What medications can cause chorea?

Drugs Causing Chorea

The most common drug-induced causes of chorea are dopamine receptor blockers (antipsychotics and antiemetics), followed by levodopa, anticonvulsants (particularly valproate and phenytoin), CNS stimulants, and oral contraceptives. 1, 2, 3

Primary Offending Drug Classes

Dopamine Receptor Blockers

• Antipsychotics (neuroleptics) such as haloperidol, chlorpromazine, and quetiapine are the most frequently implicated medications causing chorea through dopamine receptor blockade 4, 2, 3
• Antiemetics including metoclopramide, domperidone, prochlorperazine, and promethazine can induce choreiform movements through similar dopaminergic mechanisms 5, 3
• These medications typically cause tardive dyskinesia with chronic use, but acute chorea can occur within days to weeks of initiation 2

Antiparkinsonian Medications

• Levodopa is a well-established cause of drug-induced chorea, particularly in patients with Parkinson's disease, representing levodopa-induced dyskinesia 1, 3
• The chorea typically emerges after prolonged treatment and correlates with peak drug concentrations 1

Anticonvulsants

• Valproic acid can cause choreiform movements, particularly in patients with severe brain damage or preexisting structural lesions (such as caudate nucleus damage) 6
• The chorea develops 30 minutes to 3 hours after ingestion, lasts 30 minutes to 8 hours, and appears dose-related 6
• Phenytoin may potentiate valproate-associated chorea when used concomitantly 6
• Other antiepileptic medications have also been implicated in movement disorders 1, 3

CNS Stimulants and Psychotropic Medications

• Stimulants including amphetamines and methylphenidate can induce chorea through dopaminergic mechanisms 1, 3
• Antidepressants (particularly tricyclic antidepressants and SSRIs) have been reported to cause or exacerbate hyperkinetic movement disorders 1, 3
• Lithium is associated with various movement disorders including chorea 3

Cardiovascular Medications

• Calcium channel blockers (particularly diltiazem and verapamil) are recognized causes of drug-induced movement disorders including chorea 3
• Digoxin has been associated with movement abnormalities, though cardiac toxicity is the primary concern 4

Other Medications

• Oral contraceptives and hormonal therapies can trigger chorea, particularly in patients with underlying susceptibility 1
• Over-the-counter medications including certain analgesics and antiheartburn medications have occasionally been implicated 1

Clinical Context and Management Approach

High-Risk Patient Populations

• Patients with severe brain damage or structural lesions (particularly involving the basal ganglia) are at substantially increased risk for drug-induced chorea 6
• Elderly patients have increased susceptibility to movement disorders from medications due to altered pharmacokinetics and pharmacodynamics 5
• Patients with antiphospholipid antibodies or antiphospholipid syndrome may develop chorea that can be confused with drug-induced etiology 4

Diagnostic Considerations

• Temporal relationship between drug initiation/dose escalation and chorea onset is critical for diagnosis 2, 6
• Peak drug concentrations often correlate with symptom appearance, particularly with valproate where chorea occurs 30 minutes to 3 hours post-dose 6
• Brain imaging should be performed when focal neurological signs are present or to exclude structural causes 4

Management Strategy

• Immediate drug withdrawal or dose reduction is the primary intervention for suspected drug-induced chorea 2, 3
• For valproate-associated chorea, switching to divalproex sodium sprinkles may decrease peak concentrations and resolve symptoms without complete drug discontinuation 6
• Symptomatic treatment with dopamine antagonists (such as tetrabenazine or deutetrabenazine) is effective for persistent chorea, though this creates a paradox when antipsychotics are the causative agent 4, 7
• VMAT2 inhibitors (tetrabenazine, deutetrabenazine, valbenazine) are considered first-line symptomatic therapy for chorea of any etiology 7

Critical Pitfalls to Avoid

• Do not assume all chorea in patients on antipsychotics is drug-induced—systemic lupus erythematosus with antiphospholipid antibodies is an important alternative diagnosis that requires different management 4
• Avoid polypharmacy as multiple drugs can synergistically increase chorea risk (e.g., valproate plus phenytoin) 6
• Do not overlook anticholinergic burden from medications like diphenhydramine and hydroxyzine, which can contribute to movement disorders 5
• Most information on drug-induced chorea comes from case reports rather than controlled trials, so clinical judgment based on temporal relationships is essential 1