Nms vs ss
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neuroleptic malignant syndrome vs serotonin syndrome
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Nms vs ss
- 1. Serotonin Syndrome vs NeurolepticMalignantSyndrome PRESENTED BY DR. RAKESH MEHTA 1
- 2. NEUROLEPTIC MALIGNANT SYNDROME • NMS is a life-threatening complication that can occur anytime during the course of antipsychotic treatment. • The syndrome consist of altered mental status, generalized rigidity, hyperthermia, and autonomic instability.
- 3. Pathophysiology • Decreased levels of dopamine activity :
- 5. Causes • Usually caused by antipsychotic drug use • Typical>Atypical • Withdrawl of dopaminergic drugs • Levodopa • Other anti-dopaminergic drugs • Metoclopramide • Amantadine • Others (Berman 2011) • Lithium • Promethazine • Phenelzine • Dosulepin
- 6. Epidemiology About 0.01 to 0.02 percent of patients treated with antipsychotics develop neuroleptic malignant syndrome. Men > Female Young> Old 6
- 7. Course and Prognosis Evolve over 24-72 hours If untreated symptoms may last for 10-14 days The diagnosis is often missed : agitation may be mistakenly as exacerbation of the psychosis Mortality : 10-20% (more if depot injection)
- 8. Risk Factors • Heredity • Organic brain disease, particularly basal ganglia disorders • Low serum iron • Rapid dose escalation • Dehydration • History of NMS • More than one antipsychotic 8
- 9. NMS - Clinical Characteristics • Develops quickly over hours to days • Early signs • Change in mental status • Catatonia like features • Extrapyramidal symptoms unresponsive to antiparkinsonian agents • Autonomic dysfunction 9
- 10. Clinical Characteristics • Hyperthermia • Muscle rigidity - “lead pipe rigidity” • Agitated Delirium and/or catatonia • Autonomic dysfunction • Tachycardia • Profuse diaphoresis • Labile blood pressure 10
- 11. Laboratory findings • Rhabdomyolysis (↑ CPK) • Leukocytosis (↑WBC) • Myoglobinuria ( may cause AKI) • Low serum iron • Metabolic acidosis 11
- 12. Differential Diagnosis of NMS • Infections • Serotonin Syndrome • Catatonia • Agitated delirium • Malignant hyperthermia • Seizures 12
- 13. Treatment of NMS • Cessation of neuroleptics • Re-introduction of dopamine agonists if removed • Hydration • Temperature reduction • Intensive monitoring • Supportive care 13
- 14. Treatment of NMS Dantrolene • Dantrolene can be administered intravenously starting with an initial bolus dose of 1 to 2.5 mg/kg followed by 1 mg/kg every 6 hours up to a maximum dose of 10mg/kg/d (Bhanushali 2004) • Bromocriptine • Administered orally (or via NG tube), starting with 2.5 mg 2 or 3 times daily and increasing doses by 2.5 mg every 24 hours until a response or until reaching a maximum dose of 45 mg/d for at least 10 days (Strawn 2007) • Amantadine • 200-400 mg/day • Levodopa 14
- 15. Treatment of NMS • Benzodiazepines • Benzodiazepines reduce rigidity • Intravenous lorazepam is preferred • Rapid onset of action • Longer effective length of action • High doses (18-24mg daily) often required and tolerated • ECT • Definitive treatment • ECT considered if… • Unresponsive to pharmacologic treatment in first 24-48 hours • Prominent features of catatonia or severe rigidity 15
- 16. Serotonin Syndrome (SS) • Serotonin syndrome can be a serious complication of treatment with SSRIs, TCAs, MAOIs and other serotonergic medications • It usually occurs when 2 or more serotonin-modifying agents are used in combination or in overdose settings 16
- 17. Pathophysiology • Occurs due to excessive serotonergic activity in the CNS and PNS, usually in the context of initiation or dose increase of a serotonergic agent. 17
- 18. 1. Increase 5-HT synthesis -Tryptophan 2. MAO inhibitors (non-selective) -Isocarboxazid -phenelzine 3. Increased 5-HT release - Amphetamine - MDMA, cocaine 4. 5- HT1A receptor agonist - Mirtazipne, Rizatriptan, ergotamine, 5. 5- HT 2A receptor antagonist - 2nd gen Antipsychotics(quetiapine, olanzapine) 6. 5-HT reuptake inhibitors - SSRI, SNRI, TCA, Opioids,
- 19. Clinical Characteristics Clinical triad 1. Cognitive/behavioral alterations Delirium Catatonia Agitation Lethargy Coma 2. Autonomic instability Hyperthermia Tachycardia Diaphoresis Dilated pupils 3. Neuromuscular abnormalities Myoclonus Hyperreflexia Rigidity seizures 19
- 20. SS - Clinical Characteristics • There are no specific tests available for the diagnosis of serotonin syndrome • Blood levels of serotonin do not correlate with clinical findings • Nonspecific laboratory findings may include… • Elevated total white blood cell count, CPK levels, and transaminases, • Decreased serum bicarbonate level • Severe cases can evolve to include… • Disseminated intravascular coagulation, rhabdomyolysis, and metabolic acidosis • Renal failure and myoglobinuria • Adult respiratory distress syndrome 20
- 21. SS – Risk Factors • Administration of 2 or more serotonergic medications • Overdose • Use of lithium • Classically MAOI and SSRI or other serotonergic agent • Now much more commonly 3-6 serotonergic agents • E.g. SSRI + trazodone + tramadol • Overdose on SSRI, SNRI, atypical antipsychotic or combination 21
- 22. SS – Differential Diagnosis • NMS • Antidepressant withdrawal syndrome • Alcohol and substance withdrawal states • Extrapyramidal side-effects 22
- 23. SS – Clinical Course and Outcomes • Clinical course and outcome • Rapid onset • Usually self-limited, with an uneventful resolution, once the offending agent has been discontinued • Clues to Serotonin Syndrome • Look for it in every case of overdose • Look for it in any patient on >4 psychiatric medications • Consider it in all catatonic patients • Keep an eye out for the twitchy patient 23
- 24. Treatment of SS • Management starts with early recognition of the syndrome, and supportive care • Discontinuation of the causative drugs • Supportive therapy • Hydration • Cooling 24
- 25. Treatment of SS • Benzodiazepines • Help with catatonic features • Act as muscle relaxants • Help with agitation • Cyproheptadine • First-generation antihistamine with serotonin antagonist properties • May consider an initial dose of 12mg followed by 2mg every 2 hours if symptoms continue • Maintenance dosage is 8mg every 6 hours • Chlorpromazine • Fairly potent 5-HT2 and 5-HT1A receptor antagonist 25
- 26. NMS vs. SS Neuroleptic Malignant Syndrome Serotonin Syndrome Precipitated by Dopamine antagonists Serotoninergic agents Onset Variable (1-3 days) Variable (<1d) Vital Signs Hypertension, tachycardia, tachypnea Hypertension, tachycardia, tachypnea Temperature Hyperthermia Hyperthermia Mucosa Sialorrhea Sialorrhea Skin Diaphoresis Diaphoresis Mental Status Delirium Delirium Muscles “Lead pipe” rigidity Increased tone Reflexes Hyporeflexia Hyperreflexia, clonus Pupils Normal Dilated 26 Adapted from Birmes et al, CMAJ 2003
- 27. References 1. Berman BD. Neuroleptic malignant syndrome: a review for neurohospitalists. The Neurohospitalist. 2011 Jan;1(1):41-7. 2. Bhanushali MJ, Tuite PJ. The evaluation and management of patients with neuroleptic malignant syndrome. Neurologic Clin. 2004;22(2):389-411 3. Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(5):870-876. 4. Birmes P, Coppin D, Schmitt L, Lauque D. Serotonin syndrome: a brief review. Cmaj. 2003 May 27;168(11):1439-42.
Editor's Notes
- This estimate is produced by pooling the results of studies reporting the occurrence of NMS among large numbers of patients treated with antipsychotics at a particular center. The wide variance is thought secondary to variance in diagnostic criteria, survey techniques and clinical settings. NMS can result from treatment with atypical antipsychotics, and that it often presents with the classic features and course of illness reported previously in associated with typical antipsychotics. Only 30%, however, met the strict criteria for NMS in a case review by Carloff and Mann in 2000 the rest presented with an incomplete picture Reference Neuroleptic Malignant Syndrome. Pileggi DJ, Cook AM. Ann Pharmacother. 2016 Nov;50(11):973-981. Trollor JN, Chen X, Sachdev PS. Neuroleptic malignant syndrome associated with atypical antipsychotic drugs. CNS Drugs. 2009;23(6):477-92. Sachdev P, Kruk J ,Kneebone M, et al. Clozapine-induced neuroleptic malignant syndrome: review and report of new cases. J Clin Psychopharmacol. 1995 Oct;15(5):365-71. Residual catatonic state following neuroleptic malignant syndrome. Caroff SN, Mann SC, Keck PE Jr, Francis A. J Clin Psychopharmacol. 2000 Apr;20(2):257-9.
- Not risk factors Age It has been reported in all age groups following administration of antipsychotics. Risk Factors Heredity There are a couple of case reports of familial occurrence of NMS (Deuschl et al.1991 and Otani et al. (1991) Neuropsychiatric Diagnosis NMS is not specific to any neuropsychiatric diagnosis. It has been reported to occur in patients receiving antipsychotics for diverse neuropsychiatric disorders, as well as in medical patients with normal brain function. Various authors, however, have proposed that certain disorders may be at risk: Schizophrenia Mood disorders Organic brain disorders Developmental disabilities Pre-existing basal ganglia disorders Substance abuse, dependence, or withdrawal A particularly vulnerable time to develop NMS may be during acute withdrawal from alcohol or CNS depressant drugs when neurological status and thermoregulatory and autonomic mechanisms are already compromised. Environmental factors NMS occurs independent of climate and ambient temperatures. High ambient temperatures and humidity may augment the risk of NMS;
- Changes in mental status Obtundation Catatonia Extrapyramidal symptoms Dysarthria Dysphagia Tremor Rigidity Autonomic system dysfunction Episodic tachycardia Hypertension Study of the pattern of system development in 153 clinical case reports. Mental status changes or rigidity constituted the initial signs of the disorder in 82.3% of the cases . (Velamoor et al. 1994) References Velamoor VR, Norman RM, Caroff SN, et al. Progression of symptoms in neuroleptic malignant syndrome. J Nerv Ment Dis. 1994 Mar;182(3):168-73.
- Hyperthermia Hyperthermia and profuse sweating occurs in 98% of reported NMS cases >38C in 87% >40C in 40% Usually develops as a late manifestation of the full blown syndrome Most distinguishing feature of NMS Sets it apart from other neuroleptic related conditions such as EPS. Need to rule out other potential sources of hyperthermia such as febrile illness do to infection. Possible sources of hyperthermia: Neuroleptic induced inhibition of central dopaminergic thermoregulatory mechanisms Increased heat production derived from neuroleptic effects on skeletal muscle tone Increased heat production resulting from increased metabolism Muscle rigidity Unresponsive to antiparkinsonian medications Generalized rigidity, described as “lead pipe” in its most severe form, is reported in 97% Rigidity may be a less impressive sign when NMS is associated with atypical antipsychotics. Mental status changes Reported in 97% of the cases Manifestations delirium catatonia
- Several laboratory abnormalities are common in NMS but are either nonspecific or reflect complications of the syndrome. Rhabdomyolysis Results from myonecrosis from rigidity, hyperthermia, and ischemia CPK elevations may occur in up to 95% of cases Myoglobinuria may occur as a consequence in 67% of the cases. Leukocytosis Nonspecific No left shift Present in 98% of the cases Low serum iron Iron deficiency associated with catatonia and specifically with malignant catatonia Metabolic acidosis Present in 75% of examined cases Electroencephalogram Abnormal EEG present in >50% of cases Nonfocal, generalized, nonspecific slowing which is consistent with encephalopathy Neuroimaging Usually normal If abnormal the findings usually represent pre-existing pathology (atrophy or trauma) not and acute change related to NMS
- The differential diagnosis of NMS encompasses a broad range of disorders presenting with elevated temperature, necessitating a through medical and neurological evaluation. The associated features of rigidity, mental status changes, and autonomic dysfunction narrow the differential diagnosis. Malignant Catatonia The potentially lethal progression of catatonic states in psychotic disorders has been well described for over a century. In these cases, unchecked hyperactivity can lead to exhaustion, stupor, hyperthermia, and death. Differential diagnosis of malignant catatonia from NMS in the stuporous patient treated with neuroleptics can be difficult. NMS is to malignant catatonia what neuroleptic induced catatonia is to simple catatonia. Exertional Heat Stroke During hot weather agitated patients are at risk for exertional heatstroke. Caused by excessive accumulation of metabolically produced heat due to environmentally induced feature of heat dissipation. High temperatures Sweating Hypotension Rhabdomyolysis Classic Heat Stroke Occurs in elderly, inactive persons, involves inadequate host heat-defense responses, and is most probably a consequence of impaired heat dissipation (SNS failure) with aging. Exposure to neuroleptics and anticholinergic agents may impair thermoregulation and increase the risk of classical heatstroke. Not related to exertion Anhidrosis Respiratory alkalosis
- Nonspecific treatment consists of supportive measures and prevention of complications. Intensive monitoring (telemetry and pulse oximetry) Supportive care DVT prophylaxis Medication discontinuation Immediate discontinuation of antipsychotics are essential in managing NMS. Lithium should be discontinued. It may be hazardous to continue lithium in dehydrated patient due to concerns of toxicity. Anticholinergic medications should be discontinued do to their ability to impair heat loss and inhibit sweating, thereby exacerbating hyperthermia. Hydration Prevent hypovolemia, hypotension, shock, and renal failure. Correct electrolyte imbalance. Temperature reduction Higher temperatures are predictive of increased morbidity and mortality.
- Dantrolene Theory Inhibits contraction and heat production in muscle. It acts by inhibiting the excitation-contraction mechanism in skeletal muscles through the sequestration of calcium in the sarcoplasmic reticulum. It is not specific for malignant hyperthermia (MH). Maybe most helpful in cases of NMS with extreme temperature elevations (>40C), rhabdomyolysis and rigidity. Side effects May cause hepatic and respiratory compromise. Cardiovascular collapse may occur when coadministered with calcium channel antagonists. Sakkas and Davis (1991) 100 cases 81% of patients were helped Benefit evident within a few hours Dosage 1mg-10mg/kg/day in divided doses 1mg/kg every 6 hours for 48 hours for MH Duration of treatment is unclear
- Benzodiazepines Use of benzodiazepines may be effective in mild cases of NMS Theory GABA-A agonists could inhibit the pars reticulata inhibitory GABA-B neurons which may result in disinhibition of neighboring pars compacta DA cells with resulting striatal DA agonism. Dosage A trial of lorazepam 2 mg IV may be warranted in mild cases with close monitoring of the patient’s respiratory status.
- Noradrenergic CNS hyperactivity may play a critical role in the pathophysiology of serotonin syndrome. CNS norepinephrine concentrations are increased in the serotonin syndrome may correlate with the clinical outcome.
- Prevalence of catatonia leads some to consider it a subtype of malignant catatonia with a specific etiology Cognitive Confusion 41-77% Agitation 37-43% ANS Hyperthermia 27-34% Tachycardia 44% Nausea/Vomitting 27% Diaphoresis 49% Neuromuscular Myoclonus 49-63% Hyperreflexia 41-44% Restlessness 29% Tremor 17-61% Adapted from Mason et al XXXX Reference Mason PJ, Morris VA, Balcezak TJ. Serotonin syndrome. Presentation of 2 cases and review of the literature. Medicine (Baltimore). 2000;79(4):201-9.
- References Lane R, Baldwin D. Selective serotonin reuptake inhibitor-induced serotonin syndrome: review. J Clin Psychopharmacol. 1997 Jun;17(3):208-21. LoCurto MJ. The serotonin syndrome. Emerg Med Clin North Am. 1997 Aug;15(3):665-75.
- The onset of symptoms is usually rapid Approximately 60 percent of patients with the serotonin syndrome present within six hours after initial use of medication, an overdose, or a change in dosing. Patients with mild manifestations may present with chronic subacute symptoms. The serotonin syndrome is not believed to resolve spontaneously as long as precipitating agents continue to be administered.
- Management of the serotonin syndrome involves several steps The removal of the precipitating drugs The provision of supportive care The control of agitation The administration of 5-HT 2a antagonists The control of autonomic instability and hyperthermia. The discontinuation of punitive agents and the administration of intravenous fluids and correction of vital signs, remains a mainstay of therapy. However, an abrupt deterioration in the condition of a patient who has been conservatively treated indicates the need for an immediate, aggressive response.
- References Birmes P, Coppin D, Schmitt L, et al. Serotonin syndrome: a brief review. CMAJ. 2003;168(11):1439-42.