How do you manage agitation in neuroleptic malignant syndrome?

From the Guidelines

Managing agitation in neuroleptic malignant syndrome (NMS) requires prompt intervention with benzodiazepines as first-line treatment. According to the most recent and highest quality study available, benzodiazepines are recommended for agitation in NMS 1. The study suggests that benzodiazepines can be used to treat agitation, and other sources support the use of benzodiazepines such as lorazepam or diazepam for this purpose 1.

Key Considerations

• Benzodiazepines work by enhancing GABA activity, producing a calming effect without exacerbating the underlying syndrome.
• Intravenous lorazepam (1-2 mg) or diazepam (5-10 mg) can be administered and repeated every 30-60 minutes as needed, with careful monitoring for respiratory depression.
• For severe agitation unresponsive to benzodiazepines, dexmedetomidine infusion may be considered in an ICU setting.
• Physical restraints should be avoided when possible as they may worsen hyperthermia and rhabdomyolysis.

Underlying NMS Treatment

• Discontinuing the causative antipsychotic medication is crucial.
• Initiating specific NMS treatments such as dantrolene and/or bromocriptine may be necessary.
• Supportive care including cooling measures, hydration, and electrolyte management is essential.

Psychiatric Symptom Management

• A careful plan for psychiatric symptom management should be developed once the acute episode resolves.
• High-potency antipsychotics that precipitated the NMS should typically be avoided.

From the FDA Drug Label

The management of NMS should include: 1) intensive symptomatic treatment and medical monitoring, and 2) treatment of any concomitant serious medical problems for which specific treatments are available Dopamine agonists, such as bromocriptine, and muscle relaxants, such as dantrolene are often used in the treatment of NMS, however, their effectiveness has not been demonstrated in controlled studies.

The management of agitation in neuroleptic malignant syndrome (NMS) involves intensive symptomatic treatment and medical monitoring.

• Dopamine agonists (e.g., bromocriptine) and muscle relaxants (e.g., dantrolene) may be used to treat NMS, including agitation, although their effectiveness has not been demonstrated in controlled studies 2.

From the Research

Management of Agitation in Neuroleptic Malignant Syndrome

• The management of agitation in neuroleptic malignant syndrome (NMS) involves a combination of supportive care and pharmacological interventions 3, 4, 5, 6.
• Supportive care includes aggressive nursing, physical therapy, cooling, rehydration, and anticoagulation 4, 6.
• Pharmacological interventions may include the use of benzodiazepines, such as lorazepam and diazepam, to manage agitation and anxiety 7.
• The use of dantrolene and dopaminergic agents, such as bromocriptine, may also be considered in the treatment of NMS 3, 4, 6.
• Immediate discontinuation of the offending antipsychotic agent is essential in the management of NMS 3, 4, 5, 6.

Pharmacological Interventions

• Benzodiazepines, such as lorazepam and diazepam, may be used to manage agitation and anxiety in NMS 7.
• Dantrolene, a peripheral muscle relaxant, may be used to manage muscle rigidity and hyperthermia 3, 4, 6.
• Dopaminergic agents, such as bromocriptine, may be used to manage the symptoms of NMS 3, 4, 6.

Supportive Care

• Aggressive nursing care, including close monitoring of vital signs and mental status, is essential in the management of NMS 4, 6.
• Physical therapy may be used to manage muscle rigidity and prevent contractures 4.
• Cooling measures, such as cooling blankets or ice packs, may be used to manage hyperthermia 4, 6.
• Rehydration and electrolyte replacement are essential in the management of NMS 4, 6.