Quetiapine-Related Dysphagia
TO THE EDITOR: Normal swallowing needs coordination between several anatomical, physiological, and neurological processes, and imbalance between any of these can cause dysphagia. Swallowing difficulties can lead to malnutrition, weight loss, dehydration, and aspiration pneumonia.
Movement disorders, including dyskinesia, dystonia, and parkinsonism are important causes of dysphagia.1 Episodes of choking are not rare in patients with psychiatric disorders and are most commonly caused by rapid eating or bradykinetic dysphagia.2 Risk factors for dysphagia include poor eating habits, psychiatric disorders, neurological disorders, institutionalization, poor dentition, older age, and exposure to neuroleptic medication.3 Newer, atypical antipsychotics are believed to be less likely to cause either movement disorders or dysphagia.
We present a case where difficulty in swallowing appeared twice in a young woman treated with quetiapine and hypothesize possible mechanisms explaining its occurrence.
Daniel Armstrong, MBChB, Niraj Ahuja, MBBS, M.D., MRCPsych, and Adrian J. Lloyd, MBBS, MRCPsych, M.D., Northumberland, Tyne and Wear NHS Trust, U.K. Quetiapine-Related Dysphagia. Psychosomatics 49:450-a-452, September-October 2008.
Case Report
A 31-year old woman, "Ms. A," who had a diagnosis of schizoaffective disorder, presented with sore throat, swallowing difficulty, and choking while eating. She had been prescribed quetiapine and valproate for approximately 2 years, now taking 750 mg quetiapine and 1,000 mg valproate daily. She also had an infected tooth. Even a week after recovery from both sore throat and tooth infection, she continued to struggle with swallowing difficulties. She stopped all her medication, and the swallowing difficulties remitted within 24 to 48 hours.
The tooth and throat infections were considered the most likely causes for her dysphagia, with medication felt unlikely to be responsible. Quetiapine (alone) was begun again 1 week later in gradually increasing dosage. Within 3 weeks, she presented again with swallowing difficulties. After discontinuation of quetiapine (400 mg daily), the dysphagia resolved completely over 24 to 48 hours.
Before being prescribed quetiapine and valproate, she had received olanzapine (discontinued after 3 weeks because of weight gain), risperidone (discontinued after 7 months because of jaw stiffness, tremors, and hyperprolactinemia), flupentixol (discontinued after 14 weeks because of akathisia and "chewing her tongue in sleep"), and amisulpride (discontinued after 14 weeks because of hyperprolactinemia).
Interestingly, she had reported stiffness in her wrists (confirmed by examination) on quetiapine 300 mg daily. Procyclidine was beneficial and had subsequently been stopped about 6 to 7 months before the onset of dysphagia, without reemergence of any noticeable extrapyramidal side effects (EPSE).
Two days after stopping quetiapine, Ms. A was started on aripiprazole 5 mg daily, slowly increased to 15 mg daily over the next 6 weeks. The swallowing difficulties have not reemerged for the last 10 months.
Discussion
Ms. A presented with swallowing difficulty while receiving quetiapine 750 mg daily and valproate 1,000 mg daily. Concomitant difficulties with sore throat and an infected tooth were felt at the time to be the most likely causes. However, 2 weeks later, she developed dysphagia again on a rechallenge with quetiapine. Using the Naranjo probability scale, the link between quetiapine and dysphagia would appear to be "probable."
We searched the literature (PubMed, MEDLINE, EMBASE, and PsychInfo) but did not find any reported cases of dysphagia associated with quetiapine. An FDA document4 records dysphagia as an infrequent adverse effect of quetiapine (occurring in 1/100 to 1/1,000 patients) and advises cautious use of antipsychotics (including quetiapine) in patients at risk for aspiration pneumonia, for example, elderly patients with advanced Alzheimer’s dementia.
We found reports of dysphagia related to other atypical antipsychotics, for example, risperidone and olanzapine, with resolution of dysphagia when antipsychotic was discontinued. A man with schizophrenia had received risperidone for 6 months before reporting difficulty in swallowing. Tardive dyskinesia (TD) was suspected as the cause, even in the absence of classical involuntary oro-facial and tongue movements.5
Quetiapine is usually associated with a low risk of EPSE, even at high doses.6 The low prevalence of EPSE and TD has been attributed to quetiapine’s low affinity for and fast dissociation from the postsynaptic dopamine D2 receptor. It has been suggested that quetiapine reduces the severity of preexisting TD caused by other antipsychotics.7
However there are three case reports of TD with quetiapine use. In one case series, six patients with mood disorders developed TD after quetiapine use, and these instances resolved completely upon discontinuation of quetiapine.8
Dysphagia is common in parkinsonism (up to 50% of patients) and TD.3 In our patient, jaw stiffness and tremor were evident on risperidone treatment, and this resolved with procyclidine. Similarly, stiffness at both wrists was noted during initial quetiapine treatment. As stated above, swallowing is normally a result of fine neurophysiological coordination. It is therefore possible that rigidity, bradykinesia, dry mouth, tooth infection, and sore throat could have sensitized our patient to dysphagia, which then recurred with quetiapine rechallenge.
The early recognition of dysphagia as a possible adverse effect of antipsychotic medication would help improve management because drug-induced dysphagia is often reversible.3
FOOTNOTES
Dr. Ahuja has received honoraria for lectures/travel grants from AstraZeneca, Boehringer-Ingelheim, Bristol-Meyer-Squibb, Eli Lilly and Company, Janssen-Cilag, and Wyeth.
Dr. Lloyd has received speaker fees or financial support (including travel funding) for academic work from AstraZeneca, Bristol-Meyer-Squibb, Eli Lilly and Company, Janssen-Cilag, Lundbeck, and Wyeth.
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