Which medications are known to cause drug‑induced chorea?

Medications That Can Cause Chorea

Antipsychotic medications (both typical and atypical), anticonvulsants (particularly phenytoin and lamotrigine in combination), CNS stimulants, antidepressants, calcium channel blockers, and metoclopramide are the primary drug classes that induce chorea. 1

Antipsychotic Medications

Dopamine receptor blockers are the most common cause of drug-induced chorea, manifesting as tardive dyskinesia with chronic use or acute hyperkinetic movements. 2

• Typical antipsychotics (e.g., haloperidol, chlorpromazine, thioridazine) carry the highest risk, causing tardive dyskinesia in up to 50% of elderly patients after 2 years of continuous use 3
• Atypical antipsychotics (e.g., quetiapine, risperidone, olanzapine) have diminished but still significant risk compared to typical agents 3
• Tardive dyskinesia is characterized by rapid involuntary facial movements (blinking, grimacing, chewing, tongue movements) and extremity or truncal movements 4
• The condition occurs in 5% of young patients per year and is more common with older "typical" antipsychotics 4

Anticonvulsant Medications

Polytherapy with certain anticonvulsants, particularly combinations containing phenytoin and lamotrigine, carries particular risk for drug-induced chorea through additive or synergistic effects on central dopaminergic pathways. 5

• Chorea typically resolves with withdrawal or tapering of one of the offending medications 5
• The mechanism likely involves pharmacodynamic drug interactions affecting dopamine neurotransmission in the basal ganglia 5, 6

Antidepressants

Tricyclic antidepressants and selective serotonin reuptake inhibitors can induce hyperkinetic movement disorders including chorea, though this is less common than with antipsychotics. 1, 2

• Tricyclic antidepressants may produce movement disorders through effects on multiple neurotransmitter systems 4
• The risk increases with higher doses and polypharmacy 7

Gastrointestinal Medications

Metoclopramide and other substituted benzamides (sulpiride, clebopride, domperidone) are frequently implicated in drug-induced movement disorders including chorea due to their dopamine receptor blocking properties. 1

Calcium Channel Blockers

Calcium antagonists, particularly older agents like bepridil, can induce chorea and other movement disorders. 1

CNS Stimulants

Stimulant medications including amphetamines and methylphenidate can precipitate or exacerbate choreiform movements through dopaminergic mechanisms. 6, 1

Lithium

Lithium therapy is associated with various movement disorders including chorea, particularly at toxic levels or with chronic use. 1

Critical Management Principles

When drug-induced chorea is suspected, immediate withdrawal of the offending agent is recommended whenever possible, after excluding other arrhythmogenic or neurologic substrates. 4

• A thorough medication history is essential for diagnosis, including over-the-counter medications and supplements 6, 2
• Most drug-induced movement disorders (except tardive syndromes) completely resolve after discontinuation of the offending agent 6
• Movement disorders are not always reversible after drug withdrawal, particularly with tardive dyskinesia from chronic antipsychotic use 1

Common Pitfalls

• Multiple drugs can induce two or more types of movement disorders simultaneously in the same patient, making diagnosis challenging 1
• Over-the-counter medications including analgesics and antiheartburn medications have occasionally been implicated but are often overlooked 2
• Drug-drug interactions may precipitate chorea even when individual agents are at therapeutic levels 5
• The temporal relationship between medication initiation and symptom onset should be clear, typically developing acutely (hours to days) or subacutely (days to weeks) 6