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Neuroleptic Malignant Syndrome
Definition
NMS is an idiosyncratic life-threatening complication
of treatment with antipsychotic drugs that is
characterized by fever severe muscle rigidity and
autonomic and mental status changes
( Strawn et al 2007)
Prevalence
Although estimates of the incidence of NMS once
ran as high as 3 of patients treated with
antipsychotics more recent data suggest an
incidence of 001ndash002
This decrease in frequency likely reflects increased
awareness of the disorder more conservative
prescribing patterns and the shift to use of atypical
antipsychotics
Morbidity and Mortality
NMS remains a significant source of morbidity and mortality among patients receiving antipsychotics For example data from the US Agency for Healthcare Research and Quality indicate that about 2000 cases of NMS are diagnosed annually in hospitals in the United States incurring health care costs of $70 million with a mortality rate of 10
Differential Diagnosis of Neuroleptic
Malignant Syndrome
Infectious
Meningitis or encephalitis
Post infectious encephalomyelitis syndrome
Brain abscess
Sepsis
Psychiatric or neurological
Idiopathic malignant catatonia
Agitated delirium
Benign extrapyramidal side effects
No convulsive status epilepticus
Structural lesions particularly involving the midbrain
Toxic or pharmacological
Anticholinergic delirium
Salicylate poisoning
Malignant hyperthermia (inhalational anaesthetics
succinylcholine)
Serotonin syndrome (monoamine oxidase inhibitors triptans
linezolid)
Substances of abuse (amphetamines hallucinogens)
Withdrawal from dopamine agonists baclofen sedative hypnotics
and alcohol
Endocrine
Thyrotoxicosis
Pheochromocytoma
Environmental
Heatstroke
Diagnosis
Box 1 Clinical and laboratory features of neuroleptic
malignant syndrome
bull The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
bull Two or more of the following diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leucocytosis laboratory evidence of muscle injury (eg elevated creatininephosphokinase)
bull The symptoms are not due to another substance (eg phencyclidine) or a neurologic or other general medical condition
bull The symptoms are not better accounted for by a mental disorder (eg mood disorder with catatonic features)
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Definition
NMS is an idiosyncratic life-threatening complication
of treatment with antipsychotic drugs that is
characterized by fever severe muscle rigidity and
autonomic and mental status changes
( Strawn et al 2007)
Prevalence
Although estimates of the incidence of NMS once
ran as high as 3 of patients treated with
antipsychotics more recent data suggest an
incidence of 001ndash002
This decrease in frequency likely reflects increased
awareness of the disorder more conservative
prescribing patterns and the shift to use of atypical
antipsychotics
Morbidity and Mortality
NMS remains a significant source of morbidity and mortality among patients receiving antipsychotics For example data from the US Agency for Healthcare Research and Quality indicate that about 2000 cases of NMS are diagnosed annually in hospitals in the United States incurring health care costs of $70 million with a mortality rate of 10
Differential Diagnosis of Neuroleptic
Malignant Syndrome
Infectious
Meningitis or encephalitis
Post infectious encephalomyelitis syndrome
Brain abscess
Sepsis
Psychiatric or neurological
Idiopathic malignant catatonia
Agitated delirium
Benign extrapyramidal side effects
No convulsive status epilepticus
Structural lesions particularly involving the midbrain
Toxic or pharmacological
Anticholinergic delirium
Salicylate poisoning
Malignant hyperthermia (inhalational anaesthetics
succinylcholine)
Serotonin syndrome (monoamine oxidase inhibitors triptans
linezolid)
Substances of abuse (amphetamines hallucinogens)
Withdrawal from dopamine agonists baclofen sedative hypnotics
and alcohol
Endocrine
Thyrotoxicosis
Pheochromocytoma
Environmental
Heatstroke
Diagnosis
Box 1 Clinical and laboratory features of neuroleptic
malignant syndrome
bull The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
bull Two or more of the following diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leucocytosis laboratory evidence of muscle injury (eg elevated creatininephosphokinase)
bull The symptoms are not due to another substance (eg phencyclidine) or a neurologic or other general medical condition
bull The symptoms are not better accounted for by a mental disorder (eg mood disorder with catatonic features)
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Prevalence
Although estimates of the incidence of NMS once
ran as high as 3 of patients treated with
antipsychotics more recent data suggest an
incidence of 001ndash002
This decrease in frequency likely reflects increased
awareness of the disorder more conservative
prescribing patterns and the shift to use of atypical
antipsychotics
Morbidity and Mortality
NMS remains a significant source of morbidity and mortality among patients receiving antipsychotics For example data from the US Agency for Healthcare Research and Quality indicate that about 2000 cases of NMS are diagnosed annually in hospitals in the United States incurring health care costs of $70 million with a mortality rate of 10
Differential Diagnosis of Neuroleptic
Malignant Syndrome
Infectious
Meningitis or encephalitis
Post infectious encephalomyelitis syndrome
Brain abscess
Sepsis
Psychiatric or neurological
Idiopathic malignant catatonia
Agitated delirium
Benign extrapyramidal side effects
No convulsive status epilepticus
Structural lesions particularly involving the midbrain
Toxic or pharmacological
Anticholinergic delirium
Salicylate poisoning
Malignant hyperthermia (inhalational anaesthetics
succinylcholine)
Serotonin syndrome (monoamine oxidase inhibitors triptans
linezolid)
Substances of abuse (amphetamines hallucinogens)
Withdrawal from dopamine agonists baclofen sedative hypnotics
and alcohol
Endocrine
Thyrotoxicosis
Pheochromocytoma
Environmental
Heatstroke
Diagnosis
Box 1 Clinical and laboratory features of neuroleptic
malignant syndrome
bull The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
bull Two or more of the following diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leucocytosis laboratory evidence of muscle injury (eg elevated creatininephosphokinase)
bull The symptoms are not due to another substance (eg phencyclidine) or a neurologic or other general medical condition
bull The symptoms are not better accounted for by a mental disorder (eg mood disorder with catatonic features)
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Morbidity and Mortality
NMS remains a significant source of morbidity and mortality among patients receiving antipsychotics For example data from the US Agency for Healthcare Research and Quality indicate that about 2000 cases of NMS are diagnosed annually in hospitals in the United States incurring health care costs of $70 million with a mortality rate of 10
Differential Diagnosis of Neuroleptic
Malignant Syndrome
Infectious
Meningitis or encephalitis
Post infectious encephalomyelitis syndrome
Brain abscess
Sepsis
Psychiatric or neurological
Idiopathic malignant catatonia
Agitated delirium
Benign extrapyramidal side effects
No convulsive status epilepticus
Structural lesions particularly involving the midbrain
Toxic or pharmacological
Anticholinergic delirium
Salicylate poisoning
Malignant hyperthermia (inhalational anaesthetics
succinylcholine)
Serotonin syndrome (monoamine oxidase inhibitors triptans
linezolid)
Substances of abuse (amphetamines hallucinogens)
Withdrawal from dopamine agonists baclofen sedative hypnotics
and alcohol
Endocrine
Thyrotoxicosis
Pheochromocytoma
Environmental
Heatstroke
Diagnosis
Box 1 Clinical and laboratory features of neuroleptic
malignant syndrome
bull The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
bull Two or more of the following diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leucocytosis laboratory evidence of muscle injury (eg elevated creatininephosphokinase)
bull The symptoms are not due to another substance (eg phencyclidine) or a neurologic or other general medical condition
bull The symptoms are not better accounted for by a mental disorder (eg mood disorder with catatonic features)
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Differential Diagnosis of Neuroleptic
Malignant Syndrome
Infectious
Meningitis or encephalitis
Post infectious encephalomyelitis syndrome
Brain abscess
Sepsis
Psychiatric or neurological
Idiopathic malignant catatonia
Agitated delirium
Benign extrapyramidal side effects
No convulsive status epilepticus
Structural lesions particularly involving the midbrain
Toxic or pharmacological
Anticholinergic delirium
Salicylate poisoning
Malignant hyperthermia (inhalational anaesthetics
succinylcholine)
Serotonin syndrome (monoamine oxidase inhibitors triptans
linezolid)
Substances of abuse (amphetamines hallucinogens)
Withdrawal from dopamine agonists baclofen sedative hypnotics
and alcohol
Endocrine
Thyrotoxicosis
Pheochromocytoma
Environmental
Heatstroke
Diagnosis
Box 1 Clinical and laboratory features of neuroleptic
malignant syndrome
bull The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
bull Two or more of the following diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leucocytosis laboratory evidence of muscle injury (eg elevated creatininephosphokinase)
bull The symptoms are not due to another substance (eg phencyclidine) or a neurologic or other general medical condition
bull The symptoms are not better accounted for by a mental disorder (eg mood disorder with catatonic features)
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Diagnosis
Box 1 Clinical and laboratory features of neuroleptic
malignant syndrome
bull The development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication
bull Two or more of the following diaphoresis dysphagia tremor incontinence changes in level of consciousness ranging from confusion to coma mutism tachycardia elevated or labile blood pressure leucocytosis laboratory evidence of muscle injury (eg elevated creatininephosphokinase)
bull The symptoms are not due to another substance (eg phencyclidine) or a neurologic or other general medical condition
bull The symptoms are not better accounted for by a mental disorder (eg mood disorder with catatonic features)
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
PCP (Phencyclidine)
Angel dust has a reputation for causing psychotic episodes but what are the true facts behind PCP
PCP or phenylcyclohexylpiperidine is a stimulant with strong hallucinogenic properties Its sold as a white crystalline powder which can be prepared for injection sniffing smoking or swallowing A liquid form commonly called embalming fluid can also be found
What are the effects of PCP
Feelings of dreaminess and mild hallucinations
Users also experience distortions in their perception of time and space
What are the risks of taking PCP
Even in low doses PCP can lead to severe psychological trauma
Users may feel agitated and paranoid leading to outbursts of violent behaviour including self-mutilation
Large doses can cause respiratory arrest or kidney failure
Excessive doses can lead to convulsions and even death
It can be difficult to administer safe doses of a drug whose strength wildly fluctuates
PCP is frequently laced with other illicit substances (such as marijuana) and the buyer not made aware of its presence
The law and PCP
Phencyclidine is a Class A drug meaning possession can carry a sentence of up to seven years in prison
Other terms for PCP
Angel dust ozone embalming fluid wack rocketfuel elephant tranquiliser dust kools and sherms
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Definitions
Diaphoresis Leukocytosis
A simple and easy way
to understand the
profuse diaphoresis
definition is to think of
this condition as simply
sweating excessively
Leukocytosis defined as a white blood cell count greater than 11000 per mm3 (11 X 109 per L)1
is frequently found in the course of routine laboratory testing
An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process Occasionally leukocytosis is the sign of a primary bone marrow abnormality in white blood cell production maturation or death (apoptosis) related to a leukemiaor myeloproliferative disorder
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Significance of elevated levels of serum
creatine phosphokinase in febrile
diseases a prospective study
Peak value of blood myoglobin predicts
acute renal failure induced by
rhabdomyolysis
The incidence and significance of elevated serum levels of creatine phosphokinase (CPK) in febrile diseases were studied prospectively in all patients admitted with fever to a department of medicine during 1 year
High serum CPK levels were detected in 70 (28) of 247 febrile patients but in only six (6) of 105 afebrile control patients (P =0001) Elevated CPK levels were not related to any specific diagnosis
Logistic regression analysis identified five factors that correlated both significantly and independently with elevation of CPK values increased blood ureanitrogen level low serum phosphate level a stuporous or comatose state tremor and muscle tenderness
Myoglobinuria detected in 14 patients was predictive of a fatal outcome but a high CPK level by itself was not an independent correlate of mortality In summary CPK elevation is not uncommon in febrile diseases but because it does not reflect a specific etiology it does not necessarily indicate that an extensive diagnostic work-up is required
Acute renal failure (ARF) is the most important complication of rhabdomyolysis Serial measurements of blood myoglobin might be useful for predicting rhabdomyolysis-induced ARF
Methods
Thirty patients with rhabdomyolysis were examined The causes of rhabdomyolysis were trauma burns and ischemia among others Serial blood myoglobin levels were measured by immunochromatography and the peak value was determined The relationship between blood myoglobin levels and the incidence of ARF was evaluated
Results
The median peak blood myoglobin level was 3335 ngmL Acute renal failure occurred in 12 patients (40) Nine patients (30) underwent renal replacement therapy Peak creatine kinase and peak blood myoglobin levels in the ARF group were significantly higher than those in the non-ARF group Three patients in the ARF group were treated with renal replacement therapy before occurrence of uremia because of extremely high levels of blood myoglobin (gt10 000 ngmL) Receiver operating characteristic analysis showed that the area under the curve for blood myoglobin that predicted ARF was 088 and the best cutoffvalue for blood myoglobin was 3865 ngmL
Conclusions
The peak value for blood myoglobin might be a good predictor of rhabdomyolysis-induced ARF Early renal protective therapies should be considered for patients with rhabdomyolysis at high risk of ARF
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Diagnosis
NMS is often difficult to distinguish from more
common extrapyramidal side effects of
antipsychotics and from other disorders presenting
with similar symptoms
About 16 of cases of NMS develop within 24 hours
after initiation of antipsychotic treatment 66 within
the first week and virtually all cases within 30 days
(11) It would be unusual for NMS to occur beyond 1
month after initiation of treatment unless the dose
was increased or an additional antipsychotic
administered
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Length of Recovery Once NMS is diagnosed and
oral antipsychotic drugs are discontinued NMS is self-limited in most cases The mean recovery time after drug discontinuation is in the range of 7ndash10 days with 63 of patients recovering within 1 week and nearly all within 30 days
However the duration of NMS episodes may be prolonged when long-acting depot antipsychotics are implicated In addition there have been several reports of patients in whom residual catatonia and parkinsonism persisted for weeks after the acute metabolic symptoms of NMS resolved
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Risk Factors
Several clinical systemic and metabolic factors
have been correlated with the incidence of NMS
including agitation dehydration restraint pre
existing abnormalities of CNS dopamine activity or
receptor function and iron deficiency
Nearly all case series of NMS patients have reported
physical exhaustion and dehydration prior to the
onset of NMS Elevated environmental temperature
has been proposed as a contributing factor in some
series although NMS can occur independent of
ambient conditions A prior episode of NMS has
been described in 15ndash20 of cases
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Treatment
Supportive Therapy
The offending agent must be withdrawn immediately after which supportive medical therapy is the mainstay of management of NMS
Volume resuscitation should be aggressive especially given that most patients with NMS are dehydrated in the acute phase of the illness Serial monitoring and correction of electrolyte abnormalities is critical
In extreme hyperthermia physical cooling measures are paramount as the peak and duration of temperature elevation are predictive of morbidity and mortality
Intensive medical care should include careful monitoring for complications including cardiorespiratory failure renal failure aspiration pneumonia and coagulopathies and may involve support of cardiac respiratory and renal function
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Pharmacological Treatments
NMS is a self-limited iatrogenic disorder and in
many cases medical management and cessation of
antipsychotic medication may suffice to reverse the
symptoms
Benzodiazepines Although a controlled evaluation
of NMS risk factors suggests that benzodiazepines
do not have a preventive effect several clinical
reports suggest that benzodiazepines administered
orally or parenterally may ameliorate symptoms and
hasten recovery in NMS particularly in milder cases
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Dopaminergic Agents Several dopaminergic drugs including
bromocriptine and amantadine may reverse parkinsonism in NMS and have been reported in case reports and meta-analyses to reduce time to recovery and halve mortality rates when used alone or in combination with other treatments
Bromocriptine can worsen psychosis and hypotension It also may precipitate vomiting and thus should be used carefully in patients at risk of aspiration Premature discontinuation of bromocriptine has resulted in rebound symptoms in some cases
Bromocriptine (Parlodel) is classified as a dopamine agonist drug that lowers prolactin levels Primarily used in Parkinsons disease patients to lower high prolactin level Bromocriptine was soon discovered to be of great use in many medical conditions as well as off label uses
Elevation of dopamine levels may lead to a marked increase in sex drive improvement in mood alertness learning ability and creativity Known off-label uses for dopaminergic drugs such as Bromocriptine include sex drive enhancement and increased ejaculation volume mood elevation appetite suppression and fat loss
Amantadine is generally initiated at 200ndash400 mgday in divided doses administered orally or through a nasogastric tube The starting dose of bromocriptine is 25 mg orally two or three times a day increased to a total daily dose of 45 mg if necessary
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Dantrolene
Because of its efficacy in anaesthetic-induced malignant hyperthermia the muscle relaxant dantrolene has been used in the treatment of NMS Dantrolene may be useful only in cases of NMS with extreme temperature elevations rigidity and true hyper metabolism
Generally rapid reversal of the hyperthermia and rigidity is observed in patients treated with dantrolene but symptoms may return if treatment is discontinued prematurely
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
ECT
A review (32) found that ECT was consistently effective even after failed pharmacotherapy and that clinical response often occurred over the course of the first several treatments Treatment response to ECT was not predicted by age sex psychiatric diagnosis or any particular features of NMS A typical ECT regimen for acute NMS would include six to 10 treatments with bilateral electrode placement
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
Antipsychotic Use Following NMS
Restarting antipsychotic treatment after resolution of an NMS episode has been associated with an estimated likelihood of developing NMS again as high as 30
At least 2 weeks should be allowed to elapse after recovery from NMS before rechallenge low doses of low-potency conventional antipsychotics or atypical antipsychotics should be titrated gradually after a test dose and patients should be carefully monitored for early signs of NMS
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
References
httpwwwsteroidsclubeubromocriptine-buy-
204html
httpwwwthesiteorgdrinkanddrugsdrugsafety
Cohen O Leibovici L Mor F Wysenbeek AJ
Significance of elevated levels of serum creatine
phosphokinase in febrile diseases a prospective
study Reviews of Infectious Diseases [1991
13(2)237-42]
Kasaoka S Todani M Kaneko T Kawamura Y Oda
Y Tsuruta R Maekawa T Peak value of blood
myoglobin predicts acute renal failure induced by
rhabdomyolysis Journal of Critical Care [2010
25(4)601-4]
