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Novel antipsychotics and the neuroleptic malignant syndrome: a review and critique
1Department of Psychiatry, Case Western Reserve University and University Hospitals of Cleveland, OH 44106, USA.
Objective:
The authors' goal was to analyze reported cases of neuroleptic malignant syndrome in patients given clozapine and risperidone.
Method:
They assessed 19 cases of clozapine-induced neuroleptic malignant syndrome and 13 cases of risperidone-induced neuroleptic malignant syndrome against three criteria sets and against extent of exclusionary workup and then designated them as high or low probability of being neuroleptic malignant syndrome.
Results:
Nine of the 19 cases of clozapine-related neuroleptic malignant syndrome and eight of the 13 cases of risperidone-related neuroleptic malignant syndrome were designated as having high probability of being neuroleptic malignant syndrome. The remainder were designated as having low probability because presentations were not linked to treatment or failed to meet criteria for the syndrome.
Conclusions:
Neuroleptic malignant syndrome can occur in patients given atypical antipsychotics and resembles "classical" neuroleptic malignant syndrome. However, side effect profiles overlap considerably with neuroleptic malignant syndrome criteria, and atypical antipsychotics may cause neurotoxicities unrelated to (but misattributed as) neuroleptic malignant syndrome. Insufficient evidence exists for "atypical" neuroleptic malignant syndrome with novel antipsychotics.
Insights
Neuroleptic malignant syndrome (NMS) can occur with atypical antipsychotics like clozapine and risperidone. Many cases resemble classical NMS, but differentiating NMS from other toxicities is challenging.
Area of Science:
- Psychiatry
- Pharmacology
- Neurology
Background:
- Neuroleptic malignant syndrome (NMS) is a rare but serious adverse reaction to antipsychotic medications.
- Atypical antipsychotics, including clozapine and risperidone, are increasingly used, raising questions about their association with NMS.
Purpose of the Study:
- To analyze reported cases of NMS in patients treated with clozapine and risperidone.
- To evaluate the probability of NMS in these cases based on established criteria and workup.
- To compare NMS presentations associated with clozapine and risperidone.
Main Methods:
- Retrospective analysis of 19 clozapine-induced NMS cases and 13 risperidone-induced NMS cases.
- Assessment of cases against three sets of NMS criteria.
- Evaluation of the extent of exclusionary workup for each case.
- Classification of cases as high or low probability for NMS.
Main Results:
- Nine of 19 clozapine cases (47%) and eight of 13 risperidone cases (62%) were classified as high probability for NMS.
- Cases classified as low probability were either not clearly linked to treatment or did not meet NMS criteria.
- Overlap between side effect profiles of atypical antipsychotics and NMS criteria was observed.
Conclusions:
- NMS can occur with atypical antipsychotics and may present similarly to classical NMS.
- Atypical antipsychotics can cause neurotoxicities that may be misattributed as NMS.
- Distinguishing NMS from other adverse effects of atypical antipsychotics requires careful evaluation due to overlapping symptoms.