Extrapyramidal Syndrome and Long-Acting Injectable Risperidone

Mr. A, a 32-year-old man, had been taking 15 mg/day of olanzapine for the last 4 months. Because of a long history of poor adherence to treatment in the community, we prescribed a depot antipsychotic. Injectable risperidone, 25 mg, was given while Mr. A was taking 15 mg/day of olanzapine. Twenty-four hours after the injection, he developed oculogyric crisis, dysarthria, torticollis, dysphagia, tremor, and rigidity. These symptoms responded to procyclidine.

Mr. B, a 36-year-old man, was taking depot zuclopenthixol decanoate, 400 mg every 2 weeks, for 12 months. Because of extrapyramidal side effects, we decided to change the zuclopenthixol decanoate to injectable risperidone. Instead of his regular depot treatment, Mr. B received 25 mg of injectable risperidone. Twenty-four hours later, his extrapyramidal symptoms worsened. These symptoms remitted in 1 week without specific treatment.

Mr. C, a 28-year-old man, was taking olanzapine, 20 mg/day, for 4 weeks. Because of a long history of poor adherence to treatment in the community, we decided to offer depot medication. Olanzapine was reduced and finally stopped within 1 week. After that, we began treatment with oral risperidone and reached 4 mg/day in 3 days. The next day, a few hours after the injection of 25 mg of risperidone, Mr. C developed akathisia, which responded to lorazepam.