potential tardive dyskinesia r/t Seroquel?

[beleanor]

Hey all,

I had a patient on tuesday who, with no axis I psych Dx, was prescribed 100mg of Seroquel daily. While seroquel is a weak neuroleptic and EPS are rare, he developed a new eye twitch during the course of the day tuesday after receiving his first dose the previous night. The twitch looked like it involved the entire right orbicularis oculi. My response: I called the physician, who ordered a stat CMB, and all electrolytes came back WNL except phosphorus, which was 4.6 (WNL = 2.5-4.5). His calcium was normal, 9.1 and the physician ended up calling it a response to a local anesthetic use earlier that day (though the patient denied circumoral parethesia or tingling/numbness of any kind). He also complained of a left calf muscle cramp for most of the day. So, of the three possibilities: high phosphorus, response to anesthesia, or Seroquel, what do people think is most likely?

On a related note, has anyone heard of Seroquel being prescribed for anxiety? I can't figure why he's even on this drug to begin with... Thanks for any help!

[Esme12, ASN, BSN, RN]

I have seen Seroquel prescribed for anxiety and sleep when racing thoughts keep people awake. http://www.webmd.com/mental-health/news/20080506/seroquel-may-help-depression-anxiety

Serious Side Effects Have Been Reported With Seroquel XR Including:

• Neuroleptic malignant syndrome (NMS): Tell your health care provider right away if you have some or all of the following symptoms: high fever, stiff muscles, confusion, sweating, changes in pulse, heart rate, and blood pressure. These may be symptoms of a rare and serious condition that can lead to death. Stop Seroquel XR and call your health care provider right away.
  
• High blood sugar (hyperglycemia): Increases in blood sugar can happen in some people who take Seroquel XR. Extremely high blood sugar can lead to coma or death. If you have diabetes or risk factors for diabetes (such as being overweight or a family history of diabetes) your health care provider should check your blood sugar before you start Seroquel XR and during therapy.
  
• Call your health care provider if you have any of these symptoms of high blood sugar while taking Seroquel XR:
  
  • 
    
    • feel very thirsty
      
    • need to urinate more than usual
      
    • feel very hungry
      
    • feel weak or tired
      
    • feel sick to your stomach
      
    • feel confused, or your breath smells fruity.
      

  [*]High cholesterol and triglyceride levels in the blood (fat in the blood): Increases in total cholesterol, triglycerides and LDL (bad) cholesterol and decreases in HDL (good) cholesterol have been reported in clinical trials with Seroquel XR. You may not have any symptoms, so your health care provider should do blood tests to check your cholesterol and triglyceride levels before you start taking Seroquel XR and during therapy.

  [*]Increase in weight (weight gain): Weight gain has been seen in patients who take Seroquel XR so you and your health care provider should check your weight regularly.

  [*]Tardive dyskinesia: Tell your health care provider about any movements you cannot control in your face, tongue, or other body parts. These may be signs of a serious condition. Tardive dyskinesia may not go away, even if you stop taking Seroquel XR. Tardive dyskinesia may also start after you stop taking Seroquel XR.

  [*]SEROQUEL XR® (quetiapine fumarate) Side Effects | Bipolar Disorder

[Sun0408, ASN, RN]

I would not consider the phos level "high" as you stated, it is slightly above the norm but not "high". Please be careful when using strong words like that. When I think of high, I think of a phos of 6 or a K+ of 7. As for the medication it could be the medication. Has the pt experienced anything like that in the past, have they ever had a reaction to local before?

You did the right thing by informing the MD, now the staff and the MD can monitor the pt and see if it continues. I have not seen seroquel ordered for anxiety but that's not to say it doesn't happen. The pts I have had on this med had some other psych issue other than anxiety.

[nurseprnRN, BSN, RN]

Is this pt taking anything else? Perhaps there's a synergistic effect going on here?

[BostonFNP, APRN]

How old is the patient? I have a few older patients I manage in primary care that respond well to quietipine for anxiety associated with dementia. I would never prescribe it for that reason but feel comfortable managing it in these patients. They are at risk for TD effects as they age with declining hepatic or renal clearance.

[loriangel14, RN]

Where I work it is regularly prescribed for anxiety, usually related to dementia.I have seen patients develop mild TD while on it.

[beleanor]

Thanks for feedback everyone -

to answer questions/clarify:

sun0408: I was typing/thinking fast when I wrote and I agree - "high" is the wrong description for 4.6. I will be more accurate. The patient has not had the experience before of numbness, tingling around the mouth, or the eye twitch.

GrnTea: Yes, Diflucan, Zosyn, Colace, Lovenox are scheduled, Oxycontin is prn. Diflucan and Seroquel do interact -> Diflucan reduces clearance of Seroquel. I believe this is the strongest case for EPS - I've also read that EPS can be an early sign of neuroleptic malignant syndrome (as de2013 implies)

De2013: He's 54, liver enzymes are WDL, BUN is 8 and creatinine is 0.81.

There is perhaps no clear answer as to whether or not the twitch is:

1. mild TD from anesthetic overdose (patient has no other signs pointing to neuroleptic malignant syndrome)

2. or muscle spasm r/t phosphorus of 4.6

THanks for confirming Seroquel for anxiety - I have come to the conclusion that this is the use for my patient. He was actually moved to a step down unit yesterday. His WBC has decreased from 26.7 to 16.1 and the C&S from an intr-aabdominal abscess came back positive for candida. He will likely be discharged in a couple days with home healthcare and IV antibiotics.

[Meriwhen, ASN, BSN, MSN, RN]

Low-dose Seroquel is not uncommon for anxiety: I often see 25/50 mg doses ordered PRN, especially in my addictions patients for which benzos aren't an option.

Phosphorus 4.6 isn't high--in some facilities such as mine, that's considered normal. It all depends on your facility's definition of WDL. Now if it is crosses 5, then I'd start getting concerned about it creeping towards elevated/high.