Quetiapine is a commonly used second-generation antipsychotic (SGA) agent for the treatment of schizophrenia (1). Although not approved for youths under 18 years of age in Denmark, it is frequently prescribed off-label, mostly as pro necessitate medication, but also as maintenance treatment. SGAs differ with respect to their receptor profiles, which – combined with individual neurobiological differences – result in substantial variations in therapeutic response and adverse effects (2). Nasal congestion is a known, but likely underreported side effect of quetiapine which can cause considerable discomfort. We present a case of severe, prolonged nasal congestion in a 17-year-old patient with schizophrenia.
The patient was diagnosed with schizophrenia at age 15. Various antipsychotic treatments had been attempted: aripiprazole had insufficient effect, paliperidone caused hyperprolactinemia and had insufficient symptom control. Quetiapine extended-release was initiated at age 16 years and 7 months, resulting in a reduction of psychotic symptoms with minimal side effects. Standardized side-effect assessment (an abbreviated version of Udvalg for Kliniske Undersøgelser side effects rating scale (UKU)) (3) had been performed repeatedly, but nasal congestion is not an item in UKU, and the patient had not reported dry mouth, which can be a proxy indicator of nasal congestion.
At age 17 years and 10 months, the patient had consulted an otorhinolaryngologist due to persistent nasal congestion. Olfactory sense was considered normal, no allergies were identified and nasal steroids had been tried at adequate doses for 6–8 weeks with-out improvement. The patient was referred to an otorhinolaryngological (ORL) department where clinical examination showed only minimal deviation of the nasal septum. However, hyperaemia and oedema of the nasal mucosa was present, especially localized to the inferior turbinates. Airflow through both nostrils was reduced and the patient was scheduled for septoplasty and resection of the inferior turbinates.
When this came to the attention of the treating psychiatrist three weeks after first visit to ORL, the surgery was promptly cancelled. Three weeks later, quetiapine was switched to lurasidone, and the nasal congestion rapidly resolved. At 74 mg lurasidone the patient again developed galactorrhoea and breast swelling, similar to the reaction on paliperidone, but these symptoms abated after dose reduction to 55,5 mg. The patient reported no worsening of psychosis, but experienced increased energy and reduced somnolence after medication switch.
Nasal congestion is not commonly described as a side effect of antipsychotic medication (4). In most literature rhinitis medicamentosa is described as a rebound phenomenon following excessive use of nasal decongestants, but is also mentioned in a 2006 review as a side effect to various other drugs, including antipsychotics. The underlying pathophysiology behind the condition remains unclear, though mechanisms such as vasodilation and increased capillary permeability, leading to mucosal oedema, are implicated (5). Although nasal congestion may appear trivial, to some patients it causes a high level of discomfort, including tiredness and headache, and may lead to sinusitis. In this particular case, the severity of symptoms led the patient to consider surgery before the association with quetiapine was recognized.
Patients in antipsychotic treatment may experience a wide range of side effects. Rhinitis is mentioned in the package insert as a less common side effect to quetiapine. A comprehensive examination of side effects is essential during antipsychotic treatment. Several structured interviews and questionnaires exist for monitoring side effects, such as the UKU mentioned above; however, nasal congestion is not included in all such tools. Based on the present case, reports of nasal congestion (or indeed any new medical symptom) in patients treated with antipsychotics should prompt asking whether the symptom occurred in relation to the medication and, if so, dose reduction or antipsychotic switch should be tried before considering other interventions.