|Year : 2016 | Volume
| Issue : 3 | Page : 182-188
Self-limiting atypical antipsychotics-induced edema: Clinical cases and systematic review
Musa Usman Umar, Aminu Taura Abdullahi
Department of Psychiatry, Bayero University, Kano; Department of Psychiatry, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||27-May-2016|
Dr. Musa Usman Umar
Department of Psychiatry, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A number of atypical antipsychotics have been associated with peripheral edema. The exact cause is not known. We report two cases of olanzapine-induced edema and a brief review of atypical antipsychotic-induced edema, possible risk factors, etiology, and clinical features. The recommendation is given on different methods of managing this side effect.
Keywords: Atypical antipsychotics, edema, side-effect
|How to cite this article:|
Umar MU, Abdullahi AT. Self-limiting atypical antipsychotics-induced edema: Clinical cases and systematic review. Indian J Psychol Med 2016;38:182-8
|How to cite this URL:|
Umar MU, Abdullahi AT. Self-limiting atypical antipsychotics-induced edema: Clinical cases and systematic review. Indian J Psychol Med [serial online] 2016 [cited 2019 Aug 20];38:182-8. Available from: http://www.ijpm.info/text.asp?2016/38/3/182/183089
| Introduction|| |
Olanzapine is an atypical antipsychotic that antagonizes dopamine D1, D2, and D4 receptors. It has antagonistic effect on histamine H1, muscarinic M4, serotonin 5HT2c, 5HT6, and 5HT7 and α1-nordrenargic receptors. It is used for the treatment of schizophrenia and a manic episode of bipolar affective disorder,, and has shown benefit in the management of bipolar depression and relapsed prevention in bipolar disorder. Weight gain, sedation, and postural hypotension are common side-effects of olanzapine, however, recent studies have reported cases of peripheral edema.,, Among atypical antipsychotics, edema has been reported in individuals using risperidone, quetiapine, ziprasidone, amisulpride, clozapine, and paliperidone.
We present two cases of peripheral edema associated with olanzapine treatment and a literature review of atypical antipsychotic-induced edema. Ethical review and clearance were obtained from the Aminu Kano Teaching Hospital Ethical Committee. Thereafter, an informed consent was sought from the two patients and their guardians.
| Case 1|| |
A 35-year-old male who was being managed for bipolar affective disorder, currently with a manic episode. He was diagnosed 5 years ago and was on maintenance treatment with sodium valproate but had poor compliance to medication. During this index presentation, he was placed on olanzapine 10 mg daily and sodium valproate 400 mg twice a day. One week into admission the dose of olanzapine was increased to 20 mg daily because of increasing restlessness and grandiose delusion. About 1 month into admission, he was in remission but was noticed to have swelling of both legs and hands. The patient was not a known hypertensive or diabetic. There was no history of use of alcohol but used cigarette and cannabis before presentation. The patient did not report any change in his dietary and fluid intake. He was not on any drug known to cause edema such as nonsteroidal anti-inflammatory drugs, steroids, antihypertensive, or immunosuppressive agents.
On examination, he had a nonpitting pedal severe edema while that of the hands were mild based on the classification of severity of edema. Blood pressure, cardiac, and abdominal examinations were normal. The urea, creatinine, electrolytes, thyroid function test, liver function tests, and serum proteins were normal. Urine test, chest X-ray, electrocardiogram and abdominopelvic ultrasound were also normal.
When the above investigation turned out to be normal olanzapine was stopped, based on emerging evidence of rare association of olanzapine with peripheral edema., One week after discontinuation of olanzapine, edema was moderately severe and therefore, frusemide 5 mg was introduced and within 2 weeks swelling completely resolved. He was then placed on risperidone 4 mg daily and sodium valproate. This patient had used sodium valproate without a report of edema in the past. The adverse effect was scored using the Naranjo's algorithm for adverse drug reaction probability scale, and a score of 7 was obtained which indicate strong association of edema with olanzapine.
| Case 2|| |
A 41-year-old man presented with 7 months history of persecutory delusion' delusion of reference, auditory hallucination, and vagrant-like behavior. A diagnosis of schizophrenia was made. He was commenced on haloperidol 5 mg bid and later increased to 10 mg bid. Four weeks later the medication was changed to olanzapine at a dose of 20 mg daily after delusion persisted and had an extrapyramidal side-effect. The patient developed swelling of both legs, moderate edema up to the knee, 2 weeks after introduction of olanzapine. Physical examination of other system was normal. The urea and electrolyte, creatinine, urinalysis, liver function test, fasting blood glucose, and lipid profile were normal. Abdominal scan and chest X-ray were also normal. The thyroid function test was normal. There was no diurnal variation of edema or skin changes or itching. The olanzapine was reduced to 10 mg. Within 1 week of reducing olanzapine, the edema resolved. Due to the presence of psychopathology, the olanzapine was again increased to 20 mg but edema reappeared by the 5th day. This time around the edema was severe compared to the earlier presentation. Olanzapine was reduced to 10 mg, and the swelling of the lower limbs resolved after 1 week. Naranjo's score was 8.
In both cases, the presence of peripheral edema could be attributed to use of olanzapine since edema disappeared in the first case when olanzapine was stopped and in the second case when it was reduced.
In the first case, the patient had been on sodium valproate before the introduction of olanzapine without peripheral edema, and edema did reduce with olanzapine stoppage while still taking sodium valproate. In some cases, it had been noted that valproate may increase the plasma concentration of antipsychotic. Chen et al. and Yalug et al. reported edema in patients in which valproate was used as co-medication with quetiapine and olanzapine respectively. By decreasing the hepatic activity of CYP3A4, a metabolizing isoenzyme, it may contribute to higher level of plasma concentration of antipsychotic. Valproate on its own has been associated with isolated peripheral edema.
On the other hand, drug-induced edema may be due to dose-dependent mechanism,,, and not related to co-medication with valproate. This is consistent with our second case in which reduction of olanzapine resulted in the disappearance of edema.
In the two cases presented, edema can be attributed to olanzapine as other causes of edema such as renal, cardiac, and other drug-induced causes were ruled out. There was a temporal relationship between the start of olanzapine and the development of edema using the Naranjo's adverse reaction scale as causal assessment is regarded as having a score of at least 7.
| Systematic Review of Atypical Antipsychotic-Induced Edema|| |
A search was performed through August, 2015 on PubMed, EMBASE, and Google Scholar with keywords including “atypical antipsychotics,” “edema,” “peripheral edema,” “olanzapine,” “risperidone,” “quetiapine,” “aripiprazole,” “ziprasidone,” “amisulpride,” “clozapine” and “paliperidone.” The references of relevant articles were reviewed for additional citations. To assess causality for atypical antipsychotic-induced edema review reports with Naranjo's probability scale score of at least 5–8, showing a probable association with the medication, were included. Furthermore, articles on angioneurotic edema were excluded. In this review, we only included studies published in English.
A total of 108 articles were retrieved by web-based searching in the first instance. Forty-eight case reports were retrieved with 30 with a total of 34 cases fulfilling the inclusion criteria while 3 cross-sectional studies of olanzapine-induced edema were also included.
The mean age of the patients in the case reports is 44 years with females constituting 70.6% of the cases, those with schizophrenia at 47.1% and bipolar disorder at 20.6%. Only 6 (17.6%) had a Naranjo score of 9 and above indicating definite causal relationship.
In a randomized, double-blind study that was aim at comparing the effect of risperidone with placebo on psychosis and behavioral disturbances in patients with dementia, reported a prevalence of 15.8% of risperidone-induced edema. This study should be interpreted with caution as the average age of the study population was 82 years. This high rate of peripheral edema might be associated with deteriorating physical health state of the patients in terms of reduced cardiac and renal functioning. On the other hand, the study by Ng et al. among 49 outpatients on olanzapine reported prevalence of 57% with 10.2% having edema with a severe degree. However, this study included patients with co-morbid medical conditions including hypertension, cardiovascular problems, and thyroid hormone abnormalities. On the other hand, a longitudinal observational study among Indian psychiatric outpatients reported that 0.85% had pedal edema in a study of adverse drug reaction from antipsychotics.
In this review of cases, risperidone, olanzapine, and quetiapine were reported at the same rate of 29.4%. In a review by Chen et al., risperidone and olanzapine were the drugs most likely to be associated with edema and followed by quetiapine.
The time to onset of edema after ingestion of atypical antipsychotic varies widely, from a day to several months., In this review, the mean time of onset from the start of antipsychotic was 22.9 days (standard deviation [SD] = 23.51) but in majority of the case reports the onset was within the first 4 weeks [Table 1]. A review by Hsu and Chang of edema related to antipsychotic reported a mean time of onset of 25.8 days.
|Table 1: Atypical antipsychotic-induced edema: Demographic characteristics and medication variables|
Click here to view
Antipsychotic-induced peripheral edema can develop bilaterally in the legs in most reported cases [Table 1] but can also affect other parts of the body either alone or in combination with pedal edema. These include the eyelids, face,, hands,, periorbital region,, forearms, lower trunk, and a combination of face, eyelid, and lower extremity.
The time of resolution of edema took <4 weeks in the cases reviewed with mean of 10.3 days (SD = 7.98).
Even though individuals with schizophrenia and bipolar were represented more in the case reports, the cross-sectional study of Ng et al. of 49 subjects receiving olanzapine reported no significant differences regarding concomitant diagnosis.
| Mechanism of Antipsychotic-Induced Edema|| |
A plausible mechanism of olanzapine-induced edema is still unknown. Various theories have been postulated.
Supersensitivity and vasodilatation theory
This state that there is super-sensitivity of α-receptors to antipsychotic which occurred during the drug-free period., The α-receptors of the peripheral vascular system cause vasodilatation and thereby raising the hydrostatic pressure by decreasing the vascular resistance in the blood capillaries. This hydrostatic pressure moves the fluid from the intravascular compartment to the interstitial space, which leads to edema., The associated vasodilatation is seen in patients using antipsychotics as a plausible cause of edema. This theory postulates that there is a “critical drug-free period” during which reinstatement of the agent, in this case, risperidone, may increase the rate of manifestation of side-effect due to super-sensitivity of the neurons.
Dose-response (dose-dependent) relationship
Yang and Cheng, reported switching their patient from oral to depot risperidone without having re-occurrence of edema. It was explained that the use of long-acting injectable risperidone leads to smaller peak-to-trough fluctuations in the plasma risperidone concentration compared with oral risperidone. On the contrary, Pelizza  reported a case of periorbital edema in a patient on depot risperidone.
For both cases in this report, the patients were on relatively high dose of olanzapine. In the second case, when olanzapine was reduced edema disappeared. This dose-dependent theory is supported by Tamam et al. where within 1 week of reduction of risperidone edema resolved. In a randomized, double-blind controlled study by Katz et al., peripheral edema developed in a dose-related pattern. Edema may be the result of antipsychotic antagonism on the renal dopamine receptors (D4) thereby altering the renal regulation of fluid and electrolyte., However, edema has been reported in individuals taking low-dose antipsychotics.,,,
Rate of dose escalation
Kores Plesnicar et al. reported that their patient that developed edema had her risperidone titrated from 2 to 6 mg within 2 weeks. Rapid dose increase of olanzapine may also be a factor in inducing peripheral edema. The rate of dose escalation of antipsychotics may be a factor in antipsychotic-induced edema. Various factors such as age, previous exposure to antipsychotic, history of side effects, the severity of illness, presence of physical health condition, and the need for a rapid response in treatment usually determine the rate of antipsychotic dose escalation.
No consensus has been reached on what is rapid dose escalation, even though Langan et al. attempted to define it mathematically. The cumulative antipsychotic dose for an individual is calculated for days 1–15 and days 16–30 and then a ratio of first 15 days to second 15 days is generated. They authors defined dose escalation as a ratio of 4 times of the cumulative dose at the second 15 days compared to the first 15 days.
Immune reaction may be implicated in the mechanism of drug-induced edema.,,, Immune components that were reported in case reports include elevated immunoglobulin E in relation to ziprasidone and amisulpride,, low C4 and C1 esterase inhibitor in relation to risperidone (Conney and Nagy, 1995). However, other studies that assessed immunological reactions as possible cause of drug-induced edema did not find any impairment.,,, Patients with abrupt onset edema could be from allergic mechanism.
Other risk factors
Older age has been suggested as a risk factor, especially in those with severe edema, but it has also been reported in children and adolescents,, and reported a mean age of 44.1 years. The mean age in this review of case reports is 44 years.
The majority of cases reported are among females (70.6%), and this was also found in the review of quetiapine-induced peripheral edema. However, the cross-sectional study by Ng et al. reported no association with gender.
Antithyroid bodies were significantly associated with olanzapine-induced edema. No other study has replicated this finding.
Antipsychotics that contain some inactive compounds such as titanium dioxide, propylene glycol, and ionic compounds that contain sodium have also been implicated.
| Management of Antipsychotic-Induced Edema|| |
In our first case, diuretic (frusemide) was given when olanzapine was stopped. This was because of the slow rate of resolution of edema. Other studies have reported using diuretics in the management of atypical antipsychotic-induced edema.,,
While in the second case, reduction of olanzapine was effective in the resolution of the edema. This method was reported in other case reports.,,, In other studies, the offending agent was reduced with the addition of diuretics., On the other hand, most case reports stopped the offending antipsychotics and substituted them with others without reoccurrence of edema.,,,,
Most of the patients in the case reports reviewed were also taking other medications such as valproate, escitolapram, and lithium which are also known to be associated with edema.,,, There are few cross-sectional and longitudinal studies addressing antipsychotic-induced thus limiting conclusion on the relationship between atypical antipsychotics and peripheral edema.
| Conclusion|| |
Antipsychotic-induced edema is not an uncommon side-effect of atypical antipsychotics. Edema is uncomfortable to patients and usually requires a number of examinations to accurately determine its causes. The clinician should be alert to the following factors that may be associated with antipsychotic-induced edema.
- Antipsychotic-induced edema can occur with any dose of atypical antipsychotic ,,
- Edema can occur in any peripheral area of the body including the face and eyelids
- Sudden increase of dose of medication may be a factor, and therefore, gradual increase is advised 
- Replacement with another antipsychotic is advocated, but in cases where the offending medication is necessary, it should be gradually reduced ,,,,
- Diuretics may be used in cases that have not resolved with the stoppage of the offending agents, although the long-term effect of using diuretic is not known ,,,
- The use of co-medication should be done with caution ,,
- Even after drug-free period with the implicated drugs, edema could still re-occur after reinstatement,, and therefore, it is preferable not to rechallenge with the offending agent ,
- During reinstatement of antipsychotic that was previously implicated as the cause of edema, it is advised that the dose should be small and gradually increased to therapeutic level 
- Antipsychotic-induced edema is not associated with any diagnosis 
- Comorbid physical factors may not be predisposing factor 
- Older age may be a risk factor.,
Edema is often not enquired by physicians unless the patient complaints about it. From the review, it shows that atypical antipsychotic-induced edema may not be a less frequent complication. Even though antipsychotic-induced edema may be transient and self-limited, it symptoms still carries with it uncomfortable feeling and, therefore, it is important to understand the risk factors and method of managing these cases and to initiate close monitoring when antipsychotic are prescribed. In the future, it is recommended that prospective studies be carried out to determine the risk factors associated with and the long-term implication of antipsychotic-induced edema.
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Conflicts of interest
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| References|| |
Stahl SM. Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Application. 3rd
ed. Cambridge: Cambridge University Press; 2008.
Barnes TR; Schizophrenia Consensus Group of British Association for Psychopharmacology. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2011;25:567-620.
Yatham LN, Goldstein JM, Vieta E, Bowden CL, Grunze H, Post RM, et al.
Atypical antipsychotics in bipolar depression: Potential mechanisms of action. J Clin Psychiatry 2005;66 Suppl 5:40-8.
Goodwin GM; Consensus Group of the British Association for Psychopharmacology. Evidence-based guidelines for treating bipolar disorder: Revised second edition – Recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2009;23:346-88.
Akin S, Bahat G, Tufan F, Saka B, Oztop N, Erten N, et al.
Olanzapine as a cause of peripheric edema in an elderly man. Aging Clin Exp Res 2013;25:115-7.
Malhotra M, Shrivastava MK. Facial edema with olanzapine. Gen Hosp Psychiatry 2013;35:682.e7-8.
Nayak V, Chogtu B, Devaramane V, Bhandary PV. Pedal edema with olanzepine. Indian J Pharmacol 2009;41:49-50.
Hosseini SH, Ahmadi A. Peripheral edema occurring during treatment with risperidone combined with citalopram. Case Rep Med 2012;2012:540732.
Chen CY, Yeh YW, Kuo SC, Shiah IS, Liu PY, Chen CL. Pedal edema associated with addition of low-dose quetiapine to valproate treatment in bipolar disorder. Prog Neuropsychopharmacol Biol Psychiatry 2009;33:1551-2.
Ku HL, Su TP, Chou YH. Ziprasidone-associated pedal edema in the treatment of schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2006;30:963-4.
Chen CK, Chou YH. Amisulpride-associated pedal edema. Eur Psychiatry 2004;19:454-5.
Durst R, Raskin S, Katz G, Zislin J, Durst R. Pedal edema associated with clozapine use. Isr Med Assoc J 2000;2:485-6.
Chen HJ, Lin ST, Hsu HC, Cheng KD, Tsang HY. Paliperidone-related peripheral edema: A case report and review of the literature. J Clin Psychopharmacol 2014;34:269-71.
Ng B, Postlethwaite A, Rollnik J. Peripheral oedema in patients taking olanzapine. Int Clin Psychopharmacol 2003;18:57-9.
Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al.
A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45.
Aichhorn W, Marksteiner J, Walch T, Zernig G, Saria A, Kemmler G. Influence of age, gender, body weight and valproate comedication on quetiapine plasma concentrations. Int Clin Psychopharmacol 2006;21:81-5.
Yalug I, Ozten E, Evren Tufan A, Alemdar M, Cerit C. Bilateral pedal edema associated with olanzapine use in manic episode of bipolar disorder: Report of two cases. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:1541-2.
Patsalos PN, Perucca E. Clinically important drug interactions in epilepsy: General features and interactions between antiepileptic drugs. Lancet Neurol 2003;2:347-56.
Lin ST, Chen CS, Yen CF, Tsei JH, Wang SY. Valproate-related peripheral oedema: A manageable but probably neglected condition. Int J Neuropsychopharmacol 2009;12:991-3.
Koleva HK, Erickson MA, Vanderlip ER, Tansey J, Mac J, Fiedorowicz JG 3 case reports of edema associated with quetiapine. Ann Clin Psychiatry 2009;21:77-80.
Kores Plesnicar B, Vitorovic S, Zalar B, Tomori M. Three challenges and a rechallenge episode of angio-oedema occurring in treatment with risperidone. Eur Psychiatry 2001;16:506-7.
Tamam L, Ozpoyraz N, Unal M. Oedema associated with risperidone. A case report and literature review. Clin Drug Invest 2002;22:411-4.
Katz IR, Jeste DV, Mintzer JE, Clyde C, Napolitano J, Brecher M. Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: A randomized, double-blind trial. Risperidone Study Group. J Clin Psychiatry 1999;60:107-15.
Sengupta G, Bhowmick S, Hazra A, Datta A, Rahaman M. Adverse drug reaction monitoring in psychiatry out-patient department of an Indian teaching hospital. Indian J Pharmacol 2011;43:36-9.
Zink M, Kuwilsky A, Knopf U. Olanzapine-associated bilateral eyelid oedema. J Clin Psychopharmacol 2007;27:214-5.
Yovtcheva SP, Yazel JJ. Olanzapine-induced bilateral pedal edema: A case report. Gen Hosp Psychiatry 2000;22:290-1.
Christensen RC. Olanzapine-associated bilateral pedal edema. J Clin Psychiatry 2003;64:972.
Deshauer D, Erwin L, Karagianis J. Case report: Edema related to olanzapine therapy. Can Fam Physician 2006;52:620-1.
Dada MU, Obadeji A, Ajayi AO. Peripheral oedema in a patient taking olanzapine: A case report. Niger J Psychiatry 2011;9:36-7.
Vohra A. Olanzapine-induced peripheral oedema in a pregnant patient with bipolar affective disorder. German J Psychiatry 2013;16:84-6.
Mathan K, Muthukrishnan V, Menon V. Olanzapine-induced tender pitting pre-tibial edema. J Pharmacol Pharmacother 2015;6:114-5.
Rozzini L, Ghianda D, Vicini Chilovi B, Padovani A, Trabucchi M. Peripheral oedema related to quetiapine therapy: A case report. Drugs Aging 2005;22:183-4.
McSkimming AJ, Dham P, Alexander J, Dinesh A. Peripheral oedema in quetiapine therapy. Aust N
Z J Psychiatry 2012;46:790-1.
Roy K, Astreika V, Dunn JE, Sappati Biyyani RS. Quetiapine-induced peripheral edema. Gen Hosp Psychiatry 2009;31:194-5.
O'Connor N, Andronikashvili L, Adra A. Quetiapine causing peripheral oedema. Australas Psychiatry 2009;17:511-2.
Chen HK, Liao HY, Huang CC. Concurrent pedal edema and sinus bradycardia associated with quetiapine. Psychiatry Clin Neurosci 2011;65:537-8.
Chan HY, Chen YW. Facial and eyelid edema using quetiapine with the addition of bilateral lower extremity edema on rechallenge in a geriatric patient. J Clin Psychopharmacol 2014;34:654-6.
Cooney C, Nagy A. Angio-oedema associated with risperidone. BMJ 1995;311:1204.
Sanders RD, Lehrer DS. Edema associated with addition of risperidone to valproate treatment. J Clin Psychiatry 1998;59:689-90.
Ravasia S. Risperidone-induced edema. Can J Psychiatry 2001;46:453-4.
Feroz-Nainar C, Selvaraj P, Roy M. Risperidone induced oedema in a child with learning disability and autism. Autism 2006;10:308-10.
Pelizza L. Long-acting risperidone-induced periorbital edema. J Clin Psychopharmacol 2008;28:709-10.
Akdag ST, Fettahoglu EC, Ozatalay E. Pedal edema induced by low-dose risperidone monotheraphy in a child. J Child Adolesc Psychopharmacol 2009;19:481-2.
Yang HN, Cheng YM. Peripheral edema associated with risperidone oral solution: A case report and a review of the literature. J Clin Psychopharmacol 2012;32:128-30.
Koola MM, Brown WV, Qualls C, Cuthbert B, Hollis JP, Kelly DL, et al.
Reduced arterial compliance in patients with psychiatric diagnoses. Schizophr Res 2012;137:251-3.
Knox ED, Stimmel GL. Clinical review of a long-acting, injectable formulation of risperidone. Clin Ther 2004;26:1994-2002.
Sun D, Schafer JA. Dopamine inhibits AVP-dependent Na transport and water permeability in rat CCD via a D4-like receptor. Am J Physiol 1996;271 (2 Pt 2):F391-400.
Baker RW, Kinon BJ, Maguire GA, Liu H, Hill AL. Effectiveness of rapid initial dose escalation of up to forty milligrams per day of oral olanzapine in acute agitation. J Clin Psychopharmacol 2003;23:342-8.
Langan J, Martin D, Shajahan P, Smith DJ. Antipsychotic dose escalation as a trigger for neuroleptic malignant syndrome (NMS): Literature review and case series report. BMC Psychiatry 2012;12:214.
Mannens G, Huang ML, Meuldermans W, Hendrickx J, Woestenborghs R, Heykants J. Absorption, metabolism, and excretion of risperidone in humans. Drug Metab Dispos 1993;21:1134-41.
Ravi PB, Ravishankar GM, Andrade C. Bilateral peripheral edema as a rare adverse effect of escitalopram. Indian J Psychiatry 2014;56:97.
Masdrakis VG, Oulis P, Kouzoupis AV, Masdrakis GV, Soldatos CR. Bilateral ankle oedema in a patient taking escitolapram. World J Biol Psychiatry 2009;10:939-41.
Singh T, Chavan BS. Pitting type pedal oedema with lithium: A case report. German J Psychiatry2008;11:76-8.