Levosulpiride-induced Movement Disorders

Case Series IntroductIonLevosulpiride, (LSP) the levorotatory enantiomer of sulpiride, is an atypical antipsychotic drug likely to act by blocking the presynaptic dopaminergic autoreceptors in low doses and the postsynaptic dopaminergic receptors in higher doses.[1] In addition to its use for psychosis and associated psychiatric disorders, it is currently being increasingly used for various gastrointestinal disorders such as irritable bowel syndrome, gastroesophageal reflux disorder, nonulcer dyspepsia, and as a prokinetic agent.Fixed dose combination (FDC) products of LSP with proton-pump inhibitors (PPIs) are being prescribed in India and other parts of the world for various gastrointestinal diseases on a long-term basis.[2] D2 receptor antagonists (antipsychotic drugs) are known to cause extrapyramidal syndrome (EPS) that includes acute muscular dystonia, neuroleptic malignant syndrome, dyskinesia, and Parkinson's disease (PD).[3] One of such kinds of drug is LSP with additional serotonin receptor affinity.The incidence of EPS caused due to LSP should be lower than the typical antipsychotics owing to its atypical antipsychotic profile.[4] In addition to these, weight gain, increase in plasma prolactin level, postural hypotension, and elevated liver transaminase were reported as adverse effects of LSP.[2] Since there are only a few published reports of LSP-induced EPS, especially dyskinesia, we intended to compile a detailed review of ten clinically suspected cases of LSP-induced dyskinesia with or without accompanying Parkinsonian features.[5][6][7] The features of drug (antipsychotics/D2 antagonists)-induced dyskinesia can be either orofacial dyskinesia or limb and trunk movements.The specific movements involved in orofacial dyskinesia can be one or combination of the following movements, for example, protrusion or twisting of the tongue, smacking and pursing of the lips, puffing of the cheeks, chewing movements of the jaw, and grimacing movements of the face.Whereas, limb and trunkWe reported a series of patients who presented with LSP-induced movement disorders specifically, dyskinetic movements.We have presented one case of LSP-induced parkinsonism and summarized ten cases of LSP-induced dyskinesia.The causality of the adverse drug reaction was assessed systematically using a validated rating system, and we extensively qualified the clinical presentation of each case of dyskinesia using a clinical rating scale.We described an unusual case of acute onset LSP-induced parkinsonism in a 56-year-aged female.The mean age of ten patients of LSP-induced dyskinesia was 65.3 years (standard deviation 10.4), and 25% of patients were female.They were consuming suspected medication for a median duration of 13 months (range 1-60 months).We noted LSP-induced dyskinesia was challenging to treat as its resolution is often incomplete even with adequate treatment.