Dystonic reactions to cyclizine

Dagg, L. E.; Wrathall, David W

doi:10.1046/j.1365-2044.2003.328016.x

Cited by 8 publications

(3 citation statements)

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“…After originally postulating that patients with central nervous system disease may be at higher risk for these dystonic reactions [58,59,60], there have also been reports of otherwise healthy patients also experiencing dystonic reactions associated with cyclizine use (at 50 mg i.v.) [61,62]. The antidopaminergic effects and potential for dystonic reactions with cyclizine (based on the reports above) may make its use ill-advised in patients with Parkinson's disease or history of EPS.…”

Section: Antihistaminesmentioning

confidence: 99%

Eliminating Postoperative Nausea and Vomiting in Outpatient Surgery with Multimodal Strategies including Low Doses of Nonsedating, Off-Patent Antiemetics: Is “Zero Tolerance“ Achievable?

Skledar

Williams

Vallejo

et al. 2007

The Scientific World JOURNAL

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For ondansetron, dexamethasone, and droperidol (when used for prophylaxis), each is estimated to reduce risk of postoperative nausea and/or vomiting (PONV) by approximately 25%. Current consensus guidelines denote that patients with 0–1 risk factors still have a 10–20% risk of encountering PONV, but do not yet advocate routine prophylaxis for all patients with 10–20% risk. In ambulatory surgery, however, multimodal prophylaxis has gained favor, and our previously published experience with routine prophylaxis has yielded PONV rates below 10%. We now propose a “zero-tolerance” antiemetic algorithm for outpatients that involves routine prophylaxis by first avoiding volatile agents and opioids to the extent possible, using locoregional anesthesia, multimodal analgesia, and low doses of three nonsedating off-patent antiemetics. Routine oral administration (immediately on arrival to the ambulatory surgery suite) of perphenazine 8 mg (antidopaminergic) or cyclizine 50 mg (antihistamine), is followed by dexamethasone 4 mg i.v. after anesthesia induction (dexamethasone is avoided in diabetic patients). At the end of surgery, ondansetron (4 mg i.v., now off-patent) is added. Rescue therapy consists of avoiding unnecessary repeat doses of drugs acting by the same mechanism: haloperidol 2 mg i.v. (antidopaminergic) is prescribed for patients pretreated with cyclizine or promethazine 6.25 mg i.v. (antihistamine) for patients having been pretreated with perphenazine. If available, a consultation for therapeutic acupuncture procedure is ordered. Our approach toward “zero tolerance” of PONV emphasizes liberal identification of and prophylaxis against common risks.

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Section: Antihistaminesmentioning

confidence: 99%

Eliminating Postoperative Nausea and Vomiting in Outpatient Surgery with Multimodal Strategies including Low Doses of Nonsedating, Off-Patent Antiemetics: Is “Zero Tolerance“ Achievable?

Skledar

Williams

Vallejo

et al. 2007

The Scientific World JOURNAL

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“…Recently, there have been case reports [1, 2] implicating cyclizine in probable dystonic reactions. The withdrawal of droperidol has been cited as a reason for the resurgence in popularity of cyclizine.…”

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confidence: 99%

Transient paralysis after administration of a single dose of cyclizine

Sandhu¹,

Clarke²,

Greaves³

et al. 2005

Anaesthesia

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SummaryTwo patients with underlying neuromuscular disorders developed varying degrees of paralysis after a single dose of cyclizine, one necessitating full mechanical ventilation. These cases appear to be unique in the literature and represent an increasing spectrum of adverse reactions seen with the greater use of cyclizine. Recently, there have been case reports [1,2] implicating cyclizine in probable dystonic reactions. The withdrawal of droperidol has been cited as a reason for the resurgence in popularity of cyclizine. Clinicians need to be aware that extra-pyramidal reactions can occur following administration of this drug, and that these symptoms need to be recognised and treated promptly. We present two patients who received correctly administered doses of cyclizine diluted in 10 ml water and given slowly intravenously. Both cases resulted in profound muscle weakness. Case 1A 19-year-old girl, weighing 24 kg, with Russell-Silver syndrome [3] and scoliosis underwent elective posterior instrumentation of the spine between T3 and L1. She was anaesthetised by total intravenous anaesthesia with propofol and remifentanil infusions and her lungs were ventilated with an air-oxygen mixture. No relaxant was used. Surgery was uneventful and she returned to the critical care unit for elective postoperative ventilation and was later extubated. Following this, she received PCA morphine for pain relief, set to deliver 0.5 mg boluses with a 5 min lockout. She became fluid overloaded on the second postoperative day, which was managed with fluid restriction and a small dose (1 mg) of furosemide, with a good response. She developed nausea and was treated initially with intravenous ondansetron 3 mg followed 30 min later by intravenous metoclopramide 3 mg with good effect. The same two drugs were repeated 12 h later in identical dosages but spaced apart by 2 h. This time they were ineffective and consequently 2 h later, she was given intravenous cyclizine 15 mg. Ten minutes later, she developed what appeared to be a flaccid paralysis of all her limbs, with loss of reflexes and an up-going gaze. She was unresponsive to oral commands. This spontaneously resolved over the next 10 min. She continued to breath effectively during the period of hypotonia. Blood was taken for serum tryptase assay to exclude a type 3 hypersensitivity reaction, but this subsequently was reported as normal. A yellow card was sent to the Committee on Safety of Medicines (CSM), reporting a suspected adverse drug reaction. Case 2A fit 19-year-old, Anglo-Indian male undergoing squint surgery lasting 1 h had an uneventful spontaneously breathing anaesthetic using a laryngeal mask airway for airway control. He received glycopyrronium, propofol and fentanyl at induction and anaesthesia was maintained with isoflurane in an oxygen and nitrous oxide gas mixture. During the procedure, intravenous ketorolac 15 mg was administered. At the end of surgery, the surgeon performed a retro-ocular nerve block with 0.25% levo-bupivacaine 3 ml. In recovery, following an epi...

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“…Although the incidence of dystonic reactions to cyclizine is thought to be low there have been a number of reports recently [1–3] and further reports may lead to the suggestion that they are more common in patients with central neurological disease.…”

mentioning

confidence: 99%