Neuroleptic malignant syndrome: Still a risk, but which patients may be in danger?
Hyperthermic reactions, though rare, can occur with any antipsychotic. Knowing the risk factors and early warning signs remains important to protecting your patients.
I recommend that you choose therapies empirically, based on the character, severity, and duration of symptoms in a given case.5,6,20
Table 4
How to treat neuroleptic malignant syndrome
| General measures | Diagnose early, discontinue antipsychotic, provide supportive care |
| Specific interventions under investigation | |
| Benzodiazepines | Parenteral lorazepam, 1 to 2 mg or higher; monitor respiratory status |
| Dopamine agonists | Bromocriptine, 2.5 mg every 8 hours or amantadine, 100 mg every 8 hours; monitor psychosis, blood pressure, nausea |
| Dantrolene | 1 to 2.5 mg/kg IV every 6 hours; monitor respiratory and hepatic function; avoid calcium channel blockers |
| ECT | Standard administration; avoid succinylcholine in patients with rhabdomyolysis |
REDUCING RISK OF RECURRENCE
Patients vary in susceptibility to recurrence after they recover from NMS, but the risk approaches 30% with future exposure to antipsychotics.5,6 You may be able to minimize recurrence risk by:
- reducing risk factors, such as dehydration
- considering alternatives to antipsychotics, such as treating bipolar disorder with lithium or ECT
- using atypical instead of conventional antipsychotics, starting with low dosages and titrating slowly.
Before you reintroduce antipsychotics, carefully document informed consent and your rationale for treatment decisions in the patient’s chart.
Related resources
- Neuroleptic Malignant Syndrome Information Service. Hotline for health professionals. (888) 667-8367. www.nmsis.org
- Mann SC, Caroff SN, Keck PE Jr, Lazarus A. Neuroleptic malignant syndrome and related conditions (2nd ed). Washington, DC: American Psychiatric Publishing, 2003.
- Caroff SN, Mann SC, Francis A, Fricchione GL. Catatonia: from psychopathology to neurobiology. Washington, DC: American Psychiatric Publishing (in press).
Drug brand names
- Amantadine • Symmetrel
- Aripiprazole • Abilify
- Bromocriptine • Parlodel
- Clozapine • Clozaril
- Dantrolene • Dantrium
- Haloperidol • Haldol
- Lorazepam • Ativan
- Metoclopramide • Reglan
- Olanzapine • Zyprexa
- Pramipexole • Mirapex
- Prochlorperazine • Compazine
- Promethazine • Phenergan
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Ropinirole • Requip
- Ziprasidone • Geodon
Disclosure
Dr. Caroff receives research support from Janssen Pharmaceutica and Pfizer Inc., and is a consultant to Eli Lilly and Co. and Bristol-Myers Squibb Co.
