Tunc Z, Celik G, Avci A, Tahiroglu A, Gamli I
Supplementation of vitamin E and N-acetylcysteine with quetiapine in tardive dyskinesia: a case report
Antipsychotics are widely used to treat several psychiatric disorders in child and adolescent populations with schizophrenia, bipolar disorders, pervasive developmental disorders and conduct disorders. The most common side effects associated with atypical antipsychotics are weight gain, diabetes and movement disorders. Antipsychotic induced movement disorders, especially tardive dyskinesia (TD), may be related to patient characteristics such as age, gender, prior exposure to medications, neuroanatomical and genetic variations. The theories about TD pathogenesis are D2 receptor up regulation with postsynaptic dopamine receptor super sensitivity, GABAergic hypo function and maladaptive synaptic plasticity hypothesis. In this paper, we present an adolescent patient with tardive dyskinesia who responds to supplementation vitamin E and N-acetylcysteine and quetiapine. A 15-year-old boy with schizophrenia was referred to our outpatient clinic for aggression, social isolation, persecution delusions, talking himself, involuntary movements including grimacing, smacking, pursing, sticking out the tongue, eye blinking and rapid movements of the arms. According to his parents, psychotic symptoms had started four years ago, but involuntary movements had occurred two months before his access to our clinic. Four years ago, “Risperidone 2 mg” and “Biperidene 1 mg” were started; one year ago “citalopram 20 mg” was added to Risperidone by another outpatient clinic. According to DSM-IV criteria, his movement disorder was diagnosed as tardive dyskinesia. This adverse effect was thought to be due to treatment with antipsychotic medications, including Risperidone and haloperidol, since the age of eleven. Initially, Risperidone and Citalopram were stopped and Quetiapine 50 mg/day was started and titrated up to 500 mg/day in two weeks. After two weeks, vitamin E 300 IU/ day and N-acetylcysteine 1200 mg/day were added to quetiapine due to persistence of tardive dyskinesia symptoms. After one month, his involuntary movements gradually decreased, and within 2 months, his tardive dyskinesia was fully improved. The movement disorders associated with antipsychotics are disabling and distressing issues for parents as well. It is recommended that all patients should be examined for movement disorders before the initiation of antipsychotic drug treatment under regular monitorization. In this case, quetiapine with vitamin E and N-acetylcysteine supplementation appears to be effective in reducing symptoms of TD although the mechanism stays unclear. Chronic neuroleptic exposure increases dopamine turnover in the brain with production of cytotoxic-free radicals. In accordance with this, antioxidant efficacy of vitamin E and N-acetylcysteine may be responsible for improving tardive symptoms besides of Risperidone and citalopram discontinuation. However, it must be considered that most drug-induced movement disorders in childhood are known to be reversible. Consequently, children and adolescents with chronic psychiatric conditions who have been treated with neuroleptic both typical and atypical should be followed up regularly for early intervention and prevention of adverse effects of these drugs.