Extrapyramidal, Dystonic and Similar Reactions ============================================== þ General - found from antipsychotic drugs, and other phenothiazines such as Compazine and Reglan. - treated with + anticholinergic effects of antihistamines (diphenhydramine, e.g., Benadryl) 15-50 mg PO, + benztropine (e.g., Cogentin) 1-2 mg IM or PO, or trihexyphinidyl (e.g., Artane). þ Extrapyramidal Symptom Classification - Dystonic Reactions + briefly sustained or fixed abnormal postues including - torticollis - oculogyric crisis - facial grimacing - opisthotonos - laryngeal spasm + often a sense of panic or fearfulness - akathisia (see below) - Parkinsonism þ Time Onset - early (acute: hours-days): acute dystonic reactions - intermediate (acute: days-weeks): parkinsonism, akathisia - late (chronic: months-years): tardive dyskinesias þ Tardive Dyskinesia (not usually classified as extrapyramidal) - involuntary buccolinguomasticatory movements including lip-smacking, tongue protrusion, grimacing, chewing - may cause occasional loss of motor control causing patient to fall - involuntary movements and sustained postures, initially of the face, eyes, lips and tongue, but sometimes also of the fingers, toes, or trunk. þ Akathisia - sense of motor restlessness - often pacing, shifting weight from foot to foot, "restless legs" - often a psychic sense of claustrophobia (KC observation) - Akathisia is very common from Reglan and Compazine [Fleishman SB, Lavin MR, Sattler M , Szarka H. Antiemetic-induced akathisia in cancer patients receiving chemotherapy. Department of Medicine and Psychiatry, Long Island Jewish Medical Center, NY. Am J Psychiatry, 151:763-765, 1994.] Abstract: A structured, prospective telephone interview was used to assess the prevalence of akathisia in 24 cancer patients receiving metoclopramide or prochlorperazine during or after chemotherapy. Half of the patients reported subjective motor restlessness, and 75% stated that they would not have informed staff. This report suggests that akathisia is frequently unrecognized in chemotherapy patients receiving metoclopramide and prochlorperazine. - Two varieties of akathisia? "I disagree. Akathisia seems to come in at least two varieties. One associated with true extrapyramidal motor problems which may respond to cogentin, benadryl, or benzos. Another, which is not associated with pathologic dystonic motor activity but more voluntary, purposeful appearing activity and an acute restless dysphoria has not, in my limited experience, responded to cogentin, benadryl, valium, ativan, versed or opiates. I have seen this rarely with droperidol which I use frequently. We had a nasty rash of these reactions to promethazine both generic and brand name. Then it stopped. The manufacturer/s could shed no light on this. I believe that several lots of the drug were contaminated or altered in some way but I have no proof. I have some references at work (I'm at home now) on akathisia and its management and will post them or e-mail them if someone wants them." þ Is Benadryl BAD for akathisia? - "Due to anticholinergic effects, benadryl could theoretically WORSEN akathisia. Tincture of time will also often be sufficient. See my... [Mariani P. Adverse reactions to chlorpromazine in the treatment of migraine Ann Emerg Med 1988;17:380.] --Peter J. Mariani MD FACEP Vice Chair, Emergency Medicine S.U.N.Y. Health Science Center Syracuse, NY 13210 marianip@vax.cs.hscsyr.edu" - "The most appropriate Rx for akathisia side effects from phenothiazines for migraines: benzodiazepines as opposed to benadryl. (Due to anticholinergic effects, benadryl could theoretically WORSEN akathisia.) Tincture of time will also often be sufficient. - On the other hand, Scientific American Medicine states that, although "akathisia may be difficult to treat, success has been obtained with beta-adrenergic blockers, benzodiazepines, and anticholicergic drugs". The reference they give is Fleischhacker WW, Roth SD, Kane JM: The pharmacologic treatment of neuroleptic-induced akathisia, J Clin Psychopharmacol 10:12, 1990. - One study showed that Benadryl slightly helped akathisia from 20 mg of IV Reglan (but not 10 mg); given together in an IV bag. [Friedman BW, Bender B, Davitt M, et al. A Randomized Trial of Diphenhydramine as Prophylaxis Against Metoclopramide-Induced Akathisia in Nauseated Emergency Department Patients. Annals of emergency medicine 2009;53:379-85.] þ Some References about Migraine and Akathisia þ References [1] Drug-induced movement disorders. Diederich NJ - Neurol Clin - 1998 Feb; 16(1): 125-39 [2] Blaisdell GD: Akathisia: A comprehensive review and treatment summary. Pharmacopsychiatry 27:139-146, 1994 [3] Prochlorperazine induces akathisia in emergency patients. Drotts DL - Ann Emerg Med - 1999 Oct; 34(4 Pt 1): 469-75 [4] Lipinski JF, Zubenko GS, Cohen BM, et al: Propranolol in the treatment of neuroleptic-induced akathisia. Am J Psychiatry 1984; 141:412-415.