eMedicine Specialties > Psychiatry > Emergency

Neuroleptic Malignant Syndrome: Follow-up

Author: Joseph Tonkonogy, MD, PhD, Clinical Professor of Psychiatry and Neurology, University of Massachusetts Medical School; Consulting Staff, Departments of Psychiatry and Neurology, University of Massachusetts Medical Center
Coauthor(s): Darius P Sholevar, MD, Fellow, Cardiovascular Disease, Albert Einstein Medical Center
Contributor Information and Disclosures

Updated: May 7, 2009

Follow-up

Complications

  • Complications of neuroleptic malignant syndrome include dehydration from poor oral intake, acute renal failure from rhabdomyolysis, and deep vein thrombosis and pulmonary embolism from rigidity and immobilization.
  • Avoiding antipsychotics can cause complications related to uncontrolled psychosis. Most patients taking antipsychotic medicines are being treated for a severe and persistent psychiatric disorder; a high likelihood exists that a patient will relapse while off antipsychotics.
  • A summary of the potential complications of neuroleptic malignant syndrome includes the following:
    • Rhabdomyolysis
    • Renal failure
    • Cardiac arrest
    • Infection
    • Aspiration
    • Respiratory failure
    • Seizure
    • Pulmonary embolism
    • Hepatic failure
    • Uncontrolled psychoses

Prognosis

  • Most series suggest that the mortality rate is 10-20%. When reporting bias is factored in, the true rate of mortality from neuroleptic malignant syndrome might be much lower. Mortality rates generally are higher in patients who develop severe muscle necrosis and resulting rhabdomyolysis.
  • Patients who have previously experienced episodes of neuroleptic malignant syndrome are at risk for recurrences. The risk of neuroleptic malignant syndrome recurrence is strongly related to the elapsed time between an episode of neuroleptic malignant syndrome and restarting antipsychotics.
    • If patients are rechallenged with antipsychotics within 2 weeks of an episode of neuroleptic malignant syndrome, 63% will have a recurrence. If more than 2 weeks has elapsed, only 30% will have a recurrence.
    • Eighty-seven percent of patients who develop neuroleptic malignant syndrome will be able to tolerate another antipsychotic at some point in the future, which is very important because most patients taking neuroleptics require them to maintain a reasonable functional status. Current practice is to switch to a different class of antipsychotic when reintroducing these medications. Often, one of the newer atypical antipsychotics is chosen because current evidence suggests a lower incidence of neuroleptic malignant syndrome with these agents.

Patient Education

  • Educational approaches can help patients and their relatives to understand what has happened to the patient, why the neuroleptic malignant syndrome has developed in the past, and what possibility of the recurrence of neuroleptic malignant syndrome if the patient is rechallenged with a different class of antipsychotics. This may help patients and their relatives to decide about giving consent to restart antipsychotics. They have to be aware of the early signs of developing neuroleptic malignant syndrome such as rigidity, hyperthermia, and changes of consciousness to bring attention of the medical staff to the possible redevelopment of neuroleptic malignant syndrome.
  • Helpful Web sites for patients include the following:

Miscellaneous

Medicolegal Pitfalls

  • When a patient develops neuroleptic malignant syndrome, especially when the result is fatal, physicians can be sued.
  • Predicting who will develop neuroleptic malignant syndrome essentially is impossible given the current state of medical technology. Knowing that men younger than 40 years and those who previously have had neuroleptic malignant syndrome are at somewhat higher risk might help in risk stratification.
  • Informed consent is particularly important before initiating treatment in these populations. Unfortunately, therapy with neuroleptics often is begun when patients are least likely to hear and interpret information accurately for informed consent, which presents a difficult area medicolegally because neuroleptic malignant syndrome is a rare but serious complication of neuroleptic therapy.
  • The safest course is to provide patients and their families with as much information as they can absorb and follow up with additional information. This can be difficult to achieve in an often less-than-ideal setting.
 


More on Neuroleptic Malignant Syndrome

Overview: Neuroleptic Malignant Syndrome
Differential Diagnoses & Workup: Neuroleptic Malignant Syndrome
Treatment & Medication: Neuroleptic Malignant Syndrome
Follow-up: Neuroleptic Malignant Syndrome
References
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Further Reading

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Keywords

neuroleptic malignant syndrome, antipsychotics, NMS, drug-induced movement disorder, lethal catatonia, neuroleptic-induced acute dystonia, neuroleptic-induced akathisia, neuroleptic-induced parkinsonism, neuroleptic-induced tardive dyskinesia, serotonin syndrome, hyperthermia, rigidity, autonomic dysregulation, 3, 4-methylenedioxymethamphetamine, MDMA, ecstasy, XTC

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Contributor Information and Disclosures

Author

Joseph Tonkonogy, MD, PhD, Clinical Professor of Psychiatry and Neurology, University of Massachusetts Medical School; Consulting Staff, Departments of Psychiatry and Neurology, University of Massachusetts Medical Center
Joseph Tonkonogy, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Neuropsychiatric Association, International Neuropsychological Society, Massachusetts Medical Society, Royal Society of Medicine, Society for Neuroscience, and United Council for Neurologic Subspecialties, Certification Behavioral Neurology and Neuropsychiatry
Disclosure: Nothing to disclose.

Coauthor(s)

Darius P Sholevar, MD, Fellow, Cardiovascular Disease, Albert Einstein Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Alan D Schmetzer, MD, Professor, Vice-Chair for Education, and Director of Residency Training in General and Addiction Psychiatry, Department of Psychiatry, Indiana University School of Medicine
Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American College of Physician Executives, American Medical Association, American Neuropsychiatric Association, American Psychiatric Association, and Association for Convulsive Therapy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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