Drug-Induced Movement Disorders

Abnormal involuntary movements (movement disorders) occur as adverse events of numerous drugs.[1] These events can cause substantial hardship for affected individuals because they tend to lower self-image and impair communication, social functioning and the ability to perform activities of daily living.[2] They also can lead patients to stop taking their medications without medical supervision, which may result in disease relapse and need for hospitalization.

Drug-induced movement disorders may affect a single or multiple body parts. They may develop hours to days after initiating treatment with the drug or may be tardive, developing gradually months to years after drug initiation.[3] The good news is that many of these adverse events tend to resolve after the causative drug is discontinued. However, some of these abnormal movements often persist long after the drug is discontinued.

Preventing these adverse events may be possible with careful monitoring of patients who take medications that can cause movement disorders.[4]

To protect yourself and your loved ones, learn about some important types of movement disorders and the drugs that can cause them (see table, page 6, for some examples).

Forms of drug-induced movement disorders

Akathisia
Akathisia is characterized by a strong feeling of restlessness accompanied by a compulsion to move to relieve this inner sense of uneasiness.[5] Thus, a person with akathisia tends to change his or her body position constantly:[6] crossing and uncrossing his or her legs while sitting and making repetitive movements of his or her trunk, hands or legs.

Drugs that cause akathisia include typical (older) antipsychotics (such as haloperidol [HALDOL]) and, to a lesser extent, atypical (newer) antipsychotics (such as clozapine [CLOZARIL, FAZACLO ODT, VERSACLOZ]).[7],[8] Other drugs that occasionally result in akathisia include certain antiepileptics (seizure drugs), such as carbamazepine (CARBATROL, EPITOL, EQUETRO, TEGRETOL, TERIL); calcium channel blocker hypertension drugs, such as amlodipine (NORVASC); tricyclic antidepressants, such as amitriptyline (generic only); and selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (PROZAC, SARAFEM, SELFEMRA).[9]

The most effective therapy for akathisia is discontinuing the causative drug. Alternatively, the dose can be lowered if the drug’s benefit is greater than the discomfort caused by akathisia.

Dystonia
Dystonia is involuntary muscle contraction that causes abnormal repetitive or twisting movements that usually are restricted to the head and neck, although they may extend to the limbs and the trunk.[10],[11]

Drug-induced dystonia mostly occurs in patients treated with older antipsychotics, atypical antipsychotics and dopamine antagonists that are used for severe nausea and acid reflux disease, such as metoclopramide (METOZOLV ODT, REGLAN). It also has been reported with various other medications, including opioids such as morphine (ARYMO ER, KADIAN, MORPHABOND ER, MS CONTIN); SSRI antidepressants and stimulants, such as methylphenidate (APTENSIO XR, CONCERTA, COTEMPLA XR-ODT, DAYTRANA, FOCALIN, METADATE, METHYLIN, QUILLICHEW ER, QUILLIVANT XR, RITALIN).

Drug-induced dystonia responds quickly to antihistamines, such as diphenhydramine (generic only).[12]

Myoclonus
Myoclonus is a sudden brief jerk caused by involuntary muscle activity.[13]

The most common drugs associated with myoclonus are certain antibiotics, such as ciprofloxacin (CIPRO); benzodiazepines, such as alprazolam (XANAX); opioids; and SSRI antidepressants.[14] Other drugs that can cause myoclonus include medications for Alzheimer’s disease, such as donepezil (ARICEPT); antiarrhythmic drugs (drugs for abnormal heart rhythms), such as amiodarone (PACERONE); antipsychotics (typical and atypical); antiepileptics; calcium channel blockers; and dopamine antagonists used for nausea. Myoclonus usually stops after the causative drug is discontinued.

Parkinsonism
Symptoms of drug-induced parkinsonism include loss of ability to control the movement of voluntary muscles (loss of arm swing can be the earliest feature) and slowness of movement resulting in expressionless face, slow initiation of movement and speech difficulties.[15] Tremor is less commonly seen with drug-induced parkinsonism. These symptoms may develop over a period of days to weeks after treatment with particular medications, as opposed to years for the type of parkinsonism mostly associated with aging.[16] Drug-induced parkinsonism accounts for about 7 percent of all parkinsonism cases.[17]

While antipsychotics and dopamine antagonists used for nausea are widely known to cause drug-induced parkinsonism,[18] many other medications, including the antiarrhythmic drug amiodarone; calcium channel blockers; mood stabilizers, such as lithium (LITHOBID); opioids; and tricyclic and SSRI antidepressants, have been implicated in this condition.[19]

Generally, 60 percent of people with drug-induced parkinsonism will recover within two months of stopping the causative drug.[20] However, some people may take as long as two years to recover.

Tardive dyskinesia
Drug-induced tardive dyskinesia is characterized by involuntary jerky movements of different muscles — resulting in random movements of the face, lips, tongue, trunk and limbs — that occur long after starting the causative drug.[21] It occurs in between 15 and 30 percent of patients who are taking antipsychotics on a longterm basis. Although both typical and atypical antipsychotics can cause tardive dyskinesia, the risk of this adverse effect is somewhat lower with the latter.

Tardive dyskinesia also can occur with long-term use of dopamine antagonists used for nausea and with prolonged use of antihistamines, such as hydroxyzine (VISTARIL), commonly used for allergies. To a lesser extent, tardive dyskinesia also has been reported with use of antidepressants and mood stabilizers.[22] Tardive dyskinesia can persist long after the causative drug is discontinued. [23]

Tics
Tics are involuntary brief and repetitive rapid movements (twitches) that can affect any voluntary muscle group, resulting in symptoms such as constant eye blinking, facial grimacing and mouth opening. Tics also can be vocal, such as humming, grunting or saying words.[24],[25]

Tics can be caused by several types of drugs, including antiepileptics, SSRI antidepressants and stimulants.[26] Drug-induced tics usually resolve with discontinuation of the causative drug.

What You Can Do

If you suddenly develop body movements that you cannot control, consult your doctor to find out whether these movements are related to a medication that you are taking currently or have taken previously. If a medication you are taking has the potential to cause movement disorders, you should always be vigilant about the drug-specific signs and symptoms of these disorders and should notify your doctor immediately if they occur. Do not stop taking any medication without consulting your doctor first.

Some Oral Drugs That Can Cause Movement Disorders

† Note: Additional examples are cited in the main text of the article.
*Classified as Limited Use by Public Citizen’s Health Research Group
**Classified as Do Not Use by Public Citizen’s Health Research Group

References

[1] Zádori D, Veres G, Szalárdy L, et al. Drug-induced movement disorders. Expert Opin Drug Saf. 2015;14(6):877-890.

[2] Chen JJ. Drug-induced movement disorders. US Pharm. 2007; 32 (11):HS16-HS32.

[3] Burkhard PR. Acute and subacute drug-induced movement disorders. Park Relat Disord. 2014;20(Suppl 1):S108-S112.

[4] Zádori D, Veres G, Szalárdy L, et al. Drug-induced movement disorders. Expert Opin Drug Saf. 2015;14(6):877-890.

[5] Rodnitzky RL. Drug-induced movement disorders in children and adolescents. Expert Opin Drug Saf. 2005;4(1):91-102.

[6] Burkhard PR. Acute and subacute drug-induced movement disorders. Park Relat Disord. 2014;20(Suppl 1):S108-S112.

[7] Rodnitzky RL. Drug-induced movement disorders in children and adolescents. Expert Opin Drug Saf. 2005;4(1):91-102.

[8] Chengappa KN, Shelton MD, Baker RW, et al. The prevalence of akathisia in patients receiving stable doses of clozapine. J Clin Psychiatry. 1994;55 (4):142-145.

[9] Rodnitzky RL. Drug-induced movement disorders in children and adolescents. Expert Opin Drug Saf. 2005;4(1):91-102.

[10] Caroff SN, Campbell EC. Drug-Induced extrapyramidal syndromes: Implications for contemporary practice. Psychiatr Clin North Am. 2016;39(3):391-411.

[11] Burkhard PR. Acute and subacute drug-induced movement disorders. Park Relat Disord. 2014;20(Suppl 1):S108-S112.

[12] Burkhard PR. Acute and subacute drug-induced movement disorders. Park Relat Disord. 2014;20(Suppl 1):S108-S112.

[13] Rosa MM, Anes AM. Drug-induced movement disorders. In: Falup- Pecurariu C, Ferreira J, Martinez-Martin P, Chaudhuri KR, eds. Movement Disorders Curricula. Springer, Vienna; 2017:401-406.

[14] Zádori D, Veres G, Szalárdy L, et al. Drug-induced movement disorders. Expert Opin Drug Saf. 2015;14(6):877-890.

[15] Parkinson’s Disease Society. Fact sheet: Drug-induced Parkinsonism. November 2009. https://s3-eu-west- 1.amazonaws.com/puk-live-1-d8-ie/2017-03/fs38_druginducedparkinsonism.pdf. Accessed December 11, 2017.

[16] Robottom BJ, Shulman LM, Weiner WJ. Drug-induced movement disorders: Emergencies and management. Neurol Clin. 2012;30(1):310-320.

[17] Parkinson’s Disease Society. Fact sheet: Drug-induced Parkinsonism. November 2009. https://s3-eu-west- 1.amazonaws.com/puk-live-1-d8-ie/2017-03/fs38_druginducedparkinsonism.pdf. Accessed December 11, 2017.

[18] Robottom BJ, Shulman LM, Weiner WJ. Drug-induced movement disorders: Emergencies and management. Neurol Clin. 2012;30(1):310-320.

[19] Rosa MM, Anes AM. Drug-induced movement disorders. In: Falup- Pecurariu C, Ferreira J, Martinez-Martin P, Chaudhuri KR, eds. Movement Disorders Curricula. Springer, Vienna; 2017:401-406.

[20] Parkinson’s Disease Society. Fact Sheet: Drug-induced Parkinsonism. November 2009. https://s3-eu-west- 1.amazonaws.com/puk-live-1-d8-ie/2017-03/fs38_druginducedparkinsonism.pdf. Accessed December 11, 2017.

[21] Cornett EM, Novitch M, Kaye AD, et al. Medication-induced tardive dyskinesia: A review and update. Ochsner J. 2017;17(2):162-174.

[22] Zádori D, Veres G, Szalárdy L, et al. Drug-induced movement disorders. Expert Opin Drug Saf. 2015;14(6):877-890.

[23] Cornett EM, Novitch M, Kaye AD, et al. Medication-induced tardive dyskinesia: A review and update. Ochsner J. 2017;17(2):162-174.

[24] Rosa MM, Anes AM. Drug-induced movement disorders. In: Falup- Pecurariu C, Ferreira J, Martinez-Martin P, Chaudhuri KR, eds. Movement Disorders Curricula. Springer, Vienna; 2017:401-406.

[25] Zádori D, Veres G, Szalárdy L, et al. Drug-induced movement disorders. Expert Opin Drug Saf. 2015;14(6):877-890.

[26] Zádori D, Veres G, Szalárdy L, et al. Drug-induced movement disorders. Expert Opin Drug Saf. 2015;14(6):877-890.