Dystonia induced by drug treatment · Dystonia induced by drug treatment 1730 Dystonia is a...

1
IMAGES IN MEDICINE 1730 Tidsskr Nor Legeforen nr. 20, 2016; 136 Images in medicine Dystonia induced by drug treatment 1730 Dystonia is a movement disorder that is characterised by intermittent or prolonged muscle contractions that result in abnormal, often repetitive movement patterns in all or parts of the body (1). Dystonia is a neuro- logical symptom, for which there may be various causes. A distinction is made between primary and secondary dystonia. Dystonia induced by drug treatment is an example of a secondary form of the disorder. Metoclopramide (Afipran) is frequently used to treat nausea and vomiting, both in hospitals and in general practice. Its antinau- seant effect is symptomatic and attributable to direct inhibition of the chemoreceptor trig- ger zone and area postrema in the medulla oblongata by blocking dopamine receptors. Acute dystonic reactions are caused by unwanted blockade of dopamine receptors (D2 receptors) in the basal ganglia (2). Extra- pyramidal side effects are estimated to be 0.2 %. Acute dystonic side effects usually occur 1 – 2 days after first taking the drug (3). A woman in her early twenties attended the accident and emergency department fol- lowing an acute onset of involuntary move- ments of the tongue and jaw – see photo and video. She had been prescribed metoclopra- mide by her GP due to stomach pains, vomi- ting and diarrhoea. She had taken a total of four tablets (40 mg) over a period of approxi- mately 24 hours, which is higher than the recommended dosage (4). The onset of sym- ptoms occurred two hours after taking the last tablet, and began with discomfort in the tongue and jaw area, involuntary stretching movement of the tongue, and deviation of the jaw to the right. The patient managed to move her tongue, but she felt that it wanted to stretch itself forward in the resting position. The video illustrates extrapyramidal side effects of dystonia in the tongue and lower jaw. The patient was given 5 mg biperiden (Akineton) intravenously with rapid effect. Acute extrapyramidal side effects after using metoclopramide are harmless and reversible, but undoubtedly a dramatic and unpleasant experience for patients. It is essential to be aware that the condition is frequently induced by drug treatment, and that drugs that inhibit dopamine receptors, including antinauseants and antipsychotics, can produce this type of adverse effect. Anti- cholinergic drugs can relieve symptoms, but the extrapyramidal side effects generally disappear rapidly by themselves provided treatment is stopped. The patient has consented to the publication of this article and video. Marianne Solberg marso2@vestreviken.no Jeanette Koht Department of Neurology Drammen Hospital Marianne Solberg (born 1980), specialty registrar. The author has completed the ICMJE form and reports no conflicts of interest. Jeanette Koht (born 1969), researcher, specia- list in neurology and senior consultant. The author has completed the ICMJE form and reports no conflicts of interest. References 1. Albanese A, Bhatia K, Bressman SB et al. Pheno- menology and classification of dystonia: a consen- sus update. Mov Disord 2013; 28: 863 – 73. 2. van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ 1999; 319: 623 – 6. 3. Hagen EM, Farbu E, Bindoff L. Akutt dystoni ved behandling med metoklopramid (Afipran). Tidsskr Nor Lægeforen 2001; 121: 2162 – 3. 4. Legemiddelverket. Nye anbefalinger ved bruk av metoklopramid (Afipran) 2013. http://legemiddelverket.no/Nyheter/Bivirkninger/ Sider/Nye-anbefalinger-ved-bruk-av- metoklopramid.aspx (8.7.2016). Received 20 April 2016, first revision submitted 17 June 2016, accepted 8 July 2016. Editor: Martine Rostadmo.

Transcript of Dystonia induced by drug treatment · Dystonia induced by drug treatment 1730 Dystonia is a...

Page 1: Dystonia induced by drug treatment · Dystonia induced by drug treatment 1730 Dystonia is a movement disorder that is characterised by intermittent or prolonged muscle contractions

IMAGES IN MEDICINE

Images in medicine

Dystonia induced by drug treatment 1730

Dystonia is a movement disorder that ischaracterised by intermittent or prolongedmuscle contractions that result in abnormal,often repetitive movement patterns in all orparts of the body (1). Dystonia is a neuro-logical symptom, for which there may bevarious causes. A distinction is madebetween primary and secondary dystonia.Dystonia induced by drug treatment is anexample of a secondary form of the disorder.

Metoclopramide (Afipran) is frequentlyused to treat nausea and vomiting, both inhospitals and in general practice. Its antinau-seant effect is symptomatic and attributableto direct inhibition of the chemoreceptor trig-ger zone and area postrema in the medullaoblongata by blocking dopamine receptors.Acute dystonic reactions are caused byunwanted blockade of dopamine receptors(D2 receptors) in the basal ganglia (2). Extra-pyramidal side effects are estimated to be0.2 %. Acute dystonic side effects usuallyoccur 1 – 2 days after first taking the drug (3).

A woman in her early twenties attendedthe accident and emergency department fol-lowing an acute onset of involuntary move-ments of the tongue and jaw – see photo andvideo. She had been prescribed metoclopra-mide by her GP due to stomach pains, vomi-ting and diarrhoea. She had taken a total offour tablets (40 mg) over a period of approxi-mately 24 hours, which is higher than therecommended dosage (4). The onset of sym-

1730

ptoms occurred two hours after taking the lasttablet, and began with discomfort in thetongue and jaw area, involuntary stretchingmovement of the tongue, and deviation of thejaw to the right. The patient managed to moveher tongue, but she felt that it wanted tostretch itself forward in the resting position.The video illustrates extrapyramidal sideeffects of dystonia in the tongue and lowerjaw. The patient was given 5 mg biperiden(Akineton) intravenously with rapid effect.

Acute extrapyramidal side effects afterusing metoclopramide are harmless andreversible, but undoubtedly a dramatic andunpleasant experience for patients. It isessential to be aware that the condition isfrequently induced by drug treatment, andthat drugs that inhibit dopamine receptors,including antinauseants and antipsychotics,can produce this type of adverse effect. Anti-cholinergic drugs can relieve symptoms, butthe extrapyramidal side effects generallydisappear rapidly by themselves providedtreatment is stopped.

The patient has consented to the publication of thisarticle and video.

Marianne [email protected] KohtDepartment of NeurologyDrammen Hospital

Marianne Solberg (born 1980), specialty registrar.

The author has completed the ICMJE form

and reports no conflicts of interest.

Jeanette Koht (born 1969), researcher, specia-

list in neurology and senior consultant.

The author has completed the ICMJE form

and reports no conflicts of interest.

References1. Albanese A, Bhatia K, Bressman SB et al. Pheno-

menology and classification of dystonia: a consen-sus update. Mov Disord 2013; 28: 863 – 73.

2. van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ 1999; 319: 623 – 6.

3. Hagen EM, Farbu E, Bindoff L. Akutt dystoni ved behandling med metoklopramid (Afipran). Tidsskr Nor Lægeforen 2001; 121: 2162 – 3.

4. Legemiddelverket. Nye anbefalinger ved bruk av metoklopramid (Afipran) 2013. http://legemiddelverket.no/Nyheter/Bivirkninger/Sider/Nye-anbefalinger-ved-bruk-av-metoklopramid.aspx (8.7.2016).

Received 20 April 2016, first revision submitted 17 June 2016, accepted 8 July 2016. Editor: Martine Rostadmo.

Tidsskr Nor Legeforen nr. 20, 2016; 136