Indian Journal of Pharmacology Medknow Publications on behalf of Indian Pharmacological Society ISSN: 0253-7613 EISSN: 1998-3751 Vol. 43, Num. 1, 2011, pp. 93-93

Indian Journal of Pharmacology, Vol. 43, No. 1, January-February, 2011, pp. 93

Letter to Editor

Tardive dyskinesia with clozapine dose reduction or withdrawal dyskinesia?

Samir Kumar Praharaj

Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India

Correspondence Address: Samir Kumar Praharaj, Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India, samirpsyche@yahoo.co.in

DOI: 10.4103/0253-7613.75686

Sir,

Shrivastava et al.[1] have reported an improvement of tardive dyskinesia (TD) with addition of clozapine that exacerbated with its dose reduction (from 200 to 150 mg/day). The patient had developed TD [score 7 on abnormal involuntary movement scale (AIMS)] while being treated with depot fluphenazine injection. It should be noted that the effect of depot injection lasts for a long period and its elimination half-life is longer than that of oral preparations. ^[2] Thus, it is possible that the index case might have developed withdrawal dyskinesia because of decrease in serum levels of fluphenazine ^[3] , and not clozapine, which has lower affinity for D ₂ receptors. There are even case reports of TD induced or worsened by clozapine therapy. ^[4],[5],[6] Nevertheless, clozapine still remains a viable treatment option for antipsychotic-induced TD, ^[7] as well as withdrawal dyskinesias, ^[8] as a maintenance treatment for long periods. ^[9]

TD was originally caused by fluphenazine. With clozapine (200 mg) treatment for 1 month, symptoms of TD were reduced, and when the dose of clozapine was decreased to 150 mg, symptoms reemerged. Half-life of fluphenazine deconate i.m., which the patient was receiving, is 6-9 days and under multiple dosing, the mean elimination half-life is increased to 14 days. ^[1] In our case, symptoms of TD reduced after 2 weeks.

Clozapine can improve or worsen TD, and we observed it to improve. The patient is presently maintained on clozapine 200 mg/day without any reemergence of symptoms for last 20 months.

References

1.	Shrivastava M, Solanke B, Dakhale G, Somani A, Waradkar P. Relapse of tardive dyskinesia due to reduction in clozapine dose. Indian J Pharmacol 2009;41:201-2.  Back to cited text no. 1  [PUBMED]
2.	Jann MW, Ereshefsky L, Saklad SR. Clinical pharmacokinetics of the depot antipsychotics. Clin Pharmacokinet 1985;10:315-33.  Back to cited text no. 2
3.	Wistedt B, Wiles D, Jψrgensen A. A depot neuroleptic withdrawal study neurological effects. Psychopharmacology (Berl) 1983;80:101-5.  Back to cited text no. 3
4.	Ertugrul A, Demir B. Clozapine-induced tardive dyskinesia: A case report. Prog Neuropsychopharmacol Biol Psychiatry 2005;29:633-5.  Back to cited text no. 4
5.	Raguraman J, Vijaysagar J. Worsening of tardive dyskinesia due to clozapine therapy. J Postgrad Med 2007;53:218.  Back to cited text no. 5  [PUBMED]
6.	Li CR, Chung YC, Park TW, Yang JC, Kim KW, Lee KH, et al. Clozapine-induced tardive dyskinesia in schizophrenic patients taking clozapine as a first-line antipsychotic drug. World J Biol Psychiatry 2009;10:919-24.  Back to cited text no. 6
7.	Margolese HC, Chouinard G, Kolivakis TT, Beauclair L, Miller R, Annable L. Tardive dyskinesia in the era of typical and atypical antipsychotics. Part 2: Incidence and management strategies in patients with schizophrenia. Can J Psychiatry 2005; 50: 703-14.  Back to cited text no. 7
8.	Mendhekar DN, Inamdar A. Withdrawal-emergent respiratory dyskinesia with risperidone treated with clozapine. J Neuropsychiatry Clin Neurosci 2010; 22: E24.  Back to cited text no. 8
9.	Louzγ MR, Bassitt DP. Maintenance treatment of severe tardive dyskinesia with clozapine: 5 years' follow-up. J Clin Psychopharmacol 2005;25:180-2.  Back to cited text no. 9

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