Pediatrik Bir Hastada Fluoksetin Kaynaklı Diskinezi: Polifarmasi ve Serotonerjik Düzenlemenin Etkileri Üzerine Bir Vaka Raporu ve Literatür İncelemesi

Abstract

Psikiyatrik ilaçlara bağlı hareket bozuklukları, çoğunlukla antipsikotik ilaçlar olan dopamin reseptör bloke edici ilaçların yan etkileriyle ilgilidir. Bu yan etkiler, akut distonik reaksiyonlar, akatizi, diskinezi, nöroleptik malign sendrom, parkinsonizm ve çeşitli tardif sendromlara neden olabilir. Diskinetik hareketler, ekstremitelerin, yüz ve perioral kaslarının hiperkinetik, tekrarlayan hareketleri ile karakterize edilir. Nadir durumlarda dolaylı bir D2 blokaj mekanizması yoluyla selektif serotonin gerialım inhibitörleri (selective serotonin reuptake inhibitors, SSRIs) kullanımı sonucu diskinetik hareketler ortaya çıkabilir. Bu olgu sunumunda, metilfenidat ve risperidon kullanan bir hastada fluoksetin doz artışı sonrasında görülen diskinezi sunulmuştur. SSRI’nın, dopamin reseptör antagonizması ile dopamin aktivitesini inhibe ettiği ve SSRI’ların CYP450 metabolizmasını inhibe ederek risperidon konsantrasyonunda bir artışa neden olabileceği düşünülmüştür. Literatürde SSRI kaynaklı diskinezi vakaları az sayıdadır, bu alanda kısıtlı bilgi mevcuttur. Bu olgu sunumu, SSRI’ların potansiyel diskinezi yan etkisine dikkat çekmektedir.

Keywords

• Diskinezi
• ekstrapiramidal yan etkiler
• dopamin reseptör blokerleri
• fluoksetin

Fluoxetine-Induced Dyskinesia in a Pediatric Patient: A Case Report and Literature Review on Implications of Polypharmacy and Serotonergic Regulation

Abstract

Movement disorders associated with psychiatric medications are primarily related to the side effects of dopamine receptor-blocking drugs, which are mostly antipsychotic medications. These side effects are acute dystonic reactions, akathisia, dyskinesia, neuroleptic malignant syndrome, parkinsonism, and various tardive syndromes. Dyskinetic movements are characterized by hyperkinetic, repetitive movements of the extremities, facial, and perioral muscles. In rare cases, dyskinetic movements may occur with the use of selective serotonin reuptake inhibitors (SSRIs) through an indirect D2 blocking mechanism. In this case report, dyskinesia observed after increasing the dose of fluoxetine in a patient using methylphenidate and risperidone was presented. It was thought that the SSRI inhibited dopamine activity through dopamine receptor antagonism and that SSRIs may increase risperidone concentrations by inhibiting CYP450 metabolism. There are few cases reported in the literature regarding SSRI-induced dyskinesia, information is limited on this subject. This case report highlights the potential dyskinesia side effect of SSRIs.

Keywords

• Dyskinesia
• extrapyramidal side effects
• dopamine receptor blockers
• fluoxetine

References

1. Caroff SN, Campbell EC. Drug-induced extrapyramidal syndromes: implications for contemporary practice. Psychiatr Clin North Am. 2016;39(3):391-411.
2. Jean FJ, Poulose M. An unexpected phenomenon: A case of citalopram-induced dyskinesia. Cureus. 2024;16(5):e61364.
3. Duma SR, Fung VS. Drug-induced movement disorders. Aust Prescr. 2019;42(2):56-61.
4. Yassa R, Camille Y, Belzile L. Tardive dyskinesia in the course of antidepressant therapy: a prevalence study and review of the literature. J Clin Psychopharmacol. 1987;7(4):243-6.
5. Cornett EM, Novitch M, Kaye AD, Kata V, Kaye AM. Medication-induced tardive dyskinesia: a review and update. Ochsner J. 2017;17(2):162-74.
6. Vasan S, Padhy RK. Tardive dyskinesia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
7. Leo RJ. Movement disorders associated with the serotonin selective reuptake inhibitors. J Clin Psychiatry. 1996;57(10):449-54.
8. Madhusoodanan S, Alexeenko L, Sanders R, Brenner R. Extrapyramidal symptoms associated with antidepressants--a review of the literature and an analysis of spontaneous reports. Ann Clin Psychiatry. 2010;22(3):148-56.

9. Mander A, McCausland M, Workman B, Flamer H, Christophidis N. Fluoxetine induced dyskinesia. Aust N Z J Psychiatry. 1994;28(2):328-30.
10. Chen JJ, Swope DM. A case of complex movement disorder induced by fluoxetine with management of dystonia by botulinum toxin type A. J Clin Psychiatry. 2005;66(2):267-8.
11. Revet A, Montastruc F, Roussin A, Raynaud JP, Lapeyre-Mestre M, Nguyen TTH. Antidepressants and movement disorders: a postmarketing study in the world pharmacovigilance database. BMC Psychiatry. 2020;20(1):308.
12. Hiemke C, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, et al. Consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology: update 2017. Pharmacopsychiatry. 2018;51(1-02):9-62.
13. Hawthorne JM, Caley CF. Extrapyramidal reactions associated with serotonergic antidepressants. Ann Pharmacother. 2015;49(10):1136-52.
14. Van Waes V, Beverley J, Marinelli M, Steiner H. Selective serotonin reuptake inhibitor antidepressants potentiate methylphenidate (Ritalin)-induced gene regulation in the adolescent striatum. Eur J Neurosci. 2010;32(3):435-47.
15. Steiner H, Van Waes V, Marinelli M. Fluoxetine potentiates methylphenidate-induced gene regulation in addiction-related brain regions: concerns for use of cognitive enhancers? Biol Psychiatry. 2010;67(6):592-4.
16. Budman CL, Bruun RD. Persistent dyskinesia in a patient receiving fluoxetine. Am J Psychiatry. 1991;48(10):1403.
17. Jeste DV, Potkin SG, Sinha S, Feder S, Wyatt RJ. Tardive dyskinesia--reversible and persistent. Arch Gen Psychiatry. 1979;36(5):585-90.
18. Dubovsky SL, Thomas M. Tardive dyskinesia associated with fluoxetine. Psychiatr Serv. 1996;47(9):991-3.
19. Coulter DM, Pillans PI. Fluoxetine and extrapyramidal side effects. Am J Psychiatry. 1995;152(1):122-5.
20. Lagière M, Navailles S, Bosc M, Guthrie M, Deurwaerdère PD. Serotonin2C receptors and the motor control of oral activity. Curr Neuropharmacol. 2013;11(2):160-70.
21. Wingen M, Kuypers KP, Ramaekers JG. The role of 5-HT1a and 5-HT2a receptors in attention and motor control: a mechanistic study in healthy volunteers. Psychopharmacology (Berl). 2007;190(3):391-400.
22. Spina E, Santoro V, D'Arrigo C. Clinically relevant pharmacokinetic drug interactions with second-generation antidepressants: an update. Clin Ther. 2008;30(7):1206-27.
23. Merrill RM, Lyon JL, Matiaco PM. Tardive and spontaneous dyskinesia incidence in the general population. BMC Psychiatry. 2013;13:152.
24. Lykouras L, Yannakis R, Hatzimanolis J, Christodoulou G. Two cases of risperidone-induced tardive dyskinesia and a review of the literature. Eur Psychiatry. 1999;14(4):245-7.
25. Friedman JH. Movement disorders induced by psychiatric drugs that do not block dopamine receptors. Parkinsonism Relat Disord. 2020;79:60-4.
26. D’Abreu A, Friedman JH. Tardive dyskinesia‐like syndrome due to drugs that do not block dopamine receptors: Rare or non‐existent: Literature review. Tremor Other Hyperkinet Mov (N Y). 2018;8:570.