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A case of tardive dystonia associated with long-acting injectable paliperidone palmitate
European Neuropsychopharmacology (2016) 26, 1251–1252
www.elsevier.com/locate/euroneuro
SHORT COMMUNICATION
A case of tardive dystonia associated with long-acting injectable paliperidone palmitate Chia-Hao Maa, Yi-Ling Chiena, Chen-Chung Liua, I-Ming Chena,b,n, Chia-Hsien Linc a
Department of Psychiatry, National Taiwan University Hospital, Taiwan Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taiwan c Department of Health Industry Management, Kainan University, Taiwan b
Received 29 February 2016; accepted 15 April 2016
KEYWORDS Paliperidone palmitate; Tardive dystonia; Clozapine; Speech therapy
1.
Introduction
A recent investigation demonstrated a high prevalence of second-generation antipsychotic-related tardive syndrome (Ryu et al., 2015). Paliperidone ER and the injectable longacting depot paliperidone palmitate have been associated with tardive dyskinesia at a low rate (Gopal et al., 2014). This is a case of paliperidone palmitate-associated tardive n
Corresponding author at: Department of Psychiatry, National Taiwan University Hospital, No. 7, Chung San South Road, Taipei, Taiwan. Tel.: +886 2 23123456x67991. E-mail address: [email protected] (I.-M. Chen). http://dx.doi.org/10.1016/j.euroneuro.2016.04.006 0924-977X/& 2016 Elsevier B.V. and ECNP. All rights reserved.
dystonia who remitted after conversion to low-dose clozapine combined with speech therapy.
2.
Case report
A 28-year-old female with schizophrenia has been hospitalized twice due to poor adherence to amisulpride, aripiprazole, and paliperidone ER. Long-acting injectable paliperidone palmitate 150 mg was administered, followed by 100 mg a week later, then 150 mg monthly for the next 5 months. Her psychotic symptoms remitted. However, obsessive symptom manifesting as recurrent intrusive images was observed on the third month of treatment. The monthly
1252
C.-H. Ma et al.
paliperidone palmitate was reduced to 100 mg for the next 6 months with resolution of the obsessions. Ten months after starting paliperidone palmitate treatment, she experienced difficulty in swallowing liquids, with frequent choking. On the next month, jaw tightness with restricted opening and tongue clumsiness developed which did not respond to adjuvant clonazepam, amantadine, and baclofen. Symptoms progressed to restricted intake, weight loss, and severe dysarthria. Tc-99m TRODAT-1 brain SPECT revealed a mildly asymmetrical decrease in dopamine transporter (DAT) binding at the bilateral basal ganglia (right4left). Paliperidone palmitate was discontinued for drug-related tardive dystonia. After olanzapine failed, her orolingual dystonia finally improved after six-week clozapine 75 mg/day and subsided around five months after the last dose of paliperidone palmitate. She also received speech therapy, including sensory input-triggered muscle relaxation, swallowing, and articulation training. Her dysphagia and dysarthria quickly improved. Clozapine was slowly tapered off after restoration of weight.
bilateral basal ganglia. The etiologic role of altered dopamine signaling of the fronto-striatal circuits in obsessivecompulsive disorder may be identical in co-morbid obsessive-compulsive symptoms of antipsychotics-associated tardive dystonia (Pauls et al., 2014). The 5-year rate of remission of dystonia is only 14% (Kiriakakis et al., 1998). Exposure of less than 10 years to neuroleptics and discontinuation of the drug after the development of tardive syndrome increase the chances of remission (Kiriakakis et al., 1998). While Kiriakakis et al. did not observe the benefit of speech therapy in their study, in the present case, speech therapy provided significant symptom relief aside from clozapine (Kiriakakis et al., 1998). Thus, early detection of tardive dystonia with concurrent pharmacotherapy and rehabilitation may improve outcomes in this severe adverse effect.
3.
References
Discussion
This is the first report of paliperidone palmitate-associated tardive dystonia. This patient with treatment-related tardive dystonia is young and responded well to therapy. Previous reported cases of tardive dyskinesia associated with paliperidone palmitate had an average age of 50 years and their exposure time ranged from 6 to 20 months, while those related to paliperidone ER had shorter exposure time ranged from 4 days to 14 months (Gopal et al., 2014). Patients with tardive dystonia is characterized by young age of onset, short exposure period, potential responsiveness to anticholinergics, and poor prognosis (GimenezRoldan et al., 1985). Symptoms at onset are usually focal, include pharyngeal, oromandibular, or lingual dystonia (Kiriakakis et al., 1998). This patient experienced transient obsessive symptoms before the emergence of tardive dystonia. Her brain SPECT revealed asymmetrical decrease of DAT binding at the
Conflict of interest None.
Gimenez-Roldan, S., Mateo, D., Bartolome, P., 1985. Tardive dystonia and severe tardive dyskinesia. A comparison of risk factors and prognosis. Acta Psychiatr. Scand. 71 (5), 488–494. Gopal, S., Xu, H., Bossie, C., Buron, J.A., Fu, D.J., Savitz, A., et al., 2014. Incidence of tardive dyskinesia: a comparison of longacting injectable and oral paliperidone clinical trial databases. Int. J. Clin. Pract. 68 (12), 1514–1522. Kiriakakis, V., Bhatia, K.P., Quinn, N.P., Marsden, C.D., 1998. The natural history of tardive dystonia. A long-term follow-up study of 107 cases. Brain J. Neurol. 121 (Pt11), 2053–2066. Pauls, D.L., Abramovitch, A., Rauch, S.L., Geller, D.A., 2014. Obsessive-compulsive disorder: an integrative genetic and neurobiological perspective. Nat. Rev. Neurosci. 15 (6), 410–424. Ryu, S., Yoo, J.H., Kim, J.H., Choi, J.S., Baek, J.H., Ha, K., et al., 2015. Tardive dyskinesia and tardive dystonia with secondgeneration antipsychotics in non-elderly schizophrenic patients unexposed to first-generation antipsychotics: a cross-sectional and retrospective study. J. Clin. Psychopharmacol. 35 (1), 13–21.
www.elsevier.com/locate/euroneuro
SHORT COMMUNICATION
A case of tardive dystonia associated with long-acting injectable paliperidone palmitate Chia-Hao Maa, Yi-Ling Chiena, Chen-Chung Liua, I-Ming Chena,b,n, Chia-Hsien Linc a
Department of Psychiatry, National Taiwan University Hospital, Taiwan Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taiwan c Department of Health Industry Management, Kainan University, Taiwan b
Received 29 February 2016; accepted 15 April 2016
KEYWORDS Paliperidone palmitate; Tardive dystonia; Clozapine; Speech therapy
1.
Introduction
A recent investigation demonstrated a high prevalence of second-generation antipsychotic-related tardive syndrome (Ryu et al., 2015). Paliperidone ER and the injectable longacting depot paliperidone palmitate have been associated with tardive dyskinesia at a low rate (Gopal et al., 2014). This is a case of paliperidone palmitate-associated tardive n
Corresponding author at: Department of Psychiatry, National Taiwan University Hospital, No. 7, Chung San South Road, Taipei, Taiwan. Tel.: +886 2 23123456x67991. E-mail address: [email protected] (I.-M. Chen). http://dx.doi.org/10.1016/j.euroneuro.2016.04.006 0924-977X/& 2016 Elsevier B.V. and ECNP. All rights reserved.
dystonia who remitted after conversion to low-dose clozapine combined with speech therapy.
2.
Case report
A 28-year-old female with schizophrenia has been hospitalized twice due to poor adherence to amisulpride, aripiprazole, and paliperidone ER. Long-acting injectable paliperidone palmitate 150 mg was administered, followed by 100 mg a week later, then 150 mg monthly for the next 5 months. Her psychotic symptoms remitted. However, obsessive symptom manifesting as recurrent intrusive images was observed on the third month of treatment. The monthly
1252
C.-H. Ma et al.
paliperidone palmitate was reduced to 100 mg for the next 6 months with resolution of the obsessions. Ten months after starting paliperidone palmitate treatment, she experienced difficulty in swallowing liquids, with frequent choking. On the next month, jaw tightness with restricted opening and tongue clumsiness developed which did not respond to adjuvant clonazepam, amantadine, and baclofen. Symptoms progressed to restricted intake, weight loss, and severe dysarthria. Tc-99m TRODAT-1 brain SPECT revealed a mildly asymmetrical decrease in dopamine transporter (DAT) binding at the bilateral basal ganglia (right4left). Paliperidone palmitate was discontinued for drug-related tardive dystonia. After olanzapine failed, her orolingual dystonia finally improved after six-week clozapine 75 mg/day and subsided around five months after the last dose of paliperidone palmitate. She also received speech therapy, including sensory input-triggered muscle relaxation, swallowing, and articulation training. Her dysphagia and dysarthria quickly improved. Clozapine was slowly tapered off after restoration of weight.
bilateral basal ganglia. The etiologic role of altered dopamine signaling of the fronto-striatal circuits in obsessivecompulsive disorder may be identical in co-morbid obsessive-compulsive symptoms of antipsychotics-associated tardive dystonia (Pauls et al., 2014). The 5-year rate of remission of dystonia is only 14% (Kiriakakis et al., 1998). Exposure of less than 10 years to neuroleptics and discontinuation of the drug after the development of tardive syndrome increase the chances of remission (Kiriakakis et al., 1998). While Kiriakakis et al. did not observe the benefit of speech therapy in their study, in the present case, speech therapy provided significant symptom relief aside from clozapine (Kiriakakis et al., 1998). Thus, early detection of tardive dystonia with concurrent pharmacotherapy and rehabilitation may improve outcomes in this severe adverse effect.
3.
References
Discussion
This is the first report of paliperidone palmitate-associated tardive dystonia. This patient with treatment-related tardive dystonia is young and responded well to therapy. Previous reported cases of tardive dyskinesia associated with paliperidone palmitate had an average age of 50 years and their exposure time ranged from 6 to 20 months, while those related to paliperidone ER had shorter exposure time ranged from 4 days to 14 months (Gopal et al., 2014). Patients with tardive dystonia is characterized by young age of onset, short exposure period, potential responsiveness to anticholinergics, and poor prognosis (GimenezRoldan et al., 1985). Symptoms at onset are usually focal, include pharyngeal, oromandibular, or lingual dystonia (Kiriakakis et al., 1998). This patient experienced transient obsessive symptoms before the emergence of tardive dystonia. Her brain SPECT revealed asymmetrical decrease of DAT binding at the
Conflict of interest None.
Gimenez-Roldan, S., Mateo, D., Bartolome, P., 1985. Tardive dystonia and severe tardive dyskinesia. A comparison of risk factors and prognosis. Acta Psychiatr. Scand. 71 (5), 488–494. Gopal, S., Xu, H., Bossie, C., Buron, J.A., Fu, D.J., Savitz, A., et al., 2014. Incidence of tardive dyskinesia: a comparison of longacting injectable and oral paliperidone clinical trial databases. Int. J. Clin. Pract. 68 (12), 1514–1522. Kiriakakis, V., Bhatia, K.P., Quinn, N.P., Marsden, C.D., 1998. The natural history of tardive dystonia. A long-term follow-up study of 107 cases. Brain J. Neurol. 121 (Pt11), 2053–2066. Pauls, D.L., Abramovitch, A., Rauch, S.L., Geller, D.A., 2014. Obsessive-compulsive disorder: an integrative genetic and neurobiological perspective. Nat. Rev. Neurosci. 15 (6), 410–424. Ryu, S., Yoo, J.H., Kim, J.H., Choi, J.S., Baek, J.H., Ha, K., et al., 2015. Tardive dyskinesia and tardive dystonia with secondgeneration antipsychotics in non-elderly schizophrenic patients unexposed to first-generation antipsychotics: a cross-sectional and retrospective study. J. Clin. Psychopharmacol. 35 (1), 13–21.