CME INDIA Case Presentation by Dr. Ishan Zaidi, MBBS, DNB Medicine, Naaz hospital, Prayagraj.

CME INDIA Case Study

How Presented?

• Levosulpiride was started 4 weeks back in a patient.
• Aged 65 years, Female, Non-diabetic. Normotensive.
• For last 10 days patient complaint of involuntary chin movement and came to consult.

CME INDIA Discussion

Dr. N. K. Singh:

• LPS Induced Dyskinesia.
• Stop the drug.

Dr. Anil Kumar, Consultant Psychiatrist, Ranchi:

• Rabbit syndrome due to LPS.
• Stop offending drugs.
• Start pacitane 2 mg twice 10 days.
• No need of any investigations.
• Anticholinergic drugs are the best-known treatment.
• Rabbit syndrome does not respond to treatment with levodopa or dopamine agonists.
• The most striking aspect of this syndrome is its specificity.
• Rabbit syndrome affects only the buccal region, and within this area it involves a highly stereotyped involuntary movement.

Dr. Ujjwal Roy, DM (Neuro), Ranchi:

Dr. Ashok Kumar (DM,Neuro), Ranchi:

• It is Rabbit Syndrome.
• Caused by Levosulpiride in this patient.
• Treatment Anticholinergic like Trihexyphenidyl (Pacitane).

CME INDIA Learning Points

• Levosulpiride is an atypical antipsychotic drug.
• It is currently being increasingly used for various gastrointestinal disorders such as irritable bowel syndrome, gastroesophageal reflux disorder, nonulcer dyspepsia, and as a prokinetic agent.
• Fixed dose combination products of Levosulpiride with proton-pump inhibitors are being prescribed in India rampantly on a long-term basis.
• It is a D2 receptor antagonists (antipsychotic drugs) and known to cause extrapyramidal syndrome (EPS) (acute muscular dystonia, neuroleptic malignant syndrome, dyskinesia, and Parkinson’s disease).
• Levosulpiride has additional serotonin receptor affinity.
• The incidence of EPS caused due to Levosulpirise appears to be lower than the typical antipsychotics owing to its atypical antipsychotic profile. It also causes   weight gain, increase in plasma prolactin level, postural hypotension, and elevated liver transaminase.
• Antipsychotics/D2 antagonists-induced dyskinesia can be either orofacial dyskinesia or limb and trunk movements.
• The specific movements involved in orofacial dyskinesia:
  • Protrusion or twisting of the tongue.
  • Smacking and pursing of the lips.
  • Puffing of the cheeks.
  • Chewing movements of the jaw.
  • Grimacing movements of the face.
  • Purposeless, jerky Choreiform movements, athetosis of the extremities, limb and axial dystonias, gait abnormalities, lordosis, shoulder shrugging, and rotatory movements of the pelvis.
  • LSP-induced parkinsonism.
• Rabbit syndrome:
  • It is an antipsychotic-induced rhythmic motion of the mouth/lips, resembling the chewing movements of a rabbit.
  • The movement consists of a vertical-only motion, at about 5Hz, with no involvement of the tongue. Usually, the involuntary movements associated with rabbit syndrome appear after a long period (in most cases months or years, some cases after few weeks too) of antipsychotic treatment.
  • The reported prevalence: 2.3 to 4.4% of patients treated with typical antipsychotics.
  • The most striking aspect of this syndrome is its specificity. Rabbit syndrome affects only the buccal region, and within this area it involves a highly stereotyped involuntary movement.
• Differentiate Rabbit syndrome with oral tardive dyskinesia:
  • Remember the key for correct diagnosis: It is the involvement of tardive tongue movements, which does not occur in rabbit syndrome. Thus, one key to differentiating the syndromes is to examine the tongue. The tongue is uninvolved in Rabbit syndrome and displays no abnormal movements.
  • The movements of Rabbit syndrome continue during stage I sleep.
  • Fatigue and anxiety can worsen the movements.
  • The worsening of the movements can occur during tasks of attention or concentration.
• Timing of the onset of Rabbit syndrome after exposure:
  • It is variable, starting in as little as a week after initiation of drug to years after start of therapy.
• The treatment of rabbit syndrome is empirical:
  • The first step is to reduce the amount of antipsychotic treatment/ Stop as much as possible.
  • Anticholinergic drugs are the best-known treatment.
  • Rabbit syndrome does not respond to treatment with levodopa or dopamine agonists.

Quick Take-Aways

References:

1. Schwartz M, Hocherman S. Antipsychotic-induced rabbit syndrome: epidemiology, management and pathophysiology. CNS Drugs. 2004;18(4):213-20. doi: 10.2165/00023210-200418040-00002. PMID: 15015902.
2. Catena M, Fagiolini A, Consoli G, Ducci F, Carlini M, Picchetti M, Marazziti D. The rabbit syndrome: state of the art. Curr Clin Pharmacol. 2007 Sep;2(3):212-6. doi: 10.2174/157488407781668820. PMID: 18690867.
3. Sansare K, Singh D, Khanna V, Karjodkar FR. Risperidone-induced rabbit syndrome: an unusual movement disorder. N Y State Dent J. 2012 Aug-Sep;78(5):44-6. PMID: 23082694.
4. Choudhury S, Chatterjee K, Singh R, Shubham S, Trivedi S, Chatterjee S, Kumar H. Levosulpiride-induced Movement Disorders. J Pharmacol Pharmacother. 2017 Oct-Dec;8(4):177-181. doi: 10.4103/jpp.JPP_32_17. PMID: 29472751; PMCID: PMC5820749.
5. Gupta S, Garg GR, Halder S, Sharma KK. Levosulpiride: A review. Delhi Psy J. 2007;10:144–6. Rabbit Syndrome – an overview | ScienceDirect Topics

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