Drug-Induced Movement Disorders: A Primer

17 Aug Drug-Induced Movement Disorders: A Primer

Cerebellar damage due to longstanding abuse (ethanol) or toxic states can also cause intention tremors that can be quite bothersome. Medication-induced tremor (MIT) is common in clinical practice and there are many medications/drugs that can cause or exacerbate tremors. MIT typically occurs by enhancement of physiological tremor (EPT), but not all drugs cause tremor in this way. In this manuscript, we review how some common examples of MIT have informed us about the pathophysiology of tremor. Have you ever wondered how often abnormal involuntary movements (AIMs) develop following use of medications? Have you been unsure about which aspects of the history, physical examination, and laboratory tests are most likely to yield meaningful information about the etiology and treatment of drug-induced abnormal movements?

Antioxidants, including vitamin E, vitamin B6 and Ginkgo biloba, have also been studied. Vitamin E had conflicting results, while vitamin B6 and Ginkgo biloba are probably useful in treating tardive movement disorders.17,18 Caution is needed with Ginkgo biloba because of its antiplatelet effects, especially in patients taking antiplatelet drugs or anticoagulants. Anticholinergic drugs to prevent, or reduce the severity of, drug-induced movement disorders have been suggested, however there is no evidence to support this. Subacute drug-induced movement disorders occur within days to weeks of drug ingestion.

Tremors & DIMD (Drug-Induced Movement Disorders)

Intermittent apomorphine injections or a continuous infusion may be required in moderate–severe cases. Over the next 30 minutes, her tremor, rigidity, eye movement deviation, and torticollis gradually resolved. All laboratory testing, including a comprehensive metabolic panel, liver function tests, thyroid function tests, and serum and urine toxicology screens, were within normal limits.

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Tremors or Drug-Induced Movement Disorders (DIMD) may harm your quality of life and general well-being. You may find it challenging to perform easy tasks, which may, in turn, affect your social functioning and interpersonal communication. You may also lose your independence as you’d need help performing easy tasks. Tremors may also result in other symptoms like depression and anxiety, which may have severe consequences. Alcohol tremors primarily affect the hands, but they affect the legs and arms in some circumstances. The tremors manifest approximately 8 hours after you stop drinking and peak about 30 hours after your last drink.

Depending on the duration of dyskinesia, the levodopa dose can usually be reduced to a lower dose which still maintains efficacy. It is worth noting that mild dyskinesias are often not bothersome to the individual and do not interfere with their function, therefore a change in levodopa dose may not be required. Referral is recommended for patients with late-stage disease for consideration of device-assisted therapy. Treatment of AIMs is based on the underlying etiology (eg, metabolic, drug induced).

• Common illegal drugs that cause Drug-Induced Movement Disorders (DIMD) are cocaine, opioids, amphetamine, and heroin.
• A report by the National Institute on Drug Abuse revealed that in 2020, approximately 92,000 U.S citizens died from a drug-related overdose of both illegal drugs and prescription opioids.
• There is a paucity of literature that deals with the mechanisms of MIT, with most manuscripts only describing the frequency and clinical settings where MIT is observed.
• We performed a PubMed literature search for published articles dealing with MIT and attempted to identify articles that especially dealt with the medication’s mechanism of inducing tremor.
• Have you ever wondered how often abnormal involuntary movements (AIMs) develop following use of medications?
• Depending on the duration of dyskinesia, the levodopa dose can usually be reduced to a lower dose which still maintains efficacy.

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Obtaining a complete psychiatric history from someone who has developed abnormal muscle movements is crucial to refining the differential diagnosis and mapping out a treatment plan. Details of the location and nature of the abnormal movements, their onset and progression, and their aggravating and relieving factors are essential. Another important aspect of the history is a review of the neurologic and neurodevelopmental history. A history of a seizure disorder might provide insight into the causes of stereotypic movements. A history of a recent stroke might contribute to athetosis, while a traumatic brain injury or Parkinson’s disease (PD) can cause akathisia or tremors. Similarly, patients with autism spectrum disorder often have stereotypic movements, while motor tics are often comorbid with attention-deficit/hyperactivity disorder (ADHD), Tourette syndrome, or obsessive-compulsive disorder (OCD).

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• The involuntary movements in cocaine addicts or recovering addicts are due to locomotor sensitization.
• In this manuscript, we review how some common examples of MIT have informed us about the pathophysiology of tremor.
• Founded in 1961, APDA has raised and invested more than $282 million to provide outstanding patient services and educational programs, elevate public awareness about the disease, and support research designed to unlock the mysteries of PD and ultimately put an end to this disease.
• Some of these treatments are within the scope of practice of primary care physicians; others will require referral to specialists.
• She was started on oral benztropine 1 mg 3 times/day for 3 days as prophylaxis against the return of acute dystonia.
• Patients are often on combinations of drugs that may cause more than one movement disorder, thereby making it challenging to identify the culprit drug.
• Typically, it subsides on cessation of the drug, but can last for months.

They can be classified chronologically based on the time of onset after drug ingestion, as acute, subacute or tardive. Drug-induced movement disorders (DIMDs), also commonly referred to as extrapyramidal symptoms (EPS), represent a variety of iatrogenic and clinically distinct movement disorders, including akathisia, tardive dyskinesia, dystonia, and parkinsonism (TABLE 1). DIMDs remain a significant burden among certain patient populations, such as those receiving treatment with dopamine receptorÒblocking agents (DRBAs; e.g., various psychotropic agents and antiemetics) (TABLE 2). DIMDs are often underrecognized, and knowledge of DIMDs will allow clinicians, pharmacists, and other health care professionals to better identify and manage patients with these conditions. Movement disorders are a common, and at times life-threatening, adverse effect of many drugs, most commonly dopamine receptor blocking drugs.

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The primary treatment for this type of parkinsonism is weaning off of the offending medication, if possible. The motor features of PD are often (but not always) very easy to see via a neurologic exam in a doctor’s office. Rest tremor (which is a tremor that goes away with movement, but often returns when the limb is at rest) for example, is seen in virtually no other illness and can therefore be very important in diagnosing PD. But there is one other common condition that induces the symptoms of PD, including a rest tremor, which must be considered every time PD is being drug induced tremors considered as a diagnosis, and that is drug-induced parkinsonism. The time of onset of the movement disorder may be acute, subacute, or chronic.

Drug-induced movement disorders can range from tremors to life-threatening syndromes. They can be classified chronologically based on the time of onset after drug ingestion, as acute, subacute or tardive. Both therapeutic and illicit drugs can cause neurological adverse effects, including movement disorders. The most common causes of drug-induced movement disorders are dopamine receptor blocking drugs, including antipsychotics and antiemetics (Table 1). Drug-induced movement disorders can range from tremors to life-threatening syndromes.

Alcohol abuse may result in alcohol shakes, also called jitters or tremors. Often, the tremors occur when a person dependent on alcohol stops taking alcohol. Your body’s dopaminergic system affects various processes, including movement control and cognition. Therefore, when cocaine increases your extracellular dopamine levels, your dopamine levels significantly decrease, affecting your motor function. On the other hand, hypokinetic disorders are characterized by lack or absence of movement due to weakness. In addition to potentially causing parkinsonism in the general population, these medications should definitely be avoided in people who have parkinsonism from other causes, such as PD.

How Can Abnormal Involuntary Movements Be Treated?

Parkinsonism, as well as various types of tremor, can be a side effect of certain medications and can resolve with stopping the offending medication. Bring all your concerns to the attention of your physicians and remember to always consult with your physician before you make any changes to your medication regimen. There is a paucity of literature that deals with the mechanisms of MIT, with most manuscripts only describing the frequency and clinical settings where MIT is observed. That being said, MIT emanates from multiple mechanisms depending on the drug and it often takes an individualized approach to manage MIT in a given patient.

Another important part of the history is the family history of inherited and genetic disorders (like Huntington’s disease and Wilson’s disease) that affect the basal ganglia and typically present with abnormal movements (including chorea, athetosis, and dystonia). Similarly, a substance use history that includes prior manifestations of intoxication or withdrawal should be obtained. Both therapeutic and illicit drugs can cause neurological adverse effects, including movement disorders. The most common causes of drug-induced movement disorders are dopamine receptor blocking drugs, including antipsychotics and antiemetics (Table 1).