Psychotropic discontinuation leading to an NMS‐like condition

Abstract

Neuroleptic malignant syndrome (NMS) is a potentially life‐threatening condition, which can occur as a complication in patients taking antipsychotic medications. Drs Kurien and Vattakatuchery present the case of a patient with paranoid schizophrenia who developed NMS‐like symptoms following abrupt discontinuation of clozapine and venlafaxine.

Rhabdomyolysis during adjunctive treatment with cariprazine in a clozapine-resistant schizophrenia patient

“…This was recorded in January 2023 at an admission before the administration of a maintenance ECT session, during which the patient presented with relatively pronounced psychopathology including inner unrest and psychomotoric tension, which we considered causal for said relatively mild elevation. The discontinuation of amisulpride prior to the reported event could also be an, albeit improbable, causal factor, as similar conditions have been described after the discontinuation of other antipsychotic drugs ( Kurien and Vattakatuchery, 2013 ). However, as a conclusion, we consider the observed signs of rhabdomyolysis to have been caused by cariprazine, as this appears to be the most plausible causative agent, taking into account our patient’s clinical course and reports of similar cases.…”

Clinical practice guideline for clozapine use in patients with COVID‐19

“…Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal idiosyncratic reaction associated with abrupt cessation of psychotropic medication, including clozapine 36,37,38 . Symptoms of NMS can overlap with that of COVID‐19 and include mostly fever and rigidity (muscle stiffness), but also diaphoresis (excessive sweating), tremor, altered consciousness and autonomic dysfunction (fluctuating blood pressure and tachycardia) and elevated creatine kinase (CK) levels, developing often within hours or days 39…”

“…Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal idiosyncratic reaction associated with abrupt cessation of psychotropic medication, including clozapine. 36,37,38 Symptoms of NMS can overlap with that of COVID-19 and include mostly fever and rigidity (muscle stiffness), but also diaphoresis (excessive sweating), tremor, altered consciousness and autonomic dysfunction (fluctuating blood pressure and tachycardia) and elevated creatine kinase (CK) levels, developing often within hours or days. 39 Clozapine withdrawal can cause a clinical picture suggestive of cholinergic rebound, including nausea, vomiting, diarrhoea, headache, agitation and confusion and diaphoresis, 40 46,47,48 Cases of COVID-19-related catatonia have been described in non-psychiatric patients.…”

Clozapine withdrawal catatonia, psychosis and associated neuroleptic malignant syndrome

“…It is also likely that paliperidone may have contributed to the NMS component that accompanied the initial episode of clozapine withdrawal catatonia [Northoff, 2002]. It probably indicates that caution should be exercised with the use of other neuroleptics in a patient undergoing sudden clozapine withdrawal [Kurien et al, 2013].…”