Journal Article

A case report of cholinergic rebound syndrome following abrupt low-dose clozapine discontinuation in a patient with type I bipolar affective disorder

Besson, Marie, Sergentanis, Ioannis, Galova, Andrea, Desmeules, Jules, Berney, Patricia

2019

Overview

Background Rebound cholinergic syndrome is a rare, but well known unwanted phenomenon occurring after abrupt clozapine discontinuation. There have been previous reported cases of cholinergic rebound in the literature; however, these reports described cholinergic rebound following cessation of high doses of clozapine in patients diagnosed with schizophrenia. Here, we report a case of rebound cholinergic syndrome and catatonia in a male patient three days after abrupt discontinuation of 50 mg of clozapine prescribed for type I bipolar affective disorder. Case presentation A 66-year old male of Spanish origin, treated for type I bipolar affective disorder for 15 years and for Crohn disease, was brought to the emergency department because of a sudden onset of mutism, dysphagia and trismus. He was described catatonic and presented hypertension, tachycardia and tachypnea. His body temperature was normal and the laboratory tests were unremarkable at presentation. A head CT and an EEG were in the normal range. While reviewing his history, it appeared the he was on clozapine 50 mg a day, first introduced 2 months ago, during a previous hospitalization for a manic episode resistant to other mood stabilizers. For an unknown reason, the patient’s psychiatrist stopped clozapine three days before the admission and replaced it by risperidone 5 mg and quetiapine 200 mg daily. A cholinergic rebound syndrome was then evoked. The patient’s ability to speak recovered dramatically and fast after the intravenous administration of 2.5 mg of biperiden supporting the diagnosis. Risperidone and quetiapine were also stopped. The patient fully recovered in 20 days after the reintroduction of 50 mg of clozapine and 2.5 mg of biperiden daily. Conclusions This case report underscores that cholinergic rebound syndrome may occur in patients suffering from bipolar affective disorders, being on clozapine as a mood stabilizer. The low dose clozapine does not preclude severe manifestations of the phenomenon. Progressive tapering should therefore be adopted in any case.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Affective disorders / Aged / Antidepressants / Antipsychotic agents / Antipsychotic Agents - adverse effects / Antipsychotic Agents - therapeutic use / Antipsychotics / Aripiprazole / Biperiden / Bipolar disorder / Bipolar Disorder - drug therapy / Body temperature / Case Report / Case reports / Case studies / Catatonia / Catatonia - chemically induced / Cholinergic Agents - adverse effects / Clozapine / Clozapine - adverse effects / Clozapine - therapeutic use / Crohn's disease / Deglutition disorders / Dopamine / Dosage and administration / Drug dosages / Drug therapy / Dysphagia / Elderly men / Emergency medical care / Health aspects / Humans / Hypertension / Intravenous administration / Laboratories / Male / Mania / Medicine / Medicine & Public Health / Mental disorders / Mood / Mood disorders / Mutism / Nervous system diseases / Patients / Psychiatrists / Psychiatry / Psychological aspects / Psychotherapy / Psychotropic drugs / Quetiapine / Reintroduction / Risk factors / Risperidone / Schizophrenia / Substance withdrawal syndrome / Substance Withdrawal Syndrome - psychology / Tachycardia / Withdrawal syndromes-cholinergic rebound syndrome-low dose clozapine -bipolar affective disorder-Pharmacodynamic properties-overlapping switch strategies-case report / Withholding Treatment