syndrome (NMS) by approximately 50 percent.
a. True “ECT reduces the mortality of NMS by approximately half.”
21. In cases that used electroconvulsive therapy (ECT) as the primary
treatment of neuroleptic malignant syndrome (NMS), the partial recovery rate was
c. approximately one-fourth of patients treated. “Of the cases in which ECT was the primary treatment, the complete recovery rate was more than half and the partial recovery rate was approximately one-fourth of patients treated.”
22. In electroconvulsive therapy (ECT) for severe neuroleptic malignant
syndrome (NMS) cases with a high risk of complications, ____________________ is the primary disorder.
c. dysphoria with psychotic features “In ECT for severe NMS cases in which there is a high risk of complications, dysphoria with psychotic features is the primary disorder, and catatonia (muscle rigidity) is the major symptom.”
23. Which of the following statements best describes the use of
anesthetic agents in neuroleptic malignant syndrome (NMS) patients?
b. succinylcholine is used in some cases. “Although controversial, the use of anesthetic agents in NMS patients is feasible. Usually succinylcholine, was used in 50% of cases.”
24. ________________ is effective in the treatment of neuroleptic malignant syndrome (NMS) by enhancement of the GABAergic system.
d. Diazepam “Treatment for NMS is generally supportive and pharmacological depending on the clinical presentation of illness stage or severity. Hyperthermia may improve with high-dose lorazepam and diazepam administration. Lorazepam and other benzodiazepines are administered to treat NMS symptoms; these drugs may reduce recovery time in NMS. Diazepam is effective in the treatment of NMS by enhancement of the GABAergic system.”
25. True or False: The cerebrospinal fluid (CSF) level of gamma-
aminobutyric acid (GABA) is significantly decreased in the active phase and the GABAergic system is considered hypofunctioning in neuroleptic malignant syndrome (NMS).
a. True “The cerebrospinal fluid (CSF) level of gamma-aminobutyric acid (GABA) is significantly decreased in the active phase and the GABAergic system is considered hypofunctioning in NMS.”
26. Low serum iron levels in neuroleptic malignant syndrome (NMS)
have been associated with
a. poor responses to benzodiazepines. “Low serum iron levels in NMS have been associated with poor responses to benzodiazepines and patients with normal iron serum levels show good responses to benzodiazepines.”
27. Which of the following is an antipsychotic drug that should be
stopped for a patient diagnosed with neuroleptic malignant syndrome (NMS)?
a. Risperidone “... antipsychotic risperidone.... A diagnosis of NMS was made and imaging and lumbar puncture were deferred as the initial reports were suggestive of NMS. Risperidone was stopped immediately,...”
28. Management of neuroleptic malignant syndrome (NMS) focuses on withdrawal of the neuroleptic medication and meticulous supportive care, which includes
d. aggressive hydration. “Management of NMS focuses on withdrawal of the neuroleptic medication and meticulous supportive care, which includes aggressive hydration.”
29. Because __________________ is a common complication in
neuroleptic malignant syndrome (NMS), strategies must be directed at managing the elevations of creatinine kinase (CK).
a. renal failure “Because renal failure is a common complication in NMS, strategies must be directed at managing the elevations of creatinine kinase (CK), with its resulting myoglobin load to the kidneys.”
30. True or False: Plasmapheresis is not a treatment that should be used
in patients with neuroleptic malignant syndrome (NMS).
b. False “Other proposed treatments of NMS include pancuronium, “G carbamazepine," amantadine, anesthesia and plasmapheresis.”
31. Approximately ____ of neuroleptic malignant syndrome (NMS) cases
can still be fatal, regardless of early diagnosis and treatment.
c. 10% “... approximately 10% of cases can be fatal, regardless of early diagnosis and treatment.”
32. True or False. Autonomic instability results in increased insensible
water losses.
a. True “Autonomic instability results in increased insensible water losses...”
33. Dantrolene sodium exerts its therapeutic effect by means of the blockade of calcium release from the muscle fiber's
c. sarcoplasmic reticulum. “Dantrolene sodium exerts its therapeutic effect by means of the blockade of calcium release from the muscle fiber's sarcoplasmic reticulum.”
34. True or False: Amisulpride, a relatively newly designed atypical
antipsychotic, has also been shown to be associated with the occurrence of NMS.
a. True “Amisulpride, a relatively newly designed atypical antipsychotic, has also been shown to be associated with the occurrence of NMS.”
35. ________________ seems to be indicated to prevent venous
thrombosis in an immobilized patient.
d. Low-dose heparin “Low-dose heparin seems to be indicated to prevent venous thrombosis in an immobilized patient. Other dopamine antagonists, such as metoclopramide, should be avoided.”
The reference section of in-text citations includes published works intended as helpful material for further reading. [These references are for a multi-part series on neuroleptic malignant syndrome (NMS) and its treatments.] 1. Berman, B. D. (Jan. 2011). Neuroleptic malignant syndrome. Neurohospitalist. 1(1): 41-47. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726098/. 2. Tse, L., Bar, A.M., Scarapicchia, V.,and Vila-Rodriguez, F. (July 2015). Neuroleptic malignant syndrome: A review from a clinically oriented perspective. Current Neuropharmacology 13(3):395-406. Obtained online at https://www.ncbi.nlm.nih.gov/pubmed/26411967 3. Oruch R., Pryme I., Engelsen B.A., & Lund, A. (Jan 2017). Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatric Disease andTreatment. 13: 161-175. 4. Berman, B. D. (Jan. 2011). Neuroleptic malignant syndrome. Neurohospitalist. 1(1). Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726098/ 5. Meltzer, H.Y. & Massey, B.W. (Feb. 2011). The role of serotonin receptors in the action of atypical antipsychotic drugs. Curr. Opin. Pharmacol. 11(1). 59-67. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/21420906 6. U.S. National Library of Medicine (2017). Olanzipine. Obtained online at https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0011473/?report=detal s 7. U.S. National Library of Medicine. (April 2017). Risperidone. Obtained online at https://pubchem.ncbi.nlm.nih.gov/compound/risperidone#section=Top 8. U.S. National Library of Medicine. (April 2017). Paliperidone. Obtained online at https://pubchem.ncbi.nlm.nih.gov/compound/Paliperidone#section=Top 9. Langan, J., Martin, D., Shajahan, P., & Smith, D. (Nov. 2012). Antipsychotic dose escalation as a trigger for Neuroleptic Malignant Syndrome (NMS): literature review and case series report. BMC Psychiatry. Obtained online at https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-12- 214 10. U.S. National Library of Medicine. (April 2017). Ziprasidone. Obtained online at https://pubchem.ncbi.nlm.nih.gov/compound/Ziprasidone#section=Top 11. U.S. National Library of Medicine. (April 2017). Quetiapine. Obtained online at https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0011909/?report=detail s
12. Bhandari, G. Neuroleptic malignant syndrome. 538-542. Obtained online at http://www.apiindia.org/medicine_update_2013/chap118.pdf 13. Mazhar, F., Akram, S., Haider, N., & Ahmed, R. (2016). Overlapping of serotonin syndrome with neuroleptic malignant syndrome due to linezolid- fluoxetine and olanzapine-metoclopramide interactions: A case report of two serious adverse drug effects caused by medication reconciliation failure on hospital admission. Case Reports in Medicine. Obtained online at https://www.hindawi.com/journals/crim/2016/7128909/cta/ 14. Caamano, A., Din, R., & Eter, A. (Dec. 2016). Serotonin syndrome induced by combined use of tramadol and escitalopram: A case report. Journal of Medical Cases. 7(12): 554-557. Obtained online at http://www.journalmc.org/index.php/JMC/article/view/2721/2049 15. Stephens, S. (Feb.-March 2011). Essential facts about essential tremor: This “quiet” disease, which affects 10 million Americans, is anything but benign. Neurology Now. 7(1): 21, 23-27. Obtained online at http://tools.aan.com/elibrary/neurologynow/?event=home.showArticle&id= ovid.com:/bib/ovftdb/01222928-201107010-00010 16. Yang, Y., Guo Y., & Zhang, A. (2014). Neuroleptic Malignant Syndrome in a patient treated with lithium carbonate and haloperidol. Shanghai Archives of Psychiatry, 26(6), 368–370. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311113/ 17. Al Owesie, R. M., & Robert, A. A. (2013). Delirium followed by neuroleptic malignant syndrome in rehabilitation setting. Is it anger reaction before discharge? The Pan African Medical Journal, 15, 26. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3758850/ 18. Dixit, S., Dutta, M. K., & Namdeo, M. (2015). A Rare Case of Myxedema Coma with Neuroleptic Malignant Syndrome (NMS). Journal of Clinical and Diagnostic Research : JCDR, 9(5), VD01–VD03. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484133/ 19. Yıldırım, V., Direk, M. Ç., Güneş, S., Okuyaz, Ç. & Toros, F. (2017). Neuroleptic Malignant Syndrome Associated with Valproate in an Adolescent. Clinical Psychopharmacology and Neuroscience, 15(1), 76–78. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5290716/ 20. Davis, A., & Khot, S. (2017). Neuroleptic Malignant Syndrome. Current Psychiatry. 16(5). Obtained online at http://www.mdedge.com/currentpsychiatry/dsm/4972/hospital- medicine/neuroleptic-malignant-syndrome 21. Oruch, R., Pryme, I. F., Engelsen, B. A., & Lund, A. (2017). Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatric Disease and Treatment, 13, 161–175. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5248946
22. Berman, B. D. (Jan. 2011). Neuroleptic malignant syndrome. Neurohospitalist. 1(1): 41-47. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726098/ 23. Tse, L., Bar, A.M., Scarapicchia, V., and Vila-Rodriguez, F. (July 2015). Neuroleptic malignant syndrome: A review from a clinically oriented perspective. Current Neuropharmacology 13(3):395-406. Obtained online at https://www.ncbi.nlm.nih.gov/pubmed/26411967 24. Antipsychotics and Neuroleptic Malignant Syndrome. (2015). Pharmacist. Obtained online at https://www.uspharmacist.com/ce/antipsychotics-and- neuroleptic-malignant-syndrome 25. Luchini, F., Medda, P., Mariani, M. G., Mauri, M., Toni, C., & Perugi, G. (2015). Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World Journal of Psychiatry, 5(2), 182–192. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4473490/ 26. Government of South Australia. (2013). Electroconvulsive therapy policy guideline. Obtained online at https://www.sahealth.sa.gov.au/wps/wcm/connect/0608270046ad5b01b8 93ba2195233e2a/Guideline_Electroconvulsive+Therapy_Dec2014.pdf?MOD =AJPERES&CACHEID=0608270046ad5b01b893ba2195233e2a 27. Belvederi Murri, M., Guaglianone, A., Bugliani, M., Calcagno, P., Respino, M., Serafini, G., Amore, M. (2015). Second-generation antipsychotics and Neuroleptic Malignant Syndrome: Systematic review and case report analysis. Drugs in R&D, 15(1), 45–62. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359181/ 28. Dosi, R., Ambaliya, A., Joshi, H., & Patell, R. (2014). Serotonin syndrome versus neuroleptic malignant syndrome: a challenging clinical quandary. BMJ Case Reports, 2014, bcr2014204154. Obtained online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069678/ 29. Perry, P.J., & Wilborn, C. (May 2012). Serotonin Syndrome vs Neuroleptic Malignant Syndrome: A contrast of causes, diagnoses, and management. Annals of Clinical Psychiatry 24(2):155-62. Obtained online at https://www.researchgate.net/publication/224916051_Serotonin_syndrom e_vs_neuroleptic_malignant_syndrome_A_contrast_of_causes_diagnoses_ and_management 30. Mazhar, F., Akram, S., Haider, N., & Ahmed, R. (2016). Overlapping of serotonin syndrome with neuroleptic malignant syndrome due to linezolid- fluoxetine and olanzapine-metoclopramide interactions: A case report of two serious adverse drug effects caused by medication reconciliation failure on hospital admission. Case Reports in Medicine. Obtained online at https://www.hindawi.com/journals/crim/2016/7128909/cta/ 31. Rajamani, B., Kumar, Y., & Rahman, S. M. F. (2016). Neuroleptic malignant syndrome. Journal of Family Medicine and Primary Care, 5(1),