What is the management of Neuroleptic Malignant Syndrome (NMS)?

From the Guidelines

The management of Neuroleptic Malignant Syndrome (NMS) requires immediate discontinuation of the offending antipsychotic medication and supportive care in an intensive care setting. This approach is based on the most recent and highest quality evidence available, which emphasizes the importance of prompt recognition and aggressive management to improve outcomes 1. The supportive measures include:

• Aggressive cooling for hyperthermia
• Intravenous fluids for hydration
• Management of complications such as renal failure, respiratory distress, and cardiac arrhythmias
• Treatment of dehydration or elevated creatine kinase and rhabdomyolysis with IV fluids
• Consideration of reintroduction of an anti-Parkinsonism drug if NMS is triggered by its abrupt withdrawal

Specific pharmacological interventions may be considered, such as:

• Benzodiazepines, like lorazepam, to manage agitation and rigidity, as suggested by experts 1
• Other agents, such as dantrolene and bromocriptine, have been used in the treatment of NMS, but their effectiveness in pediatric populations is less clear 1

Close monitoring of vital signs, creatine kinase levels, renal function, and electrolytes is essential to guide management and prevent further complications. After resolution, which typically takes 7-14 days, antipsychotic reintroduction should be delayed for at least 2 weeks, using a different class of medication at low doses with gradual titration. NMS is a life-threatening emergency with significant morbidity and mortality, making prompt recognition and aggressive management crucial for improving outcomes 1.

From the Research

Management of Neuroleptic Malignant Syndrome (NMS)

The management of NMS involves a combination of nonpharmacologic and pharmacologic interventions.

• Nonpharmacologic management includes:
  • Aggressive supportive care
  • Vigilant nursing
  • Physical therapy
  • Cooling
  • Rehydration
  • Anticoagulation 2
• Pharmacologic interventions include:
  • Immediate discontinuation of antipsychotics
  • Judicious use of anticholinergics
  • Adjunctive benzodiazepines 2
  • Use of specific agents such as dantrolene and bromocriptine, which have been considered for the treatment of NMS 2, 3, 4
  • Electroconvulsive therapy (ECT) as a second-line treatment 2, 3

Prevention and Risk Reduction

Prevention of NMS is crucial, and this can be achieved by:

• Reducing risk factors such as dehydration, agitation, and exhaustion 5
• Early recognition of suspected cases and prompt discontinuation of the offending agent 5
• Monitoring patients daily for dehydration and elevated temperature, checking vital signs, and watching for agitation 5
• Using antipsychotics conservatively with gradual titration of doses 5

Treatment Outcomes

The effectiveness of different NMS therapies has been compared, and the results show that:

• No statistically significant differences were found between dantrolene, bromocriptine, or ECT compared to supportive care in terms of mortality rate or duration of treatment 3
• However, a subgroup analysis showed that specific NMS pharmacotherapy (dantrolene, bromocriptine) and ECT were superior to symptomatic therapy in severe NMS cases 3
• The use of dantrolene has been reported as a potential treatment for NMS, leading to off-label use for NMS 6