Clozapine overdose/withdrawal
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Constipation, orthostasis, dizziness and seizure-like activity: case report. A 57-year-old man developed constipation, orthostasis, dizziness due to overdose of clozapine; he also developed seizure-like activity after clozapine withdrawal. The man with schizoaffective disorder, bipolar type, was hospitalised in psychiatric facility and treated with clozapine. Additionally, he received valproate semisodium [divalproex], Levothyroxine sodium [levothyroxine], multiple vitamin, nicotine and combination of bowel regimen including dioctyl sulfosuccinic acid [docusate], senna alexandrina [senna] and polyethylene glycol [Miralax]. He received clozapine 500mg in the morning and 900mg in the evening with total 1400mg daily [route not stated] for schizoaffective disorder. His recent clozapine level was 628 ng/mL. He developed severe constipation and physical evaluation confirmed abdominal distension. Abdominal X-ray revealed distended colon with large stool burden. His potassium level was elevated at 5.8 mEq/L, which was thought secondary to constipation and dehydration. After laxative interventions and IV fluids [specific drugs not stated], he was able to move his bowels. After 4 days, he continued to have dizziness and constipation with standing BP of 76/44 and sitting BP of 87/54. Dizziness and orthostasis were thought to be secondary to the dehydration and clozapine’s alpha 1 antagonism. In laboratory examination his potassium level was found to be increased at 6.7mEq/L. The elevated potassium level was considered to be related to the magnesium citrate and magnesium hydroxide [milk of magnesia] laxatives. Therefore, magnesium citrate and magnesium hydroxide were discontinued. He continued to have constipation. Physical evaluation revealed palpable stool in the abdomen with no impaction on the rectal exam. Therefore, clozapine was stopped without tapering and he was continued on the initially started valproate semisodium for seizure prophylaxis. Approximately 72 hours from clozapine withdrawal, the man developed seizure like activity. He was shaking his arms and head rhythmically and did not responded to verbal stimuli. Intermittently, he answered questions. His body was not stiff or rigid. He urinated on himself and was hitting his groin area and head with his right arm. He was not able to ambulate. It was not known if he had fallen. His left side of the face appeared to droop. He had no medical history of seizures. Despite on valproate semisodium after withdrawal of clozapine, he developed the seizure like activity. The man was transferred to the vascular centre after he had seizure and cerebrovascular accident. CT revealed a 4 to 5mm thick lateral convexity subdural haematoma with slight cortical mass effect but no mid-line shift. Without any medical intervention he was discharged and prescribed with levetiracetam. The levetiracetam was discontinued after readmission to the psychiatric facility. Possible seizure was differentially diagnosed and he was instructed to follow up with neurology [outcomes not stated]. S
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