Treatment of Neuroleptic Malignant Syndrome

Initial Management

The primary treatment for neuroleptic malignant syndrome (NMS) is immediate discontinuation of the precipitating antipsychotic medication and providing aggressive supportive care, including treatment of agitation with benzodiazepines, management of hyperthermia through cooling measures, and address autonomic instability with IV fluids and other agents to normalize vital signs 1, 2
Discontinue the offending agent, which is the first and most critical step in NMS management, and provide supportive care 2

Dopaminergic agents, such as bromocriptine, may be used to address dopamine deficiency in severe cases of NMS 3
Muscle relaxants, such as dantrolene sodium, may be used to reduce muscle rigidity and hyperthermia in severe cases of NMS 3

Emergency sedation, neuromuscular paralysis, and intubation may be required for cases with extreme hyperthermia (>41.1°C) 1
Intensive care unit admission is necessary for approximately 25% of patients with NMS 1

Laboratory testing should include complete blood count, electrolytes, renal function, liver function, creatine kinase, arterial blood gases, and coagulation studies 1
Careful monitoring for complications such as rhabdomyolysis with elevated creatine kinase, metabolic acidosis, elevated liver enzymes, renal failure, seizures, and disseminated intravascular coagulation is necessary 1, 2, 3

With proper treatment, mortality from NMS has decreased from 76% in the 1960s to less than 10-15% in recent years, and early recognition and prompt management are crucial for improving outcomes 2, 4
Avoid physical restraints as they may exacerbate isometric muscle contractions, worsening hyperthermia and lactic acidosis, thereby increasing mortality 1

The American Academy of Child and Adolescent Psychiatry indicates Electroconvulsive Therapy (ECT) as a second-line treatment for severe and persistent Neuroleptic Malignant Syndrome, particularly if the patient has a concurrent psychiatric condition that would benefit from ECT 5

The American Academy of Child and Adolescent Psychiatry recommends avoiding pro re nata (p.r.n.) chemical restraints, which are prohibited 6

The American College of Medical Toxicology recommends avoiding anticholinergics for routine prevention of extrapyramidal symptoms, as they may worsen autonomic instability 7