This handout is for neuroleptic malignant syndrome. Your care team identified this based on: recent start / dose increase of an antipsychotic or dopamine-blocking antiemetic (metoclopramide, prochlorperazine, promethazine) [strawn 2007 nms consensus].
Other reasons your team may use this plan: abrupt withdrawal / dose reduction / malabsorption of levodopa, amantadine, or a dopamine agonist in parkinson disease (parkinsonism-hyperpyrexia syndrome) [dsm-5; critical-care tox review]; lead-pipe rigidity + hyperthermia + autonomic instability + altered mental status evolving over 1–3 days [strawn 2007; dsm-5 nms criteria]; core temperature >38°c with generalized muscular rigidity in a patient on a dopamine antagonist [strawn 2007].
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| discontinue_offending_dopamine_antagonist | Immediately STOP all dopamine-D2 antagonists — antipsychotics (typical/atypical, including depot) and dopamine-blocking antiemetics (metoclopramide, prochlorperazine, promethazine) | medication_discontinuation | immediate and sustained | Strawn 2007 — removing the dopamine blockade is the single most important intervention; depot agents prolong the course and warrant a longer supportive window |
| restore_dopaminergic_therapy | RESTART (do NOT further withhold) levodopa/carbidopa, amantadine, or dopamine agonist at the prior steady-state dose; use enteral/NG route if absorption compromised | PO/NG | resume scheduled dosing | Critical-care tox review — withdrawal-type NMS (parkinsonism-hyperpyrexia syndrome) is treated by reinstating dopaminergic tone, NOT by stopping medication |
Plan: NMS — stop dopamine antagonist / restart dopaminergic → supportive ICU + active cooling → fluids/rhabdo-AKI → benzodiazepine → moderate–severe dantrolene ± bromocriptine/amantadine → refractory ECT → severe sedation+intubation±paralysis → safe later antipsychotic rechallenge (Strawn 2007; DSM-5)
Call 911 or go to the nearest emergency room right away if you have:
Document the offending agent as an allergy/adverse-reaction; defer ANY antipsychotic rechallenge ≥2 weeks after full recovery, then use a lower-potency / different-class agent with slow titration and close monitoring; restore steady-state dopaminergic therapy for Parkinson patients; psychiatry/neurology continuity, nephrology if AKI, patient/family NMS education and return precautions [Strawn 2007]
Guideline: Strawn et al. Am J Psychiatry 2007 NMS consensus + 2024-2025 critical-care toxicology / psychiatry reviews of NMS and parkinsonism-hyperpyrexia syndrome; DSM-5 NMS diagnostic criteria