Soft diagnosis, guidelines and hard choices

Thank you for this excellent and concise article outlining the complexities involved in neuroleptic malignant syndrome (NMS) in association with atypical antipsychotics.¹ It serves as a reminder of how guidelines and diagnostic criteria can, for all their clarity, lead to vexing and imperfect choices.

This article brings to mind recent clinical cases where empiric treatment of a soft NMS diagnosis led to challenging decisions. The trouble lay in following guidelines in a patient with very clear treatment-resistant schizophrenia who had improved with clozapine. After the withdrawal of the causative agent, the duration for which antipsychotic treatment should be withheld is not completely clear. There are recognised guidelines indicating at least 5 days and monitoring for symptom resolution, whereas other guidelines say to wait 2 weeks after symptoms have settled.^2,3 In addition, the atypical presentation of clozapine-associated NMS itself can lead to uncertainty and serves as a frustrating obstacle which clouds the process of decision-making.¹ Moving forward, the recommendation to avoid the precipitating antipsychotic does not provide a clear answer in further management of such a patient on clozapine where other options have proved insufficient or inadequate.⁴

Further difficulty then may arise in persuading someone that the medication, which is associated with such an unpleasant clinical experience, is the correct choice. Particularly when recurrence of NMS on rechallenge with antipsychotics was found to be between 30 and 50%.⁴

In clinical practice there often is no perfect answer and rarely does the right one present itself as the easy choice. An article such as this serves to highlight the challenges present in applying uniform guidelines to complex presentations.