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Acute dystonia after initial doses of ziprasidone: A case report
Progress in Neuro-Psychopharmacology & Biological Psychiatry 30 (2006) 745 – 747 www.elsevier.com/locate/pnpbp
Case Report
Acute dystonia after initial doses of ziprasidone: A case report Mehmet Yumru a , Haluk A. Savas a,⁎, Salih Selek a , Esen Savas b a b
Department of Psychiatry, Gaziantep University Faculty of Medicine, Gaziantep, Turkey Department of Internal Medicine, Av. Cengiz Gokcek State Hospital, Gaziantep, Turkey Accepted 30 January 2006 Available online 6 March 2006
Abstract We present the case of an 18-year-old man, who was admitted with an obsessive compulsive disorder (OCD) since 17 years old. He had symmetry and contamination obsessions and cleaning compulsions, and had been treated with fluoxetine 40 mg/day for 2 months. The patient was not taking additional psychotropic medication. We made ziprasidone augmentation to the treatment. First day, ziprasidone 40 mg bid was applied. Four hours after the evening dose, the patient complained about distress. He demonstrated a notable torticollis and dystonic posture to his left side. Intramuscular biperiden lactate (5 mg) was given, and dystonic symptoms resolved within 30 min. Ziprasidone is a new atypical antipsychotic with reported low potential for extrapyramidal side effects. To our knowledge, acute dsytonic reaction with initial doses of ziprasidone in adult has not been reported yet. This case report describes a male patient with OCD developed acute dystonia shortly after initial doses (80 mg/day) of ziprasidone and discusses precautions in antipsychotic use. © 2006 Elsevier Inc. All rights reserved. Keywords: Acute dystonia; Atypical antipsychotics; Ziprasidone
1. Introduction Acute dystonia induced by antipsychotic drugs is described as “sustained abnormal postures or muscle spasms that develop within seven days of starting or rapidly raising the dose of the antipsychotic medication, or of reducing the medication used to treat (or prevent) acute extrapyramidal symptoms (e.g. anticholinergic agents)” (American Psychiatric Association, 1994). Acute dystonia induced by drug treatment can be a side effect of treatment with antipsychotic drugs and other drugs, and it may occur at an early stage of treatment. The prevalence varies widely from 2% to 90% (Casey, 1992, 1994). Ziprasidone, which was approved by the Food and Drug Administration Of United States in February 2001, is an atypical antipsychotic with a unique combination of pharmacologic properties that may benefit patients with anxietyspectrum disorders (Crane, 2005). Various augmentation
strategies have been employed to treat patients with OCD whose symptoms are refractory to standard pharmacotherapy. Common approaches include augmentation with benzodiazepines, antidepressants, and mood stabilizers (Coplan et al., 1993; Hollander et al., 2002). Recent findings suggest that adjunctive therapy with the newer atypical antipsychotics may offer a promising treatment option for patients with refractory OCD (Marazziti and Pallanti, 1999; Etxebeste et al., 2000; Marusic and Farmer, 2000). Ziprasidone is a second-generation antipsychotic that is reported to induce extrapyramidal side effects at a rate similar to that of placebo (Weiden Peter et al., 2002). To our knowledge, acute dsytonic reaction with initial doses of ziprasidone in adult has not been reported. The following case report describes a male patient with OCD, who developed acute dystonia shortly after an initial dose of ziprasidone. 2. Case
Abbreviations: OCD, obsessive compulsive disorder. ⁎ Corresponding author. Tel.: +90 342 3606060x76361; fax: +90 342 3603350. E-mail address: [email protected] (H.A. Savas). 0278-5846/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pnpbp.2006.01.024
An 18-year-old man was admitted to the outpatient psychiatry unit with a diagnosis of OCD for a 1-year period. He has been admitted to the outpatient unit of a state hospital
746
M. Yumru et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry 30 (2006) 745–747
with obsessive symptoms such as symmetry obsession and cleaning compulsion. Yale Brown Obsessive Compulsive Scale (Goodman et al., 1989) score was 31. Although he had previously been treated with fluoxetine 40 mg/day for the last 2 months, he had never been on other treatments before. The patient was not taking any other psychotropic medication. We added ziprasidone on to the treatment. First day, ziprasidone 40 mg bid was applied. Four hours after the second dose, the patient complained about irritability. The day after he admitted to our clinic urgently, he complained about a notable torticollis and dystonic posture to his left. Upon admission, a complete medical history and physical examination was performed, revealing no additional physical symptoms on physical examination was found, and the results of a comprehensive metabolic panel were later found to be within normal limits. The patient was diagnosed as neuroleptic induced acute dystonia according to DSM IV criteria (American Psychiatric Association, 1994). Therefore, ziprasidone was discontinued and then biperiden lactate (5mg) was applied intramuscularly. Thirty minutes following the first dose of biperiden lactate, acute dystonia diminished and dystonic symptoms such as back pain were completely resolved within the next 24 h. 3. Discussion Acute dystonia is a distressing and sometimes life-threatening form of extrapyramidal syndrome, occuring within 3 days of initiation of antipsychotic therapy in 90% of cases (Kaplan and Sadock, 1995). Previously described risk factors include young age, male gender, history of acute dystonic reactions and cocaine use (van Harten et al., 1999). Our case was young and male, thus carrying some risk factors. The results of clinical trials of the newer antipsychotic drugs such as clozapine, risperidone, olanzapine, amisulpride, quetiapine and sertindole suggest a lower liability for acute dystonic reactions than conventional antipsychotic drugs such as haloperidol. The growing use of atypical antipsychotics has led to a decrease of acute dystonic reactions. However with the introduction and common usage of atypicals in psychiatric disorders some cases of acute dystonia due to these drugs were reported previously (Kropp et al., 2004; Alevizos et al., 2003; Brody, 1996). Although three cases of ziprasidone-induced acute dystonia were reported in the literature; dystonia due to initial doses has not been reported yet. Ramos et al. (2003) reported an oculogyric crisis in an adolescent. Two reports of acute dystonia was reported in adult; a case in the second (Dew and Hughes, 2004) and a case in the fourth day (Mason et al., 2005) of the treatment with ziprasidone. In this case, acute dystonia developed in an OCD patient who was receiving initial doses of ziprasidone (80 mg/day). To the best of our knowledge this is the first case in the literature reporting an acute dystonia due to an initial doses of ziprasidone (80 mg/day) in the treatment of OCD. Ziprasidone has higher affinity for human 5HT2A receptors than dopamine D2 receptors. D2 receptor affinity of ziprasidone for human receptors and rat transporters relatively lower than haloperidol and risperidone, but higher than olanzapine and
quetiapine (Schmidt et al., 2001). So this kind of D2 receptor affinity may cause higher frequency of extrapyramidal syndromes including acute dystonia than other atypical antipsychotics. A pharmacokinetic interaction between ziprasidone and fluoxetine through CYP 3A4 might be kept in mind but ziprasidone is mainly metabolized via aldehyde oxidase pathway and as authors we think that this interaction plays no importance in this side effect case (Weiden Peter et al., 2002). On the other hand dystonia may be caused by fluoxetine which has already been used by the patient. But the stability of the dose and the relatively long time period for fluoxetine usage excludes such a possibility. Fluoxetine induced acute dystonia was reported in the literature, but developed short after the medication (Dominguez-Moran et al., 2001). 4. Conclusion Although ziprasidone have been reported extrapyramidal syndrome rates lower or similar to placebo, it may cause acute dystonia. We recommend to behave more cautiously when starting to, even an atypical antipsychotic such as ziprasidone, in order to avoid from unwanted events such as acute dystonia, especially in young and male patients. References Alevizos B, Papageorgiou C, Christodoulou GN. Acute dystonia caused by low dosage of olanzapine. J Neuropsychiatry Clin Neurosci 2003;15:241. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: APA; 1994. Schmidt Anne W, Lebel Lorraine A, Harry R, Howard Jr, Zorn Stevin H. Ziprasidone: a novel antipsychotic agent with a unique human receptor binding profile. Eur J Pharmacol 2001;425:197–201. Brody AL. Acute dystonia induced by rapid increase in risperidone dosage. J Clin Psychopharmacol 1996;16:461–2. Casey DE. Neuroleptic−induced acute dystonia. In: Lang AE, Weiner WJ, editors. Drug-induced movement disorders. Mount Kisco, NY: Futura; 1992. p. 21–40. Casey DE. Neuroleptic-induced acute dystonia. In: Widiger TA, Frances AJ, Pincus HA, First MB, Ross R, Davis W, editors. DSM-IV Source Book, vol. 1. Washington: American Psychiatric Association; 1994. p. 545–59. Coplan JD, Tiffon L, Gorman JM. Therapeutic strategies for the patient with treatment-resistant anxiety. J Clin Psychiatry 1993;54:69–74. Crane DL. Ziprasidone as an augmenting agent in the treatment of anxietyspectrum disorders. CNS Spectr 2005;10:176–9. Dew RE, Hughes D. Acute dystonic reaction with moderate-dose ziprasidone. J Clin Psychopharmacol 2004;24:563–4. Dominguez-Moran JA, Callejo JM, Fernandez-Ruiz LC, Martinez-Castrillo JC. Acute paroxysmal dystonia induced by fluoxetine. Mov Disord 2001;16:767–9. Etxebeste M, Aragues E, Malo P, Pacheco L. Olanzapine and panic attacks. Am J Psychiatry 2000;157:659–60. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale brown obsessive compulsive scale: I. Development, use and reliability. Arch Gen Psychiatry 1989;46:1006. Hollander E, Beinstock CA, Koran LM, Pallanti S, Marazziti D, Rasmussen SA, et al. Refractory obsessive-compulsive disorder: state-of-the-art treatment. J Clin Psychiatry 2002;63:20–9. Kaplan HI, Sadock BJ. Comprehensive textbook of psychiatry. 6th ed. Baltimore: Williams & Wilkins; 1995. p. 2003–4. Kropp S, Hauser U, Ziegenbein M. Quetiapine-associated acute dystonia. Ann Pharmacother 2004;38:719–20.
M. Yumru et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry 30 (2006) 745–747 Marazziti D, Pallanti S. Effectiveness of olanzapine treatment for severe obsessive-compulsive disorder. Am J Psychiatry 1999;156:1834–5. Marusic A, Farmer A. Antidepressant augmentation with low-dose olanzapine in obsessive-compulsive disorder. Br J Psychiatry 2000;177:567. Mason MN, Johnson CE, Piasecki M. Ziprasidone-induced acute dystonia. Am J Psychiatry 2005;162:625–6. Ramos AE, Shytle RD, Silver AA, Sanberg PR. Ziprasidone-induced oculogyric crisis. J Am Acad Child Adolesc Psych 2003;42:1013–4.
747
van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ 1999;319:623–6. Weiden Peter J, Naveed Iqbal, Mendelowitz Alan J, Rajiv Tandon, Zimbroff Dan L, Ruth Ross. Best clinical practice with ziprasidone: update after one year of experience. J Psychiatr Pract 2002;8:81–97.
Case Report
Acute dystonia after initial doses of ziprasidone: A case report Mehmet Yumru a , Haluk A. Savas a,⁎, Salih Selek a , Esen Savas b a b
Department of Psychiatry, Gaziantep University Faculty of Medicine, Gaziantep, Turkey Department of Internal Medicine, Av. Cengiz Gokcek State Hospital, Gaziantep, Turkey Accepted 30 January 2006 Available online 6 March 2006
Abstract We present the case of an 18-year-old man, who was admitted with an obsessive compulsive disorder (OCD) since 17 years old. He had symmetry and contamination obsessions and cleaning compulsions, and had been treated with fluoxetine 40 mg/day for 2 months. The patient was not taking additional psychotropic medication. We made ziprasidone augmentation to the treatment. First day, ziprasidone 40 mg bid was applied. Four hours after the evening dose, the patient complained about distress. He demonstrated a notable torticollis and dystonic posture to his left side. Intramuscular biperiden lactate (5 mg) was given, and dystonic symptoms resolved within 30 min. Ziprasidone is a new atypical antipsychotic with reported low potential for extrapyramidal side effects. To our knowledge, acute dsytonic reaction with initial doses of ziprasidone in adult has not been reported yet. This case report describes a male patient with OCD developed acute dystonia shortly after initial doses (80 mg/day) of ziprasidone and discusses precautions in antipsychotic use. © 2006 Elsevier Inc. All rights reserved. Keywords: Acute dystonia; Atypical antipsychotics; Ziprasidone
1. Introduction Acute dystonia induced by antipsychotic drugs is described as “sustained abnormal postures or muscle spasms that develop within seven days of starting or rapidly raising the dose of the antipsychotic medication, or of reducing the medication used to treat (or prevent) acute extrapyramidal symptoms (e.g. anticholinergic agents)” (American Psychiatric Association, 1994). Acute dystonia induced by drug treatment can be a side effect of treatment with antipsychotic drugs and other drugs, and it may occur at an early stage of treatment. The prevalence varies widely from 2% to 90% (Casey, 1992, 1994). Ziprasidone, which was approved by the Food and Drug Administration Of United States in February 2001, is an atypical antipsychotic with a unique combination of pharmacologic properties that may benefit patients with anxietyspectrum disorders (Crane, 2005). Various augmentation
strategies have been employed to treat patients with OCD whose symptoms are refractory to standard pharmacotherapy. Common approaches include augmentation with benzodiazepines, antidepressants, and mood stabilizers (Coplan et al., 1993; Hollander et al., 2002). Recent findings suggest that adjunctive therapy with the newer atypical antipsychotics may offer a promising treatment option for patients with refractory OCD (Marazziti and Pallanti, 1999; Etxebeste et al., 2000; Marusic and Farmer, 2000). Ziprasidone is a second-generation antipsychotic that is reported to induce extrapyramidal side effects at a rate similar to that of placebo (Weiden Peter et al., 2002). To our knowledge, acute dsytonic reaction with initial doses of ziprasidone in adult has not been reported. The following case report describes a male patient with OCD, who developed acute dystonia shortly after an initial dose of ziprasidone. 2. Case
Abbreviations: OCD, obsessive compulsive disorder. ⁎ Corresponding author. Tel.: +90 342 3606060x76361; fax: +90 342 3603350. E-mail address: [email protected] (H.A. Savas). 0278-5846/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pnpbp.2006.01.024
An 18-year-old man was admitted to the outpatient psychiatry unit with a diagnosis of OCD for a 1-year period. He has been admitted to the outpatient unit of a state hospital
746
M. Yumru et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry 30 (2006) 745–747
with obsessive symptoms such as symmetry obsession and cleaning compulsion. Yale Brown Obsessive Compulsive Scale (Goodman et al., 1989) score was 31. Although he had previously been treated with fluoxetine 40 mg/day for the last 2 months, he had never been on other treatments before. The patient was not taking any other psychotropic medication. We added ziprasidone on to the treatment. First day, ziprasidone 40 mg bid was applied. Four hours after the second dose, the patient complained about irritability. The day after he admitted to our clinic urgently, he complained about a notable torticollis and dystonic posture to his left. Upon admission, a complete medical history and physical examination was performed, revealing no additional physical symptoms on physical examination was found, and the results of a comprehensive metabolic panel were later found to be within normal limits. The patient was diagnosed as neuroleptic induced acute dystonia according to DSM IV criteria (American Psychiatric Association, 1994). Therefore, ziprasidone was discontinued and then biperiden lactate (5mg) was applied intramuscularly. Thirty minutes following the first dose of biperiden lactate, acute dystonia diminished and dystonic symptoms such as back pain were completely resolved within the next 24 h. 3. Discussion Acute dystonia is a distressing and sometimes life-threatening form of extrapyramidal syndrome, occuring within 3 days of initiation of antipsychotic therapy in 90% of cases (Kaplan and Sadock, 1995). Previously described risk factors include young age, male gender, history of acute dystonic reactions and cocaine use (van Harten et al., 1999). Our case was young and male, thus carrying some risk factors. The results of clinical trials of the newer antipsychotic drugs such as clozapine, risperidone, olanzapine, amisulpride, quetiapine and sertindole suggest a lower liability for acute dystonic reactions than conventional antipsychotic drugs such as haloperidol. The growing use of atypical antipsychotics has led to a decrease of acute dystonic reactions. However with the introduction and common usage of atypicals in psychiatric disorders some cases of acute dystonia due to these drugs were reported previously (Kropp et al., 2004; Alevizos et al., 2003; Brody, 1996). Although three cases of ziprasidone-induced acute dystonia were reported in the literature; dystonia due to initial doses has not been reported yet. Ramos et al. (2003) reported an oculogyric crisis in an adolescent. Two reports of acute dystonia was reported in adult; a case in the second (Dew and Hughes, 2004) and a case in the fourth day (Mason et al., 2005) of the treatment with ziprasidone. In this case, acute dystonia developed in an OCD patient who was receiving initial doses of ziprasidone (80 mg/day). To the best of our knowledge this is the first case in the literature reporting an acute dystonia due to an initial doses of ziprasidone (80 mg/day) in the treatment of OCD. Ziprasidone has higher affinity for human 5HT2A receptors than dopamine D2 receptors. D2 receptor affinity of ziprasidone for human receptors and rat transporters relatively lower than haloperidol and risperidone, but higher than olanzapine and
quetiapine (Schmidt et al., 2001). So this kind of D2 receptor affinity may cause higher frequency of extrapyramidal syndromes including acute dystonia than other atypical antipsychotics. A pharmacokinetic interaction between ziprasidone and fluoxetine through CYP 3A4 might be kept in mind but ziprasidone is mainly metabolized via aldehyde oxidase pathway and as authors we think that this interaction plays no importance in this side effect case (Weiden Peter et al., 2002). On the other hand dystonia may be caused by fluoxetine which has already been used by the patient. But the stability of the dose and the relatively long time period for fluoxetine usage excludes such a possibility. Fluoxetine induced acute dystonia was reported in the literature, but developed short after the medication (Dominguez-Moran et al., 2001). 4. Conclusion Although ziprasidone have been reported extrapyramidal syndrome rates lower or similar to placebo, it may cause acute dystonia. We recommend to behave more cautiously when starting to, even an atypical antipsychotic such as ziprasidone, in order to avoid from unwanted events such as acute dystonia, especially in young and male patients. References Alevizos B, Papageorgiou C, Christodoulou GN. Acute dystonia caused by low dosage of olanzapine. J Neuropsychiatry Clin Neurosci 2003;15:241. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: APA; 1994. Schmidt Anne W, Lebel Lorraine A, Harry R, Howard Jr, Zorn Stevin H. Ziprasidone: a novel antipsychotic agent with a unique human receptor binding profile. Eur J Pharmacol 2001;425:197–201. Brody AL. Acute dystonia induced by rapid increase in risperidone dosage. J Clin Psychopharmacol 1996;16:461–2. Casey DE. Neuroleptic−induced acute dystonia. In: Lang AE, Weiner WJ, editors. Drug-induced movement disorders. Mount Kisco, NY: Futura; 1992. p. 21–40. Casey DE. Neuroleptic-induced acute dystonia. In: Widiger TA, Frances AJ, Pincus HA, First MB, Ross R, Davis W, editors. DSM-IV Source Book, vol. 1. Washington: American Psychiatric Association; 1994. p. 545–59. Coplan JD, Tiffon L, Gorman JM. Therapeutic strategies for the patient with treatment-resistant anxiety. J Clin Psychiatry 1993;54:69–74. Crane DL. Ziprasidone as an augmenting agent in the treatment of anxietyspectrum disorders. CNS Spectr 2005;10:176–9. Dew RE, Hughes D. Acute dystonic reaction with moderate-dose ziprasidone. J Clin Psychopharmacol 2004;24:563–4. Dominguez-Moran JA, Callejo JM, Fernandez-Ruiz LC, Martinez-Castrillo JC. Acute paroxysmal dystonia induced by fluoxetine. Mov Disord 2001;16:767–9. Etxebeste M, Aragues E, Malo P, Pacheco L. Olanzapine and panic attacks. Am J Psychiatry 2000;157:659–60. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale brown obsessive compulsive scale: I. Development, use and reliability. Arch Gen Psychiatry 1989;46:1006. Hollander E, Beinstock CA, Koran LM, Pallanti S, Marazziti D, Rasmussen SA, et al. Refractory obsessive-compulsive disorder: state-of-the-art treatment. J Clin Psychiatry 2002;63:20–9. Kaplan HI, Sadock BJ. Comprehensive textbook of psychiatry. 6th ed. Baltimore: Williams & Wilkins; 1995. p. 2003–4. Kropp S, Hauser U, Ziegenbein M. Quetiapine-associated acute dystonia. Ann Pharmacother 2004;38:719–20.
M. Yumru et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry 30 (2006) 745–747 Marazziti D, Pallanti S. Effectiveness of olanzapine treatment for severe obsessive-compulsive disorder. Am J Psychiatry 1999;156:1834–5. Marusic A, Farmer A. Antidepressant augmentation with low-dose olanzapine in obsessive-compulsive disorder. Br J Psychiatry 2000;177:567. Mason MN, Johnson CE, Piasecki M. Ziprasidone-induced acute dystonia. Am J Psychiatry 2005;162:625–6. Ramos AE, Shytle RD, Silver AA, Sanberg PR. Ziprasidone-induced oculogyric crisis. J Am Acad Child Adolesc Psych 2003;42:1013–4.
747
van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ 1999;319:623–6. Weiden Peter J, Naveed Iqbal, Mendelowitz Alan J, Rajiv Tandon, Zimbroff Dan L, Ruth Ross. Best clinical practice with ziprasidone: update after one year of experience. J Psychiatr Pract 2002;8:81–97.