Levodopa withdrawal syndrome identical to neuroleptic malignant syndrome

Abstract

Summary A 60 year old woman with idiopathic Parkinson's disease had been prescribed thioridazine for schizophrenia. Five months after this was stopped, Sinemet also considered of dubious therapeutic value, was withdrawn. One week later she developed features of the neuroleptic malignant syndrome (NMS) accompanied by myoglobinuric renal failure. Post-mortem examination confirmed Lewy body degeneration in the substantia nigra. It is proposed that NMS may be caused by levodopa withdrawal in Parkinson's disease, and that it is withdrawal of dopaminergic drive that causes the syndrome.

Case files of the Program in Medical Toxicology at Brown University: Amantadine withdrawal and the neuroleptic malignant syndrome

“…These symptoms include varying degrees of tremor; muscle rigidity; autonomic instability (manifested by tachycardia, hypertension, and diaphoresis); delirium; elevation of serum CPK; and in some cases, fever. Similar symptoms have been noted after the rapid cessation of levodopa or bromocriptine [16][17][18]. The severity of symptoms and the presence of fever are important distinctions in classifying patients along a spectrum of amantadine withdrawal from worsening tremor to neuroleptic malignant syndrome (NMS).…”

Medication management on sick days

“…2 For some medicines, this can be associated with a withdrawal or discontinuation syndrome (see Table), 3,4 which is predictable and potentially avoidable. This is a particular concern with shorter acting drugs in a controlledrelease formulation (which depends on normal gut transit time) when the decrease in plasma concentration reduces the patient's functional status (e.g.…”

Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome

“…In part, this is because the main risk factor for NMS is usually exposure to a dopamine antagonist, although rarely it can occur after withdrawal of a dopamine agonist. NMS was more common with FGAs because they bind to dopamine receptors more avidly than second-generation antipsychotics (SGAs) (12). Table 1 contains a list of medications that have been associated with NMS.…”