Flupenthixol/Melitracen induced tardive dystonia. Case report

Abstract

Flupenthixol is a typical antipsychotic drug referred to thioxanthines. It has anxiolytic and antidepressant effects and is often used in psychiatry for treatment of schizophrenia. In neurology, the medicine is used in low concentrations in combination of melitracen. Melitracen is a tricyclic antidepressant drug. It is used in management of depression, apathy, insomnia and anxiety.
Flupenthixol/Melitracen (Deanxit®) is a soft-acting combination medicine that makes it widely used in clinical practice. However, the preparation is not harmless due to the risk of tardive dyskinesia and is banned for use in some countries - USA, Canada, UK, Australia, Japan and India.
Dyskinesias are due to dopaminergic overactivity due to the increased sensitivity in the striatum of D1 dopamine receptors and the emergence of new D2 receptors due to their long-term blockade with neuroleptics. There is evidence of loss of GABA-ergic activity in the subthalamic nucleus and various changes in glutamate and other neuropeptides. These mechanisms can explain the late onset of dyskinesias and their persistence after cessation of treatment. Because of the risk of late motor complications, it is required to refine the use of Flupenthixol / Melitracen, short-term intake and regular follow-up of patients.
We present a clinical case of a woman with tardive oromandibular dystonia after long-standing treatment with Flupenthixol/Melitracen. We used somatic and neurological examination, blood test, electromyography (EMG) and MRI of the brain.
The symptoms of dystonia reduced after discontinuation of the drug and application of botulinum toxin A in orbicularis oris muscle, masseter muscle and glandula parotis. We also used GABA receptor agonist, an anticholinergic agent, benzodiazepines and an atypical antipsychotic.