Journal of Clinical Psychopharmacology

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Letters to the Editors

TABLE 1. Characteristics of Cases and Controls

No. patients Nonusers of study drugs Antipsychotics use* Risperidone Quetiapine Olanzapine Follow-up Age Medical conditions (%) Hyperthyroidism Cirrhosis Kidney failure Prescription drugs (%) Cimetidine Omeprazole Spirinolactone Flutamide Bicalutamide Nilutamide

Cases

Controls

8285 8197

82,850 82,222

27 35 26 2.9 T 2.2 65.5 T 14.5

147 348 133 2.9 T 2.2 65.5 T 14.5

0.11 3.27 11.01

0.08 1.16 5.61

0.91 11.4 11.61 0.14 1.67 0.04

0.28 8.47 1.56 0.05 0.47 0.01

AUTHOR DISCLOSURE INFORMATION The authors declare no conflicts of interest. Mahyar Etminan, PharmD, MSc Department of Pediatrics Faculty of Medicine University of British Columbia Vancouver, Canada and Therapeutic Evaluation Unit * 2014 Lippincott Williams & Wilkins

4. Correll CU. From receptor pharmacology to improved outcomes: individualising the selection, dosing, and switching of antipsychotics. Eur Psychiatry. 2010;25(suppl 2):S12YS21. 5. Bird ST, Etminan M, Brophy JM, et al. Risk of acute kidney injury associated with the use of fluoroquinolones. CMAJ. 2013;185:475Y482. 6. Roke Y, van Harten PN, Boot AM, et al. Antipsychotic medication in children and adolescents: a descriptive review of the effects on prolactin level and associated side effects. J Child Adolesc Psychopharmacol. 2009;19: 403Y414. 7. Kinsella C Jr, Landfair A, Rottgers SA, et al. The psychological burden of idiopathic adolescent gynecomastia. Plast Reconstr Surg. 2012;129:1Y7. 8. Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. Lancet. 2006;367:595Y604.

*Numbers based on recent use of an antipsychotic.

the risk for gynecomastia with risperidone. These results are consistent with the number of reported cases of gynecomastia with atypical antipsychotic drugs to the Food and Drug Administration,2 with risperidone having had the highest number of reported cases. A study in the Netherlands has also shown that risperi done has the highest incidence of hyperprolactinemia when compared with olanzapine or quetiapine.6 The strength of our study is the large sample size that allowed us to assess the risk for this relatively rare event. Because of a small number of gynecomastia cases that were on risperidone (27 cases), we were not able to perform a dose-response analysis. Gynecomastia has been shown to have a high psychological burden in men7 and may increase the risk for breast cancer in men.8 The results of this study will allow clinicians to consider gynecomastia as an adverse event when prescribing risperidone to men.

3. Szarfman A, Tonning JM, Levine JG, et al. Atypical antipsychotics and pituitary tumors: a pharmacovigilance study. Pharmacotherapy. 2006;26:748Y758.

Child and Family Research Institute University of British Columbia Vancouver, Canada [email protected]; [email protected]

Benji Heran, PhD Department of Family Medicine Faculty of Medicine University of British Columbia and Vancouver Coastal Health - Richmond Vancouver, Canada

Bruce Carleton, PharmD Department of Pediatrics Faculty of Medicine University of British Columbia Vancouver, Canada and Therapeutic Evaluation Unit Child and Family Research Institute University of British Columbia Vancouver, Canada

James M. Brophy, MD, PhD Department of Medicine McGill University Royal Victoria Hospital Montreal, Canada

REFERENCES 1. Leonhauser M. Antipsychotics: multiple indications help drive growth. Available at http://www.imshealth.com/ims/Global/ Content/Corporate/Press%20Room/ IMS%20in%20the%20News/Documents/ PM360_IMS_Antipsychotics_0112.pdf. Accessed April 1, 2014. 2. Mabini R, Wergowske G, Baker FM. Galactorrhea and gynecomastia in a hypothyroid male being treated with risperidone. Psychiatr Serv. 2000;51:983Y985.

Serpentine Tongue Syndrome Associated With Risperidone Long-Acting Injection Treatment To the Editors: erpentine tongue as a form of isolated lingual dyskinesia, with partial voluntary control, has been first documented by Sheehy et al1 as part of a Parkinsonian tardive disorder (TD) due to levodopa therapy.1,2 Second-generation antipsychotics have been associated with lesser risks for TD when compared to first-generation antipsychotics3 and relate to their atypical action via fast dissociation from D2 receptors.4 Of the second-generation antipsychotics, tardive dyskinesia has never been reported with risperidone long-acting injection (LAI).5 We report the first case of serpentine tongue as an isolated tardive lingual dyskinesia, occurring with risperidone LAI. Mr BV, a 48-year-old male patient with schizophrenia, on treatment with risperidone LAI, 37.5 mg initially and then 50 mg, for the last 3 years, with no changes in dosage made for the last 2 years, presented with involuntary movements of the tongue with difficulty in speaking, which he had noticed for the last 2 to 3 months. On examination, he had involuntary movements of the tongue, which were observed when the tongue was kept on the floor of the mouth and nearly disappeared on protrusion.

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These movements were in the form of repetitive twisting and turning of the tongue, of varying frequency and speed, and the patient could partially suppress these movements. There were no darting movements or forward protrusions of the tongue or any other abnormal movements of the lips, jaws, or any dyskinesias in any other parts of the body. He had a history of cannabis and amphetamine abuse and development of extrapyramidal syndrome with initiation of risperidone LAI, which subsequently disappeared. His physical examination was unremarkable and results of routine hematological and blood biochemistry including thyroid function tests were normal. A urine toxicology screen did not reveal the presence of any drugs of abuse, which was confirmed by the patient’s own report. Our patient’s symptoms were of relatively recent onset and he did not undergo neuroimaging; therefore, other types of adult-onset Parkinsonism known to be associated with facial or lingual dyskinesias, such as multiple system atrophy or adultonset neurodegeneration with brain iron accumulation cannot be ruled out with certainty. However, given the fact that he was only on risperidone LAI and that he had no other abnormal movements made us diagnose him to be experiencing drug-related tardive lingual dyskinesia, also known as serpentine tongue. Because one of the most prominent theories about pathogenesis has been about D2 receptor up-regulation with postsynaptic dopamine receptor supersensitivity based on the clinical observation that increasing the dose can temporarily alleviate the symptoms of TD,3 we therefore decided to increase the dose of risperidone by adding 2 mg of oral medication and benztropine 2 mg, to which he responded completely. We, however, wanted to highlight the risks of developing TD in a male, middleaged patient, contrary to the information available.5 We believe that our client, who had a history of amphetamine abuse and had developed early extra-pyramidal syndrome with initiation of risperidone LAI, was at high risk of developing a tardive syndrome. We therefore urge clinicians to closely monitor clients on long-acting antipsychotic injections, for risk factors, which can prevent the later onset of troublesome, hard to treat adverse effects. AUTHOR DISCLOSURE INFORMATION The authors declare no conflicts of interest. Sahoo Saddichha, BA, MBBS, DPM, MD Melbourne Health Melbourne, Victoria Australia [email protected]

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Daisy Talukdar, MSc Community Support Program Australian Red Cross Melbourne, Victoria, Australia

REFERENCES 1. Sheehy SH, Lawrence T, Thevathasan AW, et al. Serpentine tongue: a lingual dyskinesia. Neurology. 2008;70:e87. 2. Prashantha DK, Pal PK. Serpentine tongue: a rare manifestation following initiation of levodopa therapy in a patient with Parkinson’s disease. Parkinsonism Relat Disord. 2009;15(9):718Y719. 3. Waln O, Jankovic J. An update on tardive dyskinesia: from phenomenology to treatment. Tremor Other Hyperkinet Mov (N Y). 2013;12:3. 4. Seeman P. An update of fast-off dopamine D2 atypical antipsychotics. Am J Psychiatry. 2005;162(10):1984Y1985. 5. Risperdal Prescribing information: Janssen CNS. Available at http://www.janssencns. com/risperdal/risperdal-prescribinginformation. Accessed March 2, 2014.

Sleep-Related Eating Disorder Associated With Quetiapine To the Editors: omnambulistic eating or nocturnal sleeprelated eating disorder (NSRED) represents a type of sleep disorder characterized by recurrent periods of unconscious eating during the night of both usual and unusual food items with partial or complete amnesia of the event. It has been known to result in weight gain from eating high caloric foods, and cause various injuries. There have been reports of patients consuming uncooked food, placing inappropriate amounts of condiments on food, consuming hot food/beverages which resulted in burns, cutting food which resulted in lacerating injuries to their digits, and consuming other unusual items such as cooking oil or cleaning solutions.1 Somnambulism is defined as a series of complex behaviors that are initiated during slow-wave sleep and result in walking during sleep, with partial to complete amnesia the next day.2 Somnambulism or sleepwalking thus represents a disorder of nonYrapid eye movement sleep and may be associated with NSRED. Many cases of medication-related somnambulism and somnambulistic eating have been discussed in the literature, but most of them focus on sedative hypnotics and anxiolytics, most commonly zolpidem. With the increased use of atypical antipsychotics in psychiatric practice, we

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are beginning to see more frequent cases of somnambulistic eating related to this drug class. Quetiapine is an atypical antipsychotic which is Food and Drug Administration approved for the treatment of schizophrenia, bipolar disorder (acute mania, depression, and maintenance), and major depressive disorder as an adjunct to an antidepressant. There have been reports of quetiapine associated with sleepwalking3 and suspected quetiapine-related NSRED compounded by sleep apnea.4 Here, we report a case of quetiapine directly associated with a sleep-related eating disorder.

CASE REPORT The patient is a 48-year-old woman who had been diagnosed with bipolar disorder, rapid cycling approximately 33 years ago. She had previously been treated with multiple antipsychotics and mood stabilizers including risperidone, aripiprazole, ziprasidone, lithium, carbamazepine, and valproic acid. Valproic acid was found to be the most effective at treating her bipolar disorder, but she developed chronic pancreatitis and elevated ammonia levels while on the medication. The patient had a body mass index of 25.6 kg/m2 and had a current diagnosis of hyperlipidemia. She had no history of snoring, sleep apnea, or somnambulism. There was no known family history of any sleep-related disorders. The patient was started on quetiapine and quickly titrated up to 100 mg before bedtime for 3 days. The patient began sleep walking within 2 days of taking 100 mg of quetiapine. After awakening in the morning, the patient began noticing food, mostly snack foods, throughout the kitchen and dining room. Her spouse was concerned by this behavior and stayed up late one night to monitor the kitchen. The patient demonstrated symptoms of somnambulism that night, and the patient’s spouse was able to coax her back to bed. The next day, the patient and her spouse took extra precautions including locking the cabinets and refrigerator. The patient’s spouse was awoken to the patient pulling on locked cabinet doors. He walked into the kitchen to find the patient holding her car keys. The patient’s spouse was concerned that she may be attempting to drive her vehicle to obtain food. The patient then called the clinic to discuss her symptoms. The patient was recommended to discontinue quetiapine and follow-up to discuss alternative medications. Since discontinuing quetiapine, the patient has not had a recurrence of any known sleep-related disorders. Having no known risk factors for a sleep disorder, she was diagnosed with sleeprelated eating disorder associated with quetiapine. * 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Serpentine tongue syndrome associated with risperidone long-acting injection treatment.

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