Treatment of Neuroleptic Malignant Syndrome
Immediately discontinue all antipsychotic medications and initiate aggressive supportive care—this is the single most critical intervention that reduces mortality from 76% to less than 10-15%. 1
Immediate Management Steps
Discontinue Offending Agents
- Stop all antipsychotic medications immediately upon suspicion of NMS—this is the first and most essential step, even before diagnostic confirmation is complete. 1
- Avoid physical restraints as they worsen isometric muscle contractions, exacerbating hyperthermia and lactic acidosis, thereby increasing mortality. 1
Aggressive Supportive Care
- Treat agitation with benzodiazepines rather than additional antipsychotics or physical restraints. 1
- Implement external cooling measures for hyperthermia, including cooling blankets and ice packs. 1, 2
- Administer IV fluids aggressively to address dehydration, autonomic instability, normalize vital signs, and prevent rhabdomyolysis-induced renal failure. 1, 2
Pharmacologic Interventions for Severe Cases
Dopaminergic Agents
- Bromocriptine (oral dopamine agonist) should be used in severe cases to address central dopamine deficiency caused by antipsychotic blockade. 1, 3, 4
- This is particularly important when rigidity and hyperthermia are prominent features. 5
Muscle Relaxants
- Dantrolene sodium (IV) should be administered to reduce muscle rigidity and hyperthermia in severe cases by acting directly on skeletal muscle. 1, 4, 5
- The combination of dantrolene and bromocriptine has shown dramatic favorable responses in severe NMS. 4, 5
Critical Care Interventions
For Extreme Hyperthermia (>41.1°C)
- Emergency sedation, neuromuscular paralysis, and intubation may be required. 1
- Approximately 25% of NMS patients require ICU admission. 1
Hemodialysis
- Initiate hemodialysis if renal failure develops from rhabdomyolysis. 2
Second-Line Treatment
Electroconvulsive Therapy (ECT)
- ECT is indicated as second-line treatment for severe and persistent NMS, particularly when the patient has a concurrent psychiatric condition that would benefit from ECT or when pharmacologic interventions fail. 1, 3, 4
Essential Monitoring
Laboratory Surveillance
- Obtain complete blood count, electrolytes, renal function, liver function, creatine kinase, arterial blood gases, and coagulation studies. 1
- Monitor for complications including rhabdomyolysis with elevated creatine kinase, metabolic acidosis, elevated liver enzymes, renal failure, seizures, and disseminated intravascular coagulation. 1
Common Pitfalls to Avoid
- Do not use anticholinergics liberally—while they may enhance bromocriptine effectiveness, they can worsen hyperthermia and autonomic instability. 4
- Do not delay treatment waiting for diagnostic confirmation—early recognition and prompt management are crucial for improving outcomes. 1, 6
- Do not rechallenge with antipsychotics for at least 2 weeks following complete resolution of NMS symptoms. 6