Neuroleptic Malignant Syndrome

Published on 07/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/04/2025

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Chapter 82 Neuroleptic Malignant Syndrome

13 What pharmacologic treatments are useful?

In most cases, cessation of antipsychotic medications and supportive medical management are sufficient to reverse the symptoms of NMS. Several empirical off-label treatment approaches can be used in a case-by-case basis:

image Recent clinical reports suggest that benzodiazepines (oral or parenteral) may ameliorate symptoms of agitation or catatonia and hasten recovery of NMS. A trial of lorazepam 1 to 2 mg parenterally is a reasonable first-line intervention for patients with acute NMS.

image Dopamine agonists, such as amantadine and bromocriptine, have been reported to reverse Parkinsonian symptoms, hasten recovery, and decrease mortality rates when used alone or in combination with other pharmacologic agents. Amantadine is generally initiated at 200 to 400 mg/day orally in divided doses. Bromocriptine can be started at 2.5 mg two to three times a day orally with a maximum daily dose of 45 mg. Be advised that bromocriptine can worsen psychosis and hypotension, as well as precipitate vomiting, and must be used with caution. Abrupt discontinuation of bromocriptine can also precipitate rebound symptoms.

image Dantrolene may be useful in cases of extreme hyperthermia, rigidity, and hypermetabolism. Typical dosing is 1 to 2.5 mg/kg intravenously initially and may be increased to 1 mg/kg every 6 hours. Side effects include respiratory impairment and hepatic toxicity.

image Electroconvulsive therapy (ECT) has been shown to be effective when NMS symptoms are refractory to supportive care and pharmacologic treatment. The typical ECT course was six to 10 bilateral treatments with initial response expected in the first few treatments. During ECT succinylcholine should be avoided in patients with rhabdomyolysis to prevent acute hyperkalemia and cardiovascular complications.