Акатизия при отмене габапентина

OBJECTIVE: To report a case of akathisia in a patient with type 2 diabetes after abrupt discontinuation of gabapentin.

CASE SUMMARY: A 76-year-old female with type 2 diabetes was admitted for change in mental status, agitation, and restless limb movements. She had been taking gabapentin 3600 mg daily for approximately 1 month for diabetic neuropathy. Her other home medications were glyburide 10 mg twice daily, oxycodone/acetaminophen 5 mg/325 mg every 6 hours as needed for leg pain, and zolpidem 5 mg at bedtime. She had taken none of these drugs for 4 days prior to admission because she was unable to have the prescriptions refilled. Subsequently, the patient exhibited repeated arm and leg motions in response to an inner restlessness. Upon admission to the emergency department, she was agitated and restless; all vital signs and results of laboratory studies were within normal limits. Gabapentin was restarted at the original dosage and the symptoms resolved within 8 hours. Because the patient developed lethargy, the gabapentin dosage was reduced and titrated to the original level over 2 days. After 3 days, the patient was well oriented and experienced no further symptoms. She was discharged on the original dosage of gabapentin.

DISCUSSION: To our knowledge, this is the first reported cases of akathisia induced by gabapentin withdrawal. Available case reports suggest that gabapentin withdrawal can occur at doses ranging from 400-8000 mg/day. Patients experienced symptoms similar to those that develop with benzodiazepine withdrawal and were taking gabapentin for as little as 3 weeks to as long as 5 years. This is the first case report to describe akathisia induced by gabapentin withdrawal. The Naranjo probability scale revealed a probable relationship between akathisia and gabapentin withdrawal.

CONCLUSIONS: If gabapentin discontinuation is desired, it is prudent to gradually taper the dose to avoid withdrawal symptoms, which may occur after as little as 1 month of treatment. Should the patient experience withdrawal symptoms, the optimal treatment is to restart gabapentin.

Akathisia Induced by Gabapentin Withdrawal

Индивидуальное дозирование антипсихотиков

Paralleling the preclinical evidence, are there clinical data to suggest antipsychotic tolerance with continuous treatment? Work with first-episode schizophrenia has confirmed three findings related to antipsychotic treatment: (a) response to lower doses; (b) sensitivity to side effects; and (c) comparatively high response rate.[2,21] In contrast, the more chronic stages of schizophrenia are associated with higher antipsychotic doses and diminished clinical response,[22,23] keeping in mind that the chronic population is more heterogeneous and includes a larger proportion of refractory patients who may be receiving higher doses. While antipsychotic tolerance has been raised to account for a progressive decline in response,[24] nonadherence and/or illness progression are routinely endorsed as more viable explanations. That as many as 25% of individuals on depot antipsychotic therapy relapse[25] tempers the nonadherence argument, but at the same time does not rule out alternative explanations, eg, a discrete breakthrough episode vs tolerance per se. In contrast, the preclinical description of behavioral dopamine supersensitivity closely parallels the notion of "supersensitivity psychosis" and withdrawal dyskinesias reported clinically, linked to D2 upregulation as a result of ongoing antipsychotic exposure and observed in the face of drug discontinuation.[26–28]

Antipsychotic Dosing: How Much but Also How Often?

Hallucinations in the Context of Varenicline Withdrawal

"Mr. A" was a 43-year-old, well-educated, healthy man with no current or previous medical or psychiatric history, including no past alcohol dependence or drug abuse. Notably, his family history was positive for schizophrenia, with one brother suffering from the illness. The patient reported smoking 10 cigarettes daily for more than 20 years. Varenicline was administered at a dose of 0.5 mg once daily for an initial period of 3 days, followed by 0.5 mg twice daily for the next 4 days. The drug was then administered at a dose of 1.0 mg twice daily.

The patient reported headaches shortly after starting varenicline. However, he was able to stop smoking after 2 weeks of treatment and therefore reduced the dose of the drug during the third week of treatment, taking only 0.5 mg once daily for 4 days. He then discontinued treatment. After taking the last tablet of varenicline on the following day, the patient began experiencing symptoms of derealization. His symptoms then progressed to visual hallucinations of unknown, distressing people who he "shooed" away. At that point, Mr. A suspected that he was having a "realistic dream." He also perceived that he had a conversation with a deceased rock star while being conscious that the person in question was actually dead. He became distressed and presented to his general practitioner, and he was started on quetiapine (50 mg at bedtime) for 10 days. The symptoms of hallucinosis rapidly disappeared. When interviewed by a psychiatrist 1 month later, the patient showed no symptoms of any psychiatric disorder, and he was not taking any medication. He had also managed to remain smoke-free.

http://ajp.psychiatryonline.org/cgi/content/short/166/5/619-a?rss=1