Dear Editor:
Ziprasidone (Geodon®) is one of the newer atypical antipsychotics that is supposed to have minimal risk for extra pyramidal symptoms. We report a case of dystonic reaction induced by ziprasidone.
Case report. Mr. C is a 37-year-old Caucasian man, seen in an outpatient clinic and diagnosed with major depressive disorder, recurrent with psychotic features. He was started on escotalopram oxalate 10mg p.o. once daily and ziprasidone 20mg p.o. bid. The dose of ziprasidone was gradually increased to 40mg b.i.d. in one month without any adverse effects. At that time, the patient still had some concern about persistent psychotic symptoms. So the dose of ziprasidone was increased to 60mg p.o. b.i.d. But as soon as the dose was increased to 60mg b.i.d., the patient started complaining of his teeth grinding and locking of the jaw (trismus). Immediately the ziprasidone was decreased to 40mg b.i.d., and benztropine (Cogentin®) was started 1mg p.o. b.i.d. Patient responded with moderate improvement, but still complained of some tightness in shoulder muscles. As a result benztropine was further increased to 1mg p.o. t.i.d. The patient reported no complaints after increase in benztropine. No adverse affects were reported from benztropine. The treatment team initially decided to continue ziprasidone because the patient had showed significant improvement in his psychotic as well depressive symptoms. But later, the patient was switched to quetiapine (Seroquel®) without any adverse event.
PubMed search revealed only three previous documented cases of ziprasidone-induced dystonia. Ramos, et al.,1 reported an oculogyric crisis in a teenage boy, while Mason, et al.,2 and Dew and Hughes3 reported acute dystonic reaction in adults. In both of those cases, moderate to high dose of ziprasidone was used with rapid dose escalation.
This case is unique in that dystonia occurred despite the slow upward titration of ziprasidone as well as the relatively lower dose.
Acute dystonic reaction reported as an adverse event was four percent with ziprasidone compared to 2.2 percent in placebo.4,5 The number of patients who needed benztropine was also higher in those treated with ziprasidone compared to placebo.4,5
Though the difference was not statistically significant, it does not rule out the possibility of this unwelcome side effect. We emphasize the need for clinicians to always remain vigilant and aware of possibility of extrapyramidal symptoms even on newer atypicals like ziprasidone.
With regards,
Tanvir Singh, MD
Muhammad I. Rajput, MD
Medical University of Ohio
Psychiatry Clinic
Toledo, Ohio
References
- 1.Ramos AE, Shytle RD, Silver AA, Sanberg PR. Ziprasidone-induced oculogyric crisis. J Am Acad Child Adolesc Psychiatry. 2003;42(9):1013–4. doi: 10.1097/01.CHI.0000070257.24125.91. [DOI] [PubMed] [Google Scholar]
- 2.Mason MN, Johnaon CE, Piasecki M. Ziprasidone-induced acute dystonia. Am J Psychiatry. 2005;162(3):625–6. doi: 10.1176/appi.ajp.162.3.625-a. [DOI] [PubMed] [Google Scholar]
- 3.Dew RE, Hughes D. Acute dystonic reaction with moderate-dose ziprasidone. J Clin Psychopharmacol. 2004;24(5):563–4. doi: 10.1097/01.jcp.0000138780.55762.36. [DOI] [PubMed] [Google Scholar]
- 4.Pfizer, Inc. Briefing document for Zeldox capsule (Ziprasidone HCL) [July 19, 2000]. US Food and Drug Administration Website. Available at: www.fda.gov/OHRMS.
- 5.Tandon R, Harrigan E, Zorn S. Ziprasidone: A novel antipsychotic with unique pharmacology and therapeutic potential. J Serotonin Res. 1997;4:159–77. [Google Scholar]