Neuroleptic Malignant Syndrome
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Q:  Neuroleptic Malignant Syndrome

What alternative drug treatments exist when a patient experiences symptoms (specifically generalized rigidity - lead pipe) of Neuroleptic Malignant Syndrome from an antipsychotic such as Zyprexa and Risperdal?

Thank you for any answer. I am having trouble finding this information anywhere. 

Hello Ms. D' -- 
Your question brings to mind answers at two different levels.  First, there is a general tendency nowadays to use antipsychotics like Zyprexa and Risperidone as "mood stabilizers" -- with clear justification, because some of them (Zyprexa is the king in this respect) do indeed solve all three problems mood stabilizers are supposed to solve: how to treat any current manic-side symptoms; and any current depression-side symptoms; as well as preventing relapse in either direction, preferably for a long period of time (that's where Zyprexa has such long-running good evidence for efficacy). 

However, in the excitement over finding that medications which work so well in the short run dealing with manic-side symptoms also do relatively well in these other dimensions (not all the atypical antipsychotics have data supporting their use in all 3 dimensions; after Zyprexa, Seroquel and aripiprazole are the closest, with data for depression and relapse prevention, respectively, as well as anti-manic effects, at this point), we seem to have lost sight somewhat of the old "mood stabilizers", the ones that are not antipsychotics. Sorry for that long sentence. 

In the old days (I can't be old enough to be talking like this, already), we used to use lithium, valproate (Depakote), and carbamazepine (Tegretol, back then) as our mainstay mood stabilizers.  These medications are still around.  Only Zyprexa has evidence for working better than these older medications.  So, the point of all this: the original mood stabilizers are all logical candidates, in answer to your question. 

The second-level answer: not all antipsychotics are the same in their risk of causing "generalized rigidity" -- which, as you have probably learned, is related to but not the same as Neuroleptic Malignant Syndrome, as the latter also includes other signs such as confusion, laboratory abnormalities, and sometimes fever.  If you didn't have those, you might have had just "generalized rigidity", which goes under the umbrella of "extra-pyramidal symptoms", or EPS. EPS is not dangerous, as such, whereas NMS clearly is. If you had NMS, then there is probably a risk of having that experience again, or worse, if you tried another antipsychotic.  Thus my first-level answer above. But, when clearly necessary, psychiatrists do give antipsychotics to people who have had NMS. Usually we pick as different an agent as possible. 

If you had EPS on risperidone, well, that's very common and does not identify you as much more prone to severe muscle (or worse) side effects from antipsychotics. If you had EPS on Zyprexa, that's much less common and may signify something about you.  If you had NMS on both, then I would agree it's worth trying to avoid antipsychotics as much as possible, although I wouldn't rule out a very cautious trial of something else in that group, say Geodon or Seroquel, perhaps (as there is some evidence that the rest of the older ones are more likely to cause NMS; and the newest one, aripiprazole, is still getting sorted out re: its risk of NMS and EPS, because it has a very different mode of action than its cousin "atypicals").  

I hope that is of some use to you.  Good luck from here. 

Dr. Phelps

Published January, 2006


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