Neuroleptic malignant syndrome and its controversies

Abstract

Some of the controversies related to NMS have an influence on our understanding of the condition and may have importance in clinical practice. There is a need for further research that should elucidate these controversies.

Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms

“…73, 79 -81 It is unclear whether these are truly risk factors or reflect the patient population with the greatest use of antipsychotic medications. 75 Coadministration of psychotropic agents seems to be an especially high risk factor for precipitating NMS; in 1 study, more than half of people with reported NMS cases were taking concomitant psychotropic agents. 77 Other risk factors include dehydration, physical exhaustion, preexisting organic brain disease, and the use of long-acting depot antipsychotics.…”

“…Administration of tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and lithium have been associated with NMS. 75 NMS also has been associated with the abrupt withdrawal of medications (eg, dopaminergic drugs used to treat Parkinson disease, such as levodopa, as well as baclofen, amantadine, some antipsychotics, and some antidepressants). 74 Lastly, the introduction to this section enumerates some of the medications commonly thought to be antiemetics or antimigraine therapies.…”

“…71,74 The incidence of NMS has been difficult to determine, with estimates ranging from 0.02% to 3%. 45,71,75 Fortunately, mortality from NMS has decreased from 76% in the 1960s to <10% to 15% more recently. 72, 76 -78 Experts suggest considering NMS in the differential diagnosis of patients presenting with fever and altered mental status who are taking or may have taken an antipsychotic.…”

“…In addition, D 2 receptor antagonism by eliminating tonic inhibition of the sympathetic nervous system leads to sympathoadrenal hyperactivity and autonomic instability. 72,75 Clinical Presentation…”

“…Fever can be treated with external cooling measures, such as cooling blankets. 72,75 Suggestions for NMS treatment are based on case reports and clinical experience, not rigorous clinical trials, limiting the strength of the evidence base. The most frequently administered drugs have been dantrolene, bromocriptine, and amantadine.…”