Is your tongue "dancing" after taking hiccups?

*For medical professional reading reference only If you encounter the oral-lingual-buccal triad, don't forget the cause! "Medicine" is a double-edged sword.
It has both positive therapeutic effects and different degrees of toxic side effects
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There are also individual differences between different patients
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Today, Tang Wei, Director of Xinhua Hospital Affiliated to Dalian University, analyzed a case for us—the adverse reaction caused by the treatment of hiccups
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Case introduction A 70-year-old male patient was admitted to the hospital with "involuntary tongue movement for 1 week"
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▌ History of present illness: The patient developed hiccups before 2 months without any inducement, which continued unrelieved.
Oral haloperidol, 1 tablet (2 mg) each time, twice a day, the hiccups improved, but there were still attacks
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Due to the epidemic, the patient himself was reluctant to go to the hospital for follow-up visits, and he took oral medication to increase the dose, 2 tablets (4 mg) each time, three times a day.
The patient stopped taking haloperidol 10 days before the hiccups
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One week ago, the patient developed involuntary movements of the lips and tongue, and the seizures were uncontrolled.
The outpatient was admitted to the hospital with "tardive dyskinesia"
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▌ Physical examination: The vital signs were stable, and the heart and lung auscultation was unremarkable
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Continued tongue out, various involuntary tongue movements, occasional mouth opening, inability to chew food, slurred speech (see video)
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(Video) The muscle strength of the limbs was grade 5, the muscle tone was normal, and the bilateral pathological signs were negative
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Magnetic resonance imaging of the head showed no obvious abnormality
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After admission, 1 mg of clonazepam was given orally twice a day.
After 1 week, the symptoms of tongue sticking improved, but did not disappear, and oral clonazepam was continued
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▌ Localization and qualitative diagnosis: It is located in the extrapyramidal system based on the abnormal involuntary slow and irregular movements of the patient's tongue, lips and mouth
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The patient was an elderly male with a clear history of taking antipsychotics, a large amount, and abrupt discontinuation of the drug.
A qualitative diagnosis of tardive dyskinesia was made
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Diagnosis: tardive dyskinesia (TD)
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Discussion 1.
Drugs for the treatment of hiccups - haloperidol Haloperidol is a commonly used drug for the treatment of hiccups, with a fast onset rate, and is the drug of choice for many doctors
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Hiccup is a clinical symptom of a special inspiratory sound and discomfort due to vagus nerve reflex or direct stimulation of the phrenic nerve and diaphragm, causing the diaphragm and intercostal muscles to involuntarily and synchronously contract suddenly for about 30 ms with vocal cord closure
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This patient's doctor chose haloperidol to treat intractable hiccups for two reasons: (1) It is an antipsychotic drug, which acts on the limbic system, hypothalamus and reticular structure.
The nerve excitability of the entire hiccup reflex arc achieves the effect of stopping hiccup
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②At the same time, it has peripheral anticholinergic effect, and plays the role of antiemetic and antihiccup
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Studies have shown that the main side effect of haloperidol treatment is sedation, which can be relieved spontaneously after drug withdrawal
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Prompt for the elderly and more sensitive people should be appropriately reduced
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2.
The cause of TD TD is the involuntary rhythmic repetitive movements of a group of muscle groups caused by long-term use of larger doses of antipsychotics
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The incidence varies by drug type, dose, duration of administration, and individual differences
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Withdrawal of antipsychotics can make tardive dyskinesia more pronounced, while increasing antipsychotic doses can temporarily reduce tardive dyskinesia
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The disease is more common in long-term (more than 1 year) high doses of antipsychotic drugs that block dopaminergic receptors, or combine with them, especially phenothiazines such as chlorpromazine, perphenazine, butyryl benzenes such as haloperidol Pidols can cause TD, and some dopamine drugs such as levodopa and medopa stabiliser can also cause similar TD
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Involuntary movements are occasionally seen with long-term use of antidepressants, antiparkinsonian drugs, antiepileptic drugs, and antihistamines, and are more likely to occur when patients are reduced or abruptly discontinued
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Relevant factors include: (1) age and gender factors: the elderly are more likely to occur and difficult to recover, and more women are than men; (2) patients with encephalopathy are more likely to use antipsychotics, and patients with negative symptoms of schizophrenia tend to develop TD at an early age and a high incidence rate; (3) Drug factors: drug dose and treatment duration are related to the occurrence of TD, and are more common in patients with Parkinson's syndrome in the early stage of treatment
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This patient took haloperidol orally for 2 months for the treatment of hiccups, and the time did not exceed 1 year, but the amount was large, and the drugs were individualized
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3.
The pathogenesis of TD The pathogenesis is still unclear, and the damage of central dopaminergic neurons is a theory
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It has also been reported that γ-aminobutyric acid (ie, γ-aminobutyric acid, GABA) hypofunction of the energy system, neurotoxicity generated by free radicals, and the direct effect of antipsychotics on the nervous system
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It is generally believed that long-term use of high-dose antipsychotic drugs, such as phenothiazines and butyryl benzenes, can block postsynaptic dopamine receptors (DR) for a long time, and increase the synthesis and release of presynaptic dopamine (DA) in a feedback manner.
Postsynaptic DR is more sensitive to DA, resulting in DR hypersensitivity.
After stopping antipsychotics, symptoms are often induced or aggravated, and DA synergists can make symptoms worse
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Pathological changes: autopsy showed degeneration and atrophy of substantia nigra and caudate nucleus cells
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This patient took haloperidol orally, 2 tablets (4 mg) each time, three times a day, with a large amount, and the sudden withdrawal of the drug induced the occurrence of this disease, which was consistent with the reports in the literature [1]
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4.
The clinical manifestations of TD usually develop after long-term antipsychotic treatment, showing abnormal involuntary slow and irregular movements of the tongue, lips, mouth and trunk, or choreoathetosis-like movements
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Perioral movement disorders are the most common, including tongue turning and tongue extension, jaw chewing and pouting
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The main clinical manifestations of tardive dyskinesia are involuntary rhythmic repetitive movements of a certain muscle group.
The common ones are: (1) Oral-lingual-buccal triad
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(2) Involuntary repetitive movements or twitching of limbs
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(3) The movement of trunk muscles is not coordinated
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(4) Others: Any muscle group in the body can be involved
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The main manifestations of this patient are tongue extension, tongue rotation, and jaw chewing movement and pouting, which is consistent with the oral-lingual-buccal triad (see video)
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5.
How to diagnose TD The diagnosis of this disease is based on the patient's history of taking antipsychotics or long-term use of antidepressants, antiparkinsonian drugs, antiepileptic drugs or antihistamines, and the occurrence of dyskinesia during medication or within 3 months after withdrawal , showing rhythmic stereotyped repetitive persistent involuntary movements
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6.
There is currently no effective drug for the treatment of TD.
It has been reported that 73% of patients can be effectively treated with propranolol (propranolol); 41% of patients with clonazepam are effective in the treatment of tardive dyskinesia; Clozapine can reduce the symptoms of tardive dyskinesia in 40%
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① For severe dyskinesia, try DA depleting agents such as reserpine (reserpine), which has short-term effects.
Start with a small dose of 0.
25 mg and gradually increase it 1 to 3 times/d.
You can also try tiapride hydrochloride, sulpiride, etc.
These drugs themselves also have side effects
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② Anticholinergic drugs such as trihexyphenidyl and scopolamine can aggravate TD symptoms
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③Antihistamines such as promethazine 25～50mg 2～3 times a day or intramuscularly once a day for 2 consecutive weeks can gradually desensitize hypersensitive DR
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④ Short-term use of DR blockers such as low-dose clozapine 100-200 mg/d
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⑤ Drugs acting on GABA: It is believed that TD is related to the hypofunction of GABA, and GABA synergists such as sodium valproate and carbamazepine may be effective
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⑥ Diazepam 2.
5～5mg, 2～3 times/d; Propranolol 10～20mg, 2～3 times/d, can stabilize the patient’s mood and reduce symptoms
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⑦ Brain metabolism drugs and vitamin E can be tried to promote the recovery of brain function
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It is worth mentioning that Deuterium Tetrabenazine Tablets is a new drug for the treatment of TD, which has been approved in the United States and China, and has good safety and tolerance
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7.
The prevention of TD is closely related to the long-term use of antipsychotics, which should be used rationally and prudently under the guidance of doctors
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Avoid using 2 or more antipsychotics in combination as much as possible.
When stopping or changing antipsychotics, the dose should be gradually reduced, and should not be stopped suddenly; Anticholinergic drugs should not be used or used sparingly when necessary
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It should be noted that tardive dyskinesia is mostly irreversible damage, and treatment is more difficult, prevention is very important
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References: [1] Liu Yuanyuan, Zuo Jinhuai.
Research progress in the treatment of tardive dyskinesia caused by antipsychotics [J].
China Chronic Disease Prevention and Control, 2021, 29(11): 866-869.
Expert Profile Professor Tang Wei Doctor of Medicine, Professor, Chief Physician, Graduate Supervisor; Director of the Fourth Department of Neurology, Xinhua Hospital Affiliated to Dalian University
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Academic part-time jobs: Standing member of the Encephalopathy Professional Committee of the Liaoning Provincial Association of Traditional Chinese Medicine, member of the Standing Committee of the Neurology Branch of the Liaoning Provincial Association of Integrative Chinese and Western Medicine, member of the Psychiatry Branch of the Liaoning Provincial Association of Rehabilitation Medicine, member of the Psychiatric Branch of the Liaoning Provincial Medical Association, member of the Liaoning Provincial Medical Association Clinical Epidemiology Member of the Chinese Society of Diseases, and vice chairman of the Psychiatry Branch of the Dalian Medical Association
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Engaged in clinical research and teaching of neurology for more than 20 years, with a solid theoretical basis in neurology and rich clinical experience, a famous lecturer in the medical industry platform, with 300,000 clicks in a single class, won 1 second prize of the provincial scientific and technological progress award, and the city's scientific and technological progress 1 second prize and 5 third prizes
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He presided over 6 provincial and municipal projects, published 60 papers, and edited 2 books
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First release of the text: Review expert of the Neurology Channel of the medical community: Professor Tang Wei Editor-in-charge of the Department of Neurology, Xinhua Hospital Affiliated to Dalian University: Mr.
Lu Li The medical community strives to be accurate and reliable when the published content is approved, but it does not care about the timeliness of the published content.
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