Drug-Drug-Induced Akathisia: Two Case Reports

Extrapyramidal side effects of psychotropic medicines are usually experienced by patients in thefirst few weeks of initiating therapy.Patients stabilized on these medications who present with distressing complaints akin to akathisia may be triggered by other factors.This report presents two cases of drug-drug-induced akathisia. Case A is a patient with schizophrenia who was being managed withrisperidone 2 mg tablet daily for the past 3 years. She fell ill and reported to a nearby clinic where she was prescribed ciprofloxacinand artemether/lumefantrine tablets for the treatment of an infection and malaria. She presented 7 days later to her psychiatristwith complaints of restlessness, tremor, palpitations, insomnia, and resurgence of obsessive thoughts. Case B is a patient whowas diagnosed withfirst-episode psychotic depression and admitted for 10 days. Her medications on admission werefluphenazine decanoate 25 mg depot injection once, olanzapine 10 mg tablet daily, andfluoxetine 20 mg capsule daily. Ondischarge, ciprofloxacin 500 mg tablet every 12 hours for 5 days andfluconazole 150 mg capsule once were added to hermedications for the treatment of a urinary tract infection. She reported back to the hospital a day after discharge withcomplaints of restlessness,“seizures,”tremor, abdominal discomfort, and weight gain. Both patients were diagnosed withakathisia using ICD-10 classification and the Barnes akathisia rating scale and managed with anticholinergics, benzodiazepines,and beta blockers. Other measures employed in managing the akathisia included reducing the dose of the antipsychotic and/orswitching antipsychotics. Despite these management measures, the symptoms of akathisia persisted and only resolved after4weeks. Upon the resolution of symptoms, Case A continued treatment on olanzapine 5 mg tablet daily andfluoxetine 20 mgcapsule daily while Case B continued treatment on risperidone 2 mg tablet daily andfluoxetine 20 mg capsule daily. UsingNaranjo’s adverse drug reaction causality assessment scale, Medscape drug interaction checker, and literature review, a possibleand probable case of drug-drug-induced akathisia was made for Case A and Case B. This report is to create more awarenessabout psychotropic-antimicrobial-induced akathisia. The information underpins the need for health professionals to consideradverse drug-drug interactions as the probable cause of extrapyramidal side effects experienced by patients on antipsychotics