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Dystonic Reactions and Akathisias

Dave Diller, MD and Matthieu DeClerck, MD
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Acute extrapyramidal syndrome aka: drug-induced dystonias and akathisia are known side effects to commonly used medications that patients may be taking at home or that we may prescribe in the urgent care setting. The most commonly used medications that can lead to acute dystonia or akathisia include both first and second generation antipsychotic medications, like haloperidol or olanzapine, and antidopaminergic medications used to treat nausea, vomiting and headaches, like prochloperazine, promethazine, and metoclopramide. Additionally, several classes of antidepressants have also been shown to induce extrapyramidal symptoms (e.g. duloxetine, sertraline, escitalopram, fluoxetine, bupropion).

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Melissa, NP -

Dystonic reaction ddx, since you mentioned tetany...what about strychnine poisoning?

Mike W., MD -


Katie S. -

Any idea which of the anti-dopaminergic medications used to treat N/V and migraine is least likely to cause akathisia? If a patient has had a reaction to one of these drugs in the past, will they likely have it with the others as well? Thanks.

Mike W., MD -

While Metoclopramide (Reglan) has been the most commonly sited anti-dopaminergic causing tardive dyskinesia (TD); the other 2 Prochlorpromazine (Compazine) and Chlorpromazine (Thorazine) less commonly implicated but can also cause TD. It may just be that they are less notorious for such because they are less commonly used, and we may see more cases of TD from Prochlorpromazine as its use for migraines increases. My clinical practice is to use Compazine first, I'll use Reglan if my first line is not available (there are some studies that show Compazine superior than Reglan in the treatment of acute migraine). I will typically not restart the pt on the primary offending drug but you can try another anti-dopaminergic its manifestation is not a true "allergy" to the offending medication.

That being said, if history of TD or high risk for TD I'll consider pretreating with Diphenhydramine (Benadryl) or as stated in the piece, diluting the anti-dopaminergic with NS and run over 15 mins to an hour rather than a bolus which has been shown to decrease the rate of TD when using these drugs.

Hope this answers your question.

Matthieu DeClerck, MD
Senior Medical Editor
HIPPO Education

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You'll Shoot Your Eye Out! Full episode audio for MD edition 189:20 min - 89 MB - M4AHippo UC RAP October 2018 Written Summary 394 KB - PDF