Letters to the Editor
Ziprasidone-Induced Tardive Dyskinesia
Dear Editor: Ziprasidone, a benzothiozolypiperazine, is the only neuroleptic that possesses 5-HT1A and 5-HT1D antagonist properties. In addition, its high ratio of 5-HT2A to dopamine D2 is thought to be responsible for its lower risk of extrapyramidal side effects (EPSEs, 1). A recent review showed that ziprasidone has an EPSE rate similar to that of placebo (2). Further, a switch study found a significant reduction from baseline in the mean Simpson–Angus Rating Scale score after a switch from conventional antipsychotics to ziprasidone (3). In contrast to these findings, we report the case of a woman with schizoaffective disorder who developed tardive dyskinesia (TD) while taking ziprasidone.
Case Report
Mrs S, aged 40 years, is married and has no family or personal history of psychiatric or neurologic illness. For the last 3 years, she has attended as a psychiatric outpatient for the treatment of schizoaffective disorder of 5 years’ duration (diagnosed according to DSM-IV criteria). For 1 year, she was treated with trifluperazine 15 mg daily; however, she discontinued this treatment owing to the emergence of finger TD in her right hand. She was subsequently switched to clozapine 100 mg daily, after which we observed complete improvement in her TD. After 6 months of clozapine therapy, she began to gain weight and became lethargic. At that time, her thyroid profile revealed hypothyroidism. We therefore started her on thyroxin sodium 0.5 mg daily and replaced clozapine with risperidone 10 mg daily. After 4 months of risperidone therapy, she developed galactorrhea (her serum prolactin level was 70 mg/mL). We stopped her risperidone and replaced it with ziprasidone 40 mg daily, which we subsequently increased to 80 mg daily without any complaint of galactorrhea (her serum prolactin level was 11 mg/mL). She was stabilized on this dosage of ziprasidone, along with thyroxin sodium 0.5 mg daily. After 6 months, while maintained on this combination therapy, she exhibited piano-like movements of her left hand that prominently involved her thumb and middle and index fingers. We noticed simultaneous lingual dyskinetic movement, but this was only obvious after she opened her jaw widely. When we asked, she could suppress all these movements for a few seconds. Although she was aware of the movements, she had no difficulty in carrying out daily activities. Her Abnormal Involuntary Movements Scale score was 9. We replaced ziprasidone with aripiperazole 10 mg daily, which we gradually increased to 20 mg daily, with marked improvement in her finger and lingual TD (observed within 6 weeks of beginning aripiperazole therapy).
This patient’s typical antipsychotic–induced TD was ameliorated by clozapine treatment. Unfortunately, because Mrs S gained weight, we had to replace clozapine with risperidone. Subsequently, we withdrew risperidone because she developed galactorrhea. Mrs S never displayed any dyskinetic movements while taking risperidone. Dyskinetic movements did reappear, but in her other hand and only after she had been taking ziprasidone for 6 months. Since hypothyroidism is not documented in any literature as a risk or contributory factor, we can firmly say that Mrs S experienced ziprasidone-induced TD. In a previous case report of ziprasidone-associated TD, the patient had been taking ziprasidone for 4 months prior to the reappearance of TD and also had a history of typical antipsychotic–induced TD (4). Interestingly, ziprasidone acted as a prolactin-sparing agent in our case; however, it caused TD, which responded well to aripiperazole.
In conclusion, ziprasidone can induce TD, especially in those patients with schizoaffective disorder and a history of typical antipsychotic–induced TD.
References
1. Gunasekara NS, Spencer CM, Keating GM. Ziprasidone: a review of its use in schizophrenia and schizoaffective disorder. Drugs 2002;62:1217–51.
2. Carnahan RM, Lund BC, Perry PJ. Ziprasidone, a new atypical antipsychotic drug. Pharmacotherapy 2001;21:717–30.
3. Daniel DG, Zimbroff DL, Potkin SG. Ziprasidone 80mg/day and 160 mg/day in an acute exacerbation of schizophrenia and schizoaffective disorder: a 6-weeks placebo controlled trial. Neuropsychopharmacology 1999;20:491–505.
4. Rosenquest KJ, Waker SS, Ghaemi SN. Tardive dyskinesia and ziprasidone. Am J Psychiatry 2002;159:1436.
DN Mendhekar, MD, DPM
New Delhi, India
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