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Letter to the Editor   |    
Conventional Psychotropic-Induced Tremor Extinguished by Olanzapine
Arthur J.L. Strauss, M.D.; Rahn K. Bailey, M.D.; Penelope W. Dralle, Ph.D.; Anthony J. Eschmann, B.C.S.W.; Richard B. Wagner, M.S.W., M.U.R.P.
Am J Psychiatry 1998;155:1132-1132.
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New Orleans, La.

Letters

TO THE EDITOR: We have observed, unexpectedly, the disappearance of prominent, persistent, and troublesome fluphenazine- or haloperidol-induced coarse tremors in three patients within days of initiation of treatment with olanzapine, 10 mg/day p.o., without discontinuance of or decrement in the dose of either fluphenazine or haloperidol. Treatment with diphenhydramine, benztropine, amantadine, and propanolol—tried in cases 1 and 2 only—had provided negligible and transient tremor relief. Our intent, then, was to wean all three patients from fluphenazine or haloperidol while starting olanzapine, but we observed the following responses:

Case 1. Mr. A, a 36-year-old Caucasian man with an 18-year history of recurrent command hallucinations, suicide attempts, paranoid delusions, severe depression, and alcohol dependence, had been in remission for 1 year on a regimen of fluphenazine decanoate, 37.5 mg i.m. every 2 weeks, and nefazodone, 100 mg p.o. at bedtime. The patient experienced coarse truncal and extremity tremors. Four days after the addition of olanzapine, 10 mg/day p.o., to his regimen, his tremors had noticeably diminished; by day 7, they were no longer apparent. Without further medication adjustment, the tremors had not returned after 26 weeks.

Case 2. Ms. B, a 25-year-old African American woman with a 2-year history of recurrent paranoid ideation, violent behavior, psychotic depression, and mania, with intercurrent marijuana, heroin, and "crack" cocaine abuse, had been in remission for 1 year on a regimen of fluphenazine decanote, 25 mg i.m. every 2 weeks; fluphenazine, 7.5 mg p.o. at bedtime; and divalproex sodium, 1000 mg p.o. twice a day. She had developed coarse hand tremors that disappeared within 7 days of the addition of olanzapine, 10 mg p.o.; her tremors had not returned after 21 weeks without other medication changes.

Case 3. Ms. C, a 34-year-old African American woman with a 20-year history of recurring severe thought disorganization or mania, had been in remission for 1 year on a regimen of haloperidol, 20 mg p.o. at bedtime; lithium carbonate, 300 mg p.o. twice a day; and divalproex sodium, 750 mg p.o. twice a day. She had unsightly coarse circumoral and hand tremors, not relieved with lithium discontinuance. Her tremors disappeared 1 week after initiation of treatment with olanzapine, 10 mg/day p.o., without other medication adjustments; her tremors had not returned after 20 weeks.

Olanzapine is active against muscarinic cholinergic receptors (R1558281), a fact that may account for the observed suppression of fluphenazine- and haloperidol-induced tremor. The patients in cases 1 and 2, however, had been treated with benztropine, an antagonist of muscarinic acetylcholine receptors, with little tremor relief, suggesting that olanzapine could suppress tremor by means other than antimuscarinic action.

Bymaster FP, Rasmussen K, Calligaro DO, Nelson DL, DeLapp NW, Wong, DT, Moore, NA: In vitro and in vivo biochemistry of olanzapine: a novel, atypical antipsychotic drug. J Clin Psychiatry 1997; 58(suppl 10): 28–36
 
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References

Bymaster FP, Rasmussen K, Calligaro DO, Nelson DL, DeLapp NW, Wong, DT, Moore, NA: In vitro and in vivo biochemistry of olanzapine: a novel, atypical antipsychotic drug. J Clin Psychiatry 1997; 58(suppl 10): 28–36
 
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