OpenHealth Q&A

Urgent Medication Assessment Required for Suspected Neuroleptic Malignant Syndrome

**Demographics:** - **Age:** 50 years - **Gender:** Male - **Location:** Georgia (country) - **Ethnicity:** Caucasian - **Health Conditions:** Paranoid schizophrenia diagnosed at 18, liver cirrhosis for the past seven years, history of treated Hepatitis C - **Recent habits:** Abandoned smoking and drinking after a stroke ## Medical Background **Chronic Issues:** - Living with paranoid schizophrenia for more than three decades treated consistently with antipsychotic medications. - Liver cirrhosis diagnosed approximately seven years ago after overcoming Hepatitis C. **Recent Medical History:** - Experienced a transient ischemic attack (TIA) about one and a half months ago, requiring a short hospital stay. - Following a stroke six days post-TIA, patient suffered from weakness, slurred speech, and issues with balance. - During the stroke, blood pressure peaked at 170-180 mmHg, with a loss of consciousness noted. - Spent 12 days in the hospital before returning home. - Noticed symptoms of muscle twitching and nerve tightness two weeks later. - Introduction of new drugs from a neurologist approximately 20 days ago; notable symptoms began 2-3 days prior, including episodes resembling "freezing" and periods of semi-consciousness. ## Current Symptoms **Primary concern:** - For the past 2-3 days, the patient has appeared semi-conscious, exhibiting extreme drowsiness yet able to respond to questions, despite delays. - Family members describe the patient's appearance as resembling someone under the influence of substances. - Prior episodes included unresponsive states marked by closed mouth and vacant stare lasting 1-2 minutes. **Additional symptoms:** - Imbalance and gait issues, difficulty in walking. - Blood pressure recorded at 150/90 mmHg, higher than his usual 120/80 mmHg. - Increased anxiety levels noted, particularly following the stroke. - Recently had nausea after eating an apple, resulting in an ER visit. - Currently no signs of fever or muscle rigidity as he is too somnolent for proper assessment. ## Laboratory Findings (August 7, 2025) - **ALT:** 21.7 - **AST:** 45.5 - **Gamma-GT:** 158.1 - **Total Cholesterol:** 3.47 - **Triglycerides:** 1.79 - **HDL-C:** 1.47 - **LDL-C:** 1.78 - **AST/ALT ratio:** 2.1 ## Recent MRI Insights - No acute anomalies detected; findings revealed: - Multiple lacunar changes in bilateral hemispheres and left pons. - Presence of leukoaraiosis. - Generalized cortical atrophy. - “Empty sella” condition noted. - No signs of aneurysm in MR angiography. ## Medications Overview **Medications prescribed prior to the stroke:** - Risperidone 4mg: Two tablets daily post meals. - Neurolepsin 400mg: One tablet once a day after meals. - Zopine (Zopiclone): Half tablet at bedtime. - Fluphenazine decanoate injection 25mg/ml: 1ml IM monthly. - Zolomax 0.5mg: As needed for anxiety (30-day supply). **Post-stroke medication regimen (from 1.5 months ago):** - Nexium 40mg: Daily before meals. - Enap 20mg: Once daily (later transitioned to Nolipril Forte). - Sorvasta 20mg: Once every evening after meals (for 2 months). - Plavix 75mg: Once daily for 1 month. - Aspirin Cardio 100mg: Once daily post-lunch. - Physiotens 0.4mg: As needed for elevated blood pressure (>150 mmHg). **Medications added by a new neurologist (20 days ago):** - Memosmart: One capsule twice daily after meals (for 2 months). - Phenibut 250mg: Half tablet twice daily until 7 PM (for 2 months). - B-complex: One vial daily (started 20 days ago). - Duomag: One capsule every evening after meals (for 2 months). **Current psychiatric medications (recently reduced by psychiatrist):** - Rispaxol 2mg: One tablet once a day at 10 AM after breakfast. - Neurolepsin 400mg: Half tablet at 9 PM. - Tizercine 25mg: One tablet at 9 PM. - Noxium injection: Frequency not specified. **New heart medications prescribed today:** - Nolpaza 20mg: Once each morning before meals (for 1 month). - Concor 5mg: Once daily at 10 AM; pulse to be monitored. - Aspirin Cardio 100mg: Once daily post-lunch. - Prestans 10/10mg: Once daily at 10 AM; blood pressure monitoring advised. - Physiotens 0.4mg: Once daily at 8 PM; blood pressure to be monitored. ## Queries 1. **Could the symptoms indicate neuroleptic malignant syndrome?** The patient's prolonged use of antipsychotics coupled with recent strokes may have resulted in this stuporous condition. 2. **Are there harmful interactions among his medications?** Concerns particularly focus on: - The combination of Phenibut and Zopiclone. - The use of multiple antipsychotics concurrently. - New heart medications interacting with ongoing psychiatric treatments. 3. **Is there a risk to the liver’s capacity to metabolize these medications** due to cirrhosis? 4. **Is immediate hospitalization warranted?** Neurologists and psychiatrists suspect medication-induced issues but have refrained from hospital admission due to the patient's non-acute status. 5. **Should we halt the new cardiac medications** until psychiatric medication levels are stabilized? ## Additional Points - The patient is compliant with medication without any overdose noted. - A 24-hour Holter monitor test returned normal results. - Multiple specialists (neurologist, psychiatrist, cardiologist) suspect a medication-related origin for current issues. - While currently conscious, the patient appears profoundly sedated. - Family members express deep concern regarding the sudden alteration in mental condition. **We seek insights on medication management and whether this situation necessitates urgent medical attention.**

Answers (1)

8/22/2025, 9:21:27 AM

OpenHealth AI

Main Points

The symptoms you've described could indeed suggest neuroleptic malignant syndrome (NMS) or another medication-related issue. Given the complex medication regimen and history of liver cirrhosis, there's a need for careful assessment and possibly urgent medical intervention.

Explanation

Neuroleptic Malignant Syndrome is a rare but serious reaction often associated with antipsychotic medications, leading to symptoms like extreme drowsiness, altered mental status, muscle rigidity, and autonomic instability. While muscle rigidity isn't clearly present in your case, the extreme sedation, episodes resembling "freezing," and altered consciousness are concerning.

Additionally, the potential harmful interactions in the patient's medications, especially given the liver cirrhosis which can impair drug metabolism, raise significant concerns. Certain combinations, such as Phenibut with Zopiclone or multiple antipsychotics, can increase sedation and confusion, further complicating the patient's current state.

Next Steps

1. Immediate Medical Assessment: Given the severity of symptoms, such as extreme drowsiness and semi-consciousness, seek urgent medical attention. If possible, contact the prescribing physicians immediately to discuss the situation. Notification may involve a psychiatrist and/or neurologist, who need to evaluate medication effects.

2. Medication Review and Adjustment: Upon consultation with medical professionals, a thorough review of all medications should be conducted. They may consider:

   • Reducing or discontinuing sedative medications (e.g., Zopiclone, Phenibut).
   • Monitoring and potentially adjusting antipsychotic doses to minimize any risks of NMS.

3. Liver Function Monitoring: Continuous monitoring of liver function tests should be conducted, especially given the cirrhosis, to ensure the liver can handle the medication load, and modifications can be made as needed.

4. Family Support: Engage family members in discussions about the patient’s health, symptoms, and care plan. Their observations about changes in the patient's awareness and behavior are valuable.

5. Avoid Further Medication Changes: Until assessed by a healthcare professional, avoid any changes in medication without professional guidance, especially the new cardiac medications or psychiatric treatments that may need stabilization first.

It’s crucial to prioritize patient safety and ensure that they are closely monitored so appropriate interventions can follow. Immediate action is recommended to better understand the cause of these alarming symptoms and to make any necessary adjustments quickly.