neuroleptic

1
Neuroleptic Malignant Syndrome
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Patho physiology

• Relative lack of dopamine
• dopamine receptor blockade
• inadequate dopamine production

3
Patho physiology

• Supporting evidence
• Neuroleptic drugs block dopamine receptors
• occurs with other dopamine blocking drugs
• occurs on sudden withdrawal of antiparkinsonian
  therapy
• responds to dopamine agonists

4
Clinical features

• Essential
• recent or current therapy with dopamine blocking
  drug
• Neuroleptic
• other drug eg metoclopramide
• recently stopped a dopamine agonist eg L-dopa

5
Autonomic dysfunction

• 2 or more of
• hypertension or labile BP
• systolic gt 30 mmHg above baseline or
• diastolic gt 20 mmHg above baseline
• variability of gt 30 mmHg systolic or gt20 mmHg
  diastolic between readings
• tachycardia (pulse gt 30 bpm above baseline)
• diaphoresis (intense perspiring)
• incontinence
• tachypnoea (gt 25 breaths/min)

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Extra pyramidal features

• 2 or more of
• Bradykinesia (Slow movement)
• lead-pipe or cogwheel rigidity
• resting tremor
• Sialorrhoea (excessive salivation)
• Dysphagia (difficulty in swallowing)
• Dysarthria / Mutism ( inability or unwillingness
  to speak)

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Minor features

• Support but are not required for diagnosis
• rise in creatinine kinase
• altered sensorium/delirium
• leucocytosis gt 15,000x109/L
• low serum iron
• Help confirm diagnosis
• therapeutic response to dopamine agonist

8
Risk factors

• Incidence 1 (0.023.23)
• Pre-NMS
• psychomotor agitation
• dehydration

9
Risk factor

• Related to treatment
• Neuroleptic dose in first 24h gt 600 mg of
  chlorpromazine
• maximum dose in any 24h gt 600 mg of
  chlorpromazine
• required restraint or seclusion
• Associated
• past ECT

10
Management

• High risk patients
• monitor temperature tds
• monitor blood pressure tds
• record episodes of diaphoresis
• On suspicion
• assess for other medical illness
• FBC(Full blood count), MBA(Microscopic Blood
  Analysis), CK( Creatinin Kinase), serum iron
• On diagnosis
• withdraw all dopamine blocking drugs

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Drug therapy

• Bromocriptine
• 2.5 mg q8h up to 5 mg q4h
• continue for 710 days after resolution then
  taper over 12 weeks (except depot preparations)
• Dantrolene
• 23 mg/kg
• extreme rigidity, very high fever (gt 40oC),
  unable to tolerate oral treatment

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Other therapy

• Benzodiazepines
• to control agitation/delirium
• ECT
• refractory to adequate trial of dopamine
  agonist/supportive care
• after resolution of acute features
• remain catatonic or
• develop ECT-responsive psychotic features
• suspected acute lethal catatonia

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Thank you