:We report two cases of acute dystonia in patients after receiving prochlorperazine to address nausea in the context of buprenorphine/naloxone (Suboxone) therapy. Both were admitted for opioid withdrawal and developed nausea and vomiting refractory to ondansetron on the first hospital day.Within six hours of receiving an intramuscular injection of ten milligrams of prochlorperazine, a 24-year-old Caucasian male developed buccolingual crisis (trismus and dysphagia). His symptoms resolved with repeated intramuscular doses of diphenhydramine, benztropine, and lorazepam.A 31-year-old Caucasian female developed laryngeal dystonia (stridor) and buccolingual crisis (dysphagia, grimacing, and tongue protrusion) within thirty minutes of receiving ten milligrams of prochlorperazine intramuscularly. Given respiratory impairment, emergency airway protection was initiated, and the patient responded to repeated intramuscular doses of benztropine and lorazepam.Although one patient was male and both were relatively young, they did not have other known risk factors for drug induced acute dystonic reactions including history of dystonic reactions, recent cocaine use, or low BMI. Neither patient had a history of exposure to antipsychotic medications and both had medical histories that were otherwise noncontributory. While both patients were at risk for or developing dehydration from nausea and vomiting, their electrolytes were within normal limits on admission, less than twelve hours earlier. We postulate potential etiologies that may possibly explain these events:1)The patients’ reactions are consistent with the expected number in the general population to have acute dystonia secondary to prochlorperazine use. A small study in 2000 showed that 3.9% of patients receiving prochlorperazine for nausea in an emergency room setting experienced acute dystonia.2)Could patients receiving intramuscular prochlorperazine during Suboxone therapy have increased risk for severe acute dystonic reactions? According to the European Medicines Agency, hypertonicity is a “common” side effect of Suboxone, occurring in 1% to 10% of patients.3)Could there be potential interactions between Suboxone and prochlorperazine or between prochlorperazine and substances detected (or undetectable, such as designer drugs) via routine toxicology screening?4)Could the acute dystonia be unrelated to medication interaction, but instead result from use of prochlorperazine in patients having rapid electrolyte shifts and exhibiting dehydration during acute opioid withdrawal?Given the known risk of opioids, with or without prochlorperazine, to cause respiratory depression and these case reports of acute dystonia with the potential to cause airway impairment due to prochlorperazine administration, we encourage prescribers to exercise caution when utilizing prochlorperazine for the management of nausea and vomiting in patients receiving Suboxone for acute opioid withdrawal.

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120 喉肌张力障碍和颊舌危机：Suboxone 治疗期间接受丙氯拉嗪的 2 例患者的肌张力障碍反应

：我们报告了两例患者在接受丙氯拉嗪治疗以解决丁丙诺啡/纳洛酮（Suboxone）治疗中的恶心症状后发生的急性肌张力障碍。两人都因阿片类药物戒断而入院，并在住院的第一天出现了对昂丹司琼无效的恶心和呕吐。在接受肌肉注射 10 毫克丙氯拉嗪的 6 小时内，一名 24 岁的高加索男性出现了颊舌危机（牙关紧闭和吞咽困难） . 反复肌肉注射苯海拉明、苯托品和劳拉西泮后，他的症状得到缓解。一名 31 岁的白人女性在服用 10 毫克丙氯拉嗪后 30 分钟内出现喉肌张力障碍（喘鸣）和颊舌危机（吞咽困难、做鬼脸和伸出舌头）肌肉注射。考虑到呼吸功能障碍，开始紧急气道保护，患者对反复肌肉注射苯托品和劳拉西泮有反应。虽然一名患者是男性，而且两人都相对年轻，但他们没有其他已知的药物引起的急性肌张力障碍反应的危险因素，包括肌张力障碍反应史，最近使用可卡因，或低 BMI。两名患者都没有接触过抗精神病药物的病史，并且都有其他无贡献的病史。虽然两名患者都有因恶心和呕吐而脱水或出现脱水的风险，但他们的电解质在入院时（不到 12 小时前）在正常范围内。我们假设可能解释这些事件的潜在病因：尽管一名患者是男性并且两人都相对年轻，但他们没有其他已知的药物引起的急性肌张力障碍反应的危险因素，包括肌张力障碍反应史、近期使用可卡因或低 BMI。两名患者都没有接触过抗精神病药物的病史，并且都有其他无贡献的病史。虽然这两名患者都有因恶心和呕吐而脱水或出现脱水的风险，但他们的电解质在入院时（不到 12 小时前）在正常范围内。我们假设可能解释这些事件的潜在病因：尽管一名患者是男性并且两人都相对年轻，但他们没有其他已知的药物引起的急性肌张力障碍反应的危险因素，包括肌张力障碍反应史、近期使用可卡因或低 BMI。两名患者都没有接触过抗精神病药物的病史，并且都有其他无贡献的病史。虽然两名患者都有因恶心和呕吐而脱水或出现脱水的风险，但他们的电解质在入院时（不到 12 小时前）在正常范围内。我们假设可能解释这些事件的潜在病因：两名患者都没有接触过抗精神病药物的病史，并且都有其他无贡献的病史。虽然两名患者都有因恶心和呕吐而脱水或出现脱水的风险，但他们的电解质在入院时（不到 12 小时前）在正常范围内。我们假设可能解释这些事件的潜在病因：两名患者都没有接触过抗精神病药物的病史，并且都有其他无贡献的病史。虽然两名患者都有因恶心和呕吐而脱水或出现脱水的风险，但他们的电解质在入院时（不到 12 小时前）在正常范围内。我们假设可能解释这些事件的潜在病因：1)患者的反应与普通人群中因使用丙氯拉嗪继发急性肌张力障碍的预期数量一致。2000 年的一项小型研究表明，在急诊室环境中接受丙氯拉嗪治疗恶心的患者中有 3.9% 出现了急性肌张力障碍。2)在 Suboxone 治疗期间接受肌肉注射丙氯拉嗪的患者是否会增加严重急性肌张力障碍反应的风险？据欧洲药品管理局称，高渗性是 Suboxone 的“常见”副作用，发生在 1% 至 10% 的患者中。3)Suboxone 与丙氯拉嗪之间或丙氯拉嗪与通过常规毒理学筛查检测到（或无法检测到，如设计药物）的物质之间是否存在潜在的相互作用？4)急性肌张力障碍是否与药物相互作用无关，而是由于在急性阿片类药物戒断期间电解质快速变化和脱水的患者使用丙氯拉嗪引起的？鉴于已知阿片类药物（无论是否使用丙氯拉嗪）引起呼吸抑制的风险，以及这些急性肌张力障碍的病例报告，可能会因服用丙氯拉嗪而导致气道受损，因此我们鼓励处方医生在使用丙氯拉嗪治疗恶心和因急性阿片类药物戒断而接受 Suboxone 的患者呕吐。