ISCHEMIC COLITIS ASSOCIATED WITH QUETIAPINE: A CASE REPORT AND REVIEW OF LITERATURE
Authors: Promdonkoy *Cathliya , Vadhanavikkit Papan , Piyawattanametha Siriwan , Paholpak Pongsatorn 
Published: February 2025

Abstract

Background
Bipolar I disorder is one of the most common mood disorders, and quetiapine is widely prescribed as acute and long-term treatments for both manic and depressive phases (Yatham et al., 2018). Regardless of its broad efficacy, prolonged use of the agent may pose a risk of chronic anticholinergic effects. The anticholinergic property may put patients at risk of developing rare, but fatal adverse effect, ischemic colitis.

Objective
To describe a case with Bipolar I disorder who has been taking quetiapine for many years and developed ischemic colitis without any significant predisposing factor. Here we also reviewed the literature about antipsychotic agents and their association with ischemic colitis.

Case Report
A 27-year-old man, without any underlying disease, was diagnosed with Bipolar I disorder, manic episode with psychotic features. The symptoms had been well controlled with quetiapine 800 mg/day, sodium valproate 2000 mg/day, and trihexyphenidyl 2 mg/day for 2 years. Due to a good clinical response, sodium valproate and quetiapine were titrated down to 1000 mg/day, and 400 mg/day, respectively.
However, quetiapine was later increased to 550 mg/day as a result of an emotional outburst. About 2 months afterward, the patient suddenly developed acute abdominal pain and was diagnosed with ischemic colitis. Exploratory laparotomy with a subsequent subtotal colectomy with end ileostomy, was performed. The pathological examination revealed transmural hemorrhagic necrosis with gangrene along the terminal ileum and colon. Computed tomography angiography (CTA) showed no intraluminal filling defect along abdominal aorta and its branches. Laboratory tests for hypercoagulable state were all negative, including tests for antiphospholipid syndrome (ANA, lupus anticoagulant, anti-cardiolipin antibodies, anti-beta-2 glycoprotein antibodies), factor V, antithrombin, protein C, and protein S. Serology tests for syphilis, hepatitis B, hepatitis C and HIV infection were all negative. There was no JAK2 V617F gene mutation where this gene mutation can be found in populations with myeloproliferative neoplasm, including essential thrombocytosis. The echocardiogram showed preserved left ventricular systolic function with no cardiac emboli. Given that cariprazine has no previous report of association with ischemic colitis, quetiapine 550 mg/day was successfully switched to cariprazine 1.5 mg/day without relapse of psychiatric symptoms.

Discussion & Conclusion
Previously, ischemic colitis was reported in 2 cases of Bipolar I disorder while taking quetiapine. One was a 65-year-old woman who developed 2 episodes of ischemic colitis at the dose of 600 mg/day and 650 mg/day (Arkfeld et al., 2018). The other was a 34-year-old man who developed ischemic colitis when taking quetiapine 600 mg/day (Cuny et al., 2017). Taken altogether, ischemic bowel disease may occur while taking quetiapine at higher dose. This life-threatening adverse event is possibly explained by its anticholinergic effects and should be monitored in all patients.

References
[1]Yatham, L. N., et al (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609
[2]Arkfeld, D. V., Svingen, L. A., Sutton, S., and Sharma, A. (2018). Repeat Ischemic Colitis in a Patient Taking Quetiapine. The primary care companion for CNS disorders, 20(6), 17l02250. https://doi.org/10.4088/PCC.17l02250
[3]Cuny, P., Houot, M., Ginisty, S., Horowicz, S., Plassart, F., Mentec, H., and Eftekhari, P. (2017). Colite isché mique sous qué tiapine associé e à d’ autres molé cules anticholinergiques : à propos d’ un cas [Quetiapine and anticholinergic drugs induced ischaemic colitis: A case study]. L'Encephale, 43(1), 81–84. https://doi.org/10.1016/j.encep.2015.12.027