Pharmacological wash out for clozapine induced tics: A case report

Abstract

Introduction Clozapine has been long used for the treatment-resistant schizophrenia. Its effectiveness in the vast schizophrenia symptoms is well established. However, its wide range of adverse effects has limited its use. Objectives/aims To present a new strategy in order to continue with clozapine treatment despite extrapyramidal adverse effects. Methods/case report Extrapyramidal symptoms are rarely reported with clozapine. Although, cases of patients with clozapine-induced tics have been described. We report the case of a 28 year-old patient with history of refractory schizophrenia that developed motor tics with clozapine 150mg total dose. Tics consisted on eye blinking, eyebrow elevation, mouth twitching, facial grimacing, lip licking, tongue protrusion and shoulder shrugging. Reduction of clozapine dose to 50mg qd was indicated to decrease the motor tics, however exacerbation of psychosis occurred. We added amisulpride and titrated it up to 600mg qd without response. By using the same principle of levodopa's washout in Parkinson disease and in order to establish a therapeutic threshold, we conducted a one-week clozapine washout. Results After this therapeutic manoeuvre, tics disappeared and no relapse was observed after clozapine reinitiation along with remission of psychotic symptoms. Conclusions Wash out might be a new strategy for treatment reinitiation after clozapine induced extrapyramidal side effects in patients with treatment-resistant schizophrenia. To our knowledge no previous report of this strategy has been reported, however further studies are needed to support its effectiveness.