Journal of Anaesthesiology Clinical Pharmacology

: 2013  |  Volume : 29  |  Issue : 2  |  Page : 269--270

Authors' reply

Mustafa Komur1, Ali E Arslankoylu2, Cetin Okuyaz1,  
1 Department of Pediatric Neurology, Mersin University School of Medicine, Mersin, Turkey
2 Department of Pediatric Intensive Care, Mersin University School of Medicine, Mersin, Turkey

Correspondence Address:
Mustafa Komur
Department of Pediatric Neurology, Mersin University School of Medicine, Mersin

How to cite this article:
Komur M, Arslankoylu AE, Okuyaz C. Authors' reply.J Anaesthesiol Clin Pharmacol 2013;29:269-270

How to cite this URL:
Komur M, Arslankoylu AE, Okuyaz C. Authors' reply. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2021 May 13 ];29:269-270
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Full Text

Dear Editor,

We read with interest the letter about our article entitled "Midazolam-induced acute dystonia reversed by diazepam," [1] in which the authors recommend us to search for another cause of acute dystonia in our case. In fact, we excluded the primary and secondary causes of acute dystonia before we attributed the acute dystonia to midazolam. There were no causes of the secondary dystonia as metabolic diseases, toxins, trauma, and infections. No drug known to cause dystonia, except midazolam had been administered to patient. Primary dystonia was excluded because there was no history of consanguinity and neurological disorders including dystonia in the family, and magnetic resonance imaging brain was normal. There was no history of neurologic disorder in the past. Midazolam-induced acute dystonia is rare, and there are only a few cases in the literature about the midazolam-induced acute dystonia. [2],[3],[4]

Although midazolam and diazepam are both in benzodiazepin family, we used diazepam because acute dystonia persisted despite flumazenil and biperiden lactate admistration. Diazepam has anti-dyskinetic effects and was shown to be effective in the treatment of acute dystonia previously. [5],[6] The authors are right that both midazolam and diazepam act at the same receptor and theoretically should show the same response, but diazepam has anti-dyskinetic effects. We think that this effect may be explained by the structural heterogenity of GABA A receptors. Further studies are needed for the detailed explanation of this subject.

We used a higher than the recommended dose of midazolam for premedication because enough sedation couldn't be obtained till a total of 0.2 mg/kg midazolam was administered.


1Nanda S, Sawhney C, Sinha C. In response to: Midazolam-induced acute dystonia reversed by diazepam. J Anaesthesiol Clin Pharmacol 2012;28:268-269.
2Prommer EE. Midazolam-Induced Extrapyramidal Side Effects. J Pain Symptom Manage 2008;36:5-6.
3Stolarek IH, Ford MJ. Acute dystonia induced by midazolam and abolished by flumazenil. BMJ 1990;300:614.
4Brown DJ, McArthur D, Moulsdale H. Subcutaneous midazolam as a cause of extrapyramidal side effects in a patient with prostate cancer. J Pain Symptom Manage 2007;34:111-3.
5Brown DJ, McArthur D, Moulsdale H. GABAergic Treatment for Tardive Dyskinesia. In: Yassa R, Nair NP, Jeste DV, editors. Neuroleptic-induced movement disorders. New York: Cambridge University Press, 1997. p. 454-70.
6Jankovic J. Treatment of dystonia. Lancet Neurol 2006;5:864-72.