Two cases of tardive dyskinesia associated with the use of paliperidone ER and their management

Paliperidone is an extended-release (ER) medication used in the treatment of schizophrenia and the recommended dose range is 3-12 mg/day (1). Tardive dyskinesia (TD) associated with the use of antipsychotics is characterized by involuntary choreic-athetoid movements occurring in the late stages of the treatment. Choreathetoid movements mostly occur around the mouth and face and athetoid movements alone mostly occur on the head-neck and pelvis (2, 3). We hereby present two cases of perioral dyskinesia who were using paliperidone, and discuss their response to the treatment. Both patients were females in their 20s and had been diagnosed with paranoid schizophrenia according to the DSM-IV-TR diagnostic criteria. Both patients had been using olanzapine before being switched to paliperidone ER. Olanzapine treatment had been discontinued due to side effects and treatment failure. The durations of paliperidone ER use were 9 months and 1 year, respectively; the doses of paliperidone ER were 9 and 12 mg/day that is consistent with the literature in terms of side effect risk (4). In one of the cases, the occurrence of side effects in combination with a psychotic exacerbation led to a change in antipsychotic drug therapy. In the other case, the drug was not discontinued due to the remission of initial psychotic symptoms and satisfaction of the patient with the treatment; however, the drug dose was reduced. In the treatment of TD associated with the use of paliperidone ER, one case responded to vitamin E 400 MU/day and omega 3 fatty acids while the other was administered propranolol 40 mg/day and clonazepam 1 mg/day. After one month, the scores of both patients on the extrapyramidal symptoms assessment scale were markedly reduced. The patient who had the psychotic exacerbation also had a history of childhood trauma, which we feel had negatively inşuenced the course of the treatment. Young age and female sex, and drug use for more than 6 months may increase the risk of TD in patients taking paliperidone; the use of vitamin E, omega 3 fatty acids, propranolol, and clonazepam may lead to a significant improvement in symptoms.

References:

1. Janicak PG, Winans EA. Paliperidone ER: a review of the clinical trial data Neuropsychiatric Disease and Treatment 2007:3(6) 869–883.
2. Kaplan HI, Sadock BJ Synopsis of Psychiatry: Eighth ed. Baltimore: Williams & Wilkins, 1998
3. Bernstein JG. Drug Therapy in Psychiatry. Third ed. St.Louis: Mosby-Year Book, 1995
4. Meltzer HY, Bobo WV, Nuamah IF, Lane R, Hough D, Kramer M, Eerdekens M. Efficacy and tolerability of oral paliperidone extended-release tablets in the treatment of acute schizophrenia: pooled data from three 6-week, placebo-controlled studies. J Clin Psychiatry 2008 May;69(5):817-29. Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S165