Relapse of tardive dyskinesia due to reduction in clozapine dose

Clozapine is a second-generation (atypical) antipsychotic agent, which has been proven efficient against the positive and negative symptoms of schizophrenia, with a low propensity to induce tardive dyskinesia (TD). Compared with typical antipsychotics, it has a greater affinity for dopamine D4 than D2 receptors and additional action on serotonin 5-HT2A receptors. Due to its weak D2 blocking action, it produces few extra pyramidal side effects and TD is rare. TD is one of the muscular side effects of antipsychotic drugs, especially the older generation like haloperidol. TD does not occur until after many months or years of taking antipsychotic drugs. TD is primarily characterized by abnormal involuntary movements of the tongue, lips or jaw, as well as facial grimacing or extremities that develop in association with the use of antipsychotic medications. TD can be embarrassing to the affected patient in public. The movements disappear during sleep and women are at greater risk than men for developing TD.


Introduction
It is established that clozapine and other second-generation antipsychotics cause less TD [1] and may also improve pre-existing TD. [2,3] Only few cases were reported having such complication.Hence, we wish to report a relapsed TD case due to reduction in clozapine dose from 200 mg to 150 mg.

Case Report
A 46-year-old female patient of schizophrenia (DSM-IV) criteria came to OPD of psychiatry in Indira Gandhi Government Medical College and Hospital, Nagpur.This institute is also a regional center for reporting an adverse drug reaction for central India.The patient was suffering from schizophrenia since last 18 years and was on fluphenazine (depot) administered intramuscularly (25 mg) once in a month and without any evidence of movement disorder.Since last 6 months, she developed continuous chewing, lip licking, and pouting movements, and diagnosis of TD was done by a psychiatrist.She scored 7 on the Abnormal Involuntary Movement Scale.Her routine biochemical profile and hemogram was in normal limits.Then, fluphenazine administered intramuscularly was discontinued and the psychiatrist decided to start clozapine tablet in the dose of 50 mg twice daily, and after 1 week, the dose was increased to 100 mg twice daily.The total blood count was determined weekly.The patient returned after 2 weeks ABSTRACT Clozapine is a second-generation (atypical) antipsychotic agent, which has been proven Clozapine is a second-generation (atypical) antipsychotic agent, which has been proven efficient against the positive and negative symptoms of schizophrenia, with a low propensity efficient against the positive and negative symptoms of schizophrenia, with a low propensity to induce tardive dyskinesia (TD).Compared with typical antipsychotics, it has a greater to induce tardive dyskinesia (TD).Compared with typical antipsychotics, it has a greater affinity for dopamine D4 than D2 receptors and additional action on serotonin 5-HT affinity for dopamine D4 than D2 receptors and additional action on serotonin 5-HT 2A 2A receptors.Due to its weak D receptors.Due to its weak D 2 2 blocking action, it produces few extra pyramidal side effects blocking action, it produces few extra pyramidal side effects and TD is rare.TD is one of the muscular side effects of antipsychotic drugs, especially and TD is rare.TD is one of the muscular side effects of antipsychotic drugs, especially the older generation like haloperidol.TD does not occur until after many months or years the older generation like haloperidol.TD does not occur until after many months or years of taking antipsychotic drugs.TD is primarily characterized by abnormal involuntary of taking antipsychotic drugs.TD is primarily characterized by abnormal involuntary movements of the tongue, lips or jaw, as well as facial grimacing or extremities that movements of the tongue, lips or jaw, as well as facial grimacing or extremities that develop in association with the use of antipsychotic medications.TD can be embarrassing develop in association with the use of antipsychotic medications.TD can be embarrassing to the affected patient in public.The movements disappear during sleep and women are to the affected patient in public.The movements disappear during sleep and women are at greater risk than men for developing TD. at greater risk than men for developing TD.

Shrivastava, et al.: Tardive dyskinesia due to reduction in clozapine dose
understood but the most commonly accepted explanation is super-sensitivity of post-synaptic dopaminergic receptors due to chronic dopaminergic blockade by antipsychotics.Older antipsychotics are more likely to cause this phenomenon, as they have stronger and irreversible dopamine blockade.Newer antipsychotic have serotonin-as well as dopamine-blocking property and slightly lower risk of TD. [6] All first-generation antipsychotic agents are associated with a risk of TD.Studies of newer antipsychotic agents suggest that TD liability is much lower with second-generation agents and clozapine is associated with substantial lower risk for the development of TD than other antipsychotic medication. [7]Although family and twin studies have elucidated the possible role of genetic factors, there is no significant association between single-nucleotide polymorphism and TD. [8,9]n this patient, due to reduction in the dose of clozapine, the post-synaptic dopaminergic receptors may not be completely blocked and the increased amount of natural dopamine reaching these super-sensitized receptors leads to dysregulated movements giving rise to TD.However, the exact pathophysiological mechanisms are still not clear and more data are required to know the typical characteristics and risk factors associated with TD due to reduction in the clozapine dose.

MEDICAL EDUCATION FELLOWSHIPS-2010 CMCL-FAIMER REGIONAL INSTITUTE, CHRISTIAN MEDICAL COLLEGE, LUDHIANA
The CMCL-FAIMER regional Institute's Fellowship is a two-year fellowship program designed for Indian medical school faculties who have the potential to play a key role in improving medical education at their institutes.The program is uniquely designed to teach education methods and leadership skills, as well as to develop strong professional bonds with other medical educators.The fellowship is now running in its Þ fth year Twenty fellowships are on offer for the year 2010.Requirements for selection include submission of a curriculum innovation project proposal and letter of support from applicant's institute.Limited funding is available to support fellows' travel, local expenses and course fee.

Important Dates
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