What medication adjustments are recommended for a patient experiencing night terrors, hallucinations, and tardive dyskinesia while on Seroquel (quetiapine) 75mg?

From the Guidelines

For a patient experiencing night terrors, hallucinations, and tardive dyskinesia while on Seroquel (quetiapine) 75mg, a gradual dose reduction or complete discontinuation of quetiapine should be considered under close medical supervision, as recommended by the American Psychiatric Association 1. The presence of tardive dyskinesia, an irreversible movement disorder, is particularly concerning and suggests the need for medication change. An alternative antipsychotic with lower risk of movement disorders, such as aripiprazole (Abilify) starting at 2-5mg daily or clozapine in severe cases, may be appropriate, as suggested by the American Psychiatric Association 1. During the transition, adding a benzodiazepine like lorazepam 0.5-1mg at bedtime temporarily (for 1-2 weeks) might help manage night terrors while the medication changes take effect, as indicated by the American Academy of Sleep Medicine 1. The hallucinations and night terrors could be side effects of quetiapine or symptoms of the underlying condition being undertreated at the current dose. Tardive dyskinesia typically develops with prolonged antipsychotic use and may worsen with continued exposure to the triggering medication, as noted in the practice parameter for the assessment and treatment of children and adolescents with schizophrenia 1. Any medication changes should occur gradually over several weeks to prevent withdrawal symptoms, and regular follow-up appointments should be scheduled to monitor symptom response and side effects. Some key points to consider in the management of this patient include:

• The importance of gradual dose reduction or discontinuation of quetiapine to minimize withdrawal symptoms
• The potential benefits of alternative antipsychotics with lower risk of movement disorders, such as aripiprazole or clozapine
• The use of benzodiazepines, such as lorazepam, for temporary management of night terrors during the transition period
• The need for regular follow-up appointments to monitor symptom response and side effects.

From the FDA Drug Label

A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs, including quetiapine If signs and symptoms of tardive dyskinesia appear in a patient on quetiapine, drug discontinuation should be considered.

The patient is experiencing tardive dyskinesia and night terrors/hallucinations while on Seroquel (quetiapine) 75mg.

• The FDA drug label recommends considering drug discontinuation if signs and symptoms of tardive dyskinesia appear in a patient on quetiapine.
• There is no clear recommendation to increase the dose of quetiapine in this situation.
• Given the patient's symptoms, the best course of action would be to reassess the need for continued treatment with quetiapine and consider alternative treatments.
• It is also important to note that increasing the dose may not necessarily improve the patient's symptoms and may even increase the risk of adverse effects.
• The patient's tardive dyskinesia and night terrors/hallucinations should be closely monitored, and the treatment plan should be adjusted accordingly 2.

From the Research

Medication Adjustments for Night Terrors, Hallucinations, and Tardive Dyskinesia

The patient is experiencing night terrors, hallucinations, and tardive dyskinesia while on Seroquel (quetiapine) 75mg. The following medication adjustments are recommended based on the available evidence:

• Increasing the dose of quetiapine may not be effective in reducing symptoms of tardive dyskinesia, as the patient is already experiencing symptoms at a dose of 75mg 3, 4.
• Switching to a different atypical antipsychotic, such as clozapine or olanzapine, may be considered, as these medications have been shown to be effective in reducing symptoms of tardive dyskinesia 3, 5.
• Adding a medication specifically for the treatment of tardive dyskinesia, such as clonazepam or ginkgo biloba, may be considered, as these medications have been shown to be effective in reducing symptoms of tardive dyskinesia 6.
• Discontinuing the use of dopamine receptor blocking agents (DRBAs) may be considered, as these medications can cause or exacerbate symptoms of tardive dyskinesia 6.

Tardive Dyskinesia Treatment Options

The following medications have been shown to be effective in reducing symptoms of tardive dyskinesia:

• Quetiapine: has been shown to be effective in reducing symptoms of tardive dyskinesia in several studies 3, 4, 5.
• Clozapine: has been shown to be effective in reducing symptoms of tardive dyskinesia, but may have a higher risk of side effects 3, 5.
• Olanzapine: has been shown to be effective in reducing symptoms of tardive dyskinesia, but may have a higher risk of side effects 5.
• Clonazepam: has been shown to be effective in reducing symptoms of tardive dyskinesia, and may be considered as an adjunctive treatment 6.
• Ginkgo biloba: has been shown to be effective in reducing symptoms of tardive dyskinesia, and may be considered as an adjunctive treatment 6.

Night Terrors and Hallucinations

The patient's night terrors and hallucinations may be related to their underlying psychiatric condition, and may require separate treatment. The following medications may be considered:

• Benzodiazepines: may be effective in reducing symptoms of night terrors and hallucinations, but may have a higher risk of side effects.
• Antipsychotics: may be effective in reducing symptoms of hallucinations, but may have a higher risk of side effects, including tardive dyskinesia.