0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letter   |    
Acute Dystonia Caused by Low Dosage of Olanzapine
Basil Alevizos, M.D.; Charalabos Papageorgiou, M.D.; George N. Christodoulou, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2003;15:241-241. doi:10.1176/appi.neuropsych.15.2.241

SIR: Clinical studies have shown that although olanzapine has a low frequency of extrapyramidal and neuroendocrine side effects, it may cause acute extrapyramidal symptoms,1,2 and it appears to be intermediate between risperidone and clozapine in inducing such symptoms. We report two cases of patients who developed acute dystonia while receiving the lowest therapeutic dose, 5 mg/day, of olanzapine.

+

Case Reports

Case 1. Mrs. M is a 56-year-old woman with a 20-year history of paranoid schizophrenia. She had previously been treated with haloperidol and trifluoperazine but experienced severe parkinsonism, akathisia, and oculogyric signs, which were controlled with biperiden 12 mg/day. After moderate improvement in her psychotic symptoms, Mrs. M switched to thioridazine 100 mg/day, tapered to 50 mg/day, plus biperiden 4 mg/day. Thioridazine was replaced by olanzapine, starting at 5 mg/day and increasing over 5 days to 10 mg/day. Even at the dose of 5 mg/day, she presented with torticollis and oculogyric signs, and with the dose of 10 mg/day, she manifested akinesia, stiffness, lingual dystonia, and dysarthria, which were not adequately controlled with benzhexol 15 mg/day. She resumed treatment with thioridazine, at 100 mg/day, with benzhexol 10 mg/day; she still manifested oculogyric crises at times. No dystonic symptoms had occurred after previous reductions of neuroleptic dosages.

Case 2. Mr. T is a 50-year-old man with schizophrenia since the age of 33. Several trials of antipsychotics had not been effective, and he had experienced severe extrapyramidal symptoms after taking neuroleptics. Recently he had been treated with risperidone 2 mg/day and biperiden 2 mg twice a day. This treatment was discontinued and, after 2 days, olanzapine 5 mg/day was begun. However, a few hours after taking the drug, a disturbing acute dystonic reaction occurred with lingual dystonia and dysarthria, spasm of the patient's neck muscles, and severe torticollis, relieved within 2 hours with biperiden 4 mg and orphenadrine 50 mg orally. Olanzapine was discontinued, and Mr. T resumed treatment with risperidone 2 mg/day and biperiden 2 mg three times a day.

+

Comment

To our knowledge, this is the first report of acute dystonia caused by the lowest therapeutic dose of olanzapine (5 mg), suggesting that olanzapine, despite its chemical and pharmacologic similarities to clozapine, has the potential to cause acute extrapyramidal symptoms even at a very low dosage. In keeping with a previous report,2 the high propensity of both of these patients to manifest extrapyramidal symptoms during previous treatment with antipsychotics placed them at a higher risk of manifesting acute dystonic reactions. Doses of 5 mg of olanzapine show D2 occupancy of 43%—64%,3 while the occupancy threshold for obtaining antipsychotic action lies in the range 65%—70%. These unwanted effects are unusual, but they may give a good measure of tolerability of the new antipsychotics beyond the premarketing trials.4 Clinicians should consider the possibility of the development of acute dystonia in susceptible individuals even with doses insufficient to obtain a true antipsychotic action.

Tollefson GD, Beasley CM Jr, Tran PV, et al: Olanzapine versus haloperidol in the treatment of schizophrenia and schizoaffective and schizophreniform disorders: results of an international collaborative trial. Am J Psychiatry 1997;154:457-465
 
Landry P, Cournoyer J: Acute dystonia with olanzapine. J Clin Psychiatry  1998; 59:384
[CrossRef] | [PubMed]
 
Kapur S, Zipursky RB, Remington G: Clinical and theoretical implications of 5-HT2 and D2 receptor occupancy of clozapine, risperidone, and olanzapine in schizophrenia. Am J Psychiatry  1999; 156:286-293
[PubMed]
 
Gerlach J: Life is not so easy: individualization in clinical psychopharmacology. Psychopharmacology (Berlin)  2002; 162:1-2
[CrossRef]
 
+

References

Tollefson GD, Beasley CM Jr, Tran PV, et al: Olanzapine versus haloperidol in the treatment of schizophrenia and schizoaffective and schizophreniform disorders: results of an international collaborative trial. Am J Psychiatry 1997;154:457-465
 
Landry P, Cournoyer J: Acute dystonia with olanzapine. J Clin Psychiatry  1998; 59:384
[CrossRef] | [PubMed]
 
Kapur S, Zipursky RB, Remington G: Clinical and theoretical implications of 5-HT2 and D2 receptor occupancy of clozapine, risperidone, and olanzapine in schizophrenia. Am J Psychiatry  1999; 156:286-293
[PubMed]
 
Gerlach J: Life is not so easy: individualization in clinical psychopharmacology. Psychopharmacology (Berlin)  2002; 162:1-2
[CrossRef]
 
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 3

Related Content
Books
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 34.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 26.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 55.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 12.  >
Topic Collections
Psychiatric News
Read more at Psychiatric News >>
APA Guidelines
PubMed Articles
Olanzapine-induced tardive dystonia: a case report. J Neuropsychiatry Clin Neurosci 2014;26(2):E24-5.