Drug-induced ataxia
Alerts and Notices
Synopsis
Antiepileptic drugs
- Phenytoin – May cause nystagmus at therapeutic doses, but ataxia is common at supratherapeutic levels. Effects are typically reversible with medication cessation, but permanent cerebellar degeneration can occur with chronic administration.
- Valproic acid – May cause cerebellar ataxia in the setting of hyperammonemia.
- Benzodiazepines – Most commonly described in children with epilepsy. Ataxia is often mild and reversible. Elderly patients are also susceptible to benzodiazepine ataxia.
- Others – Carbamazepine, oxcarbazepine, lacosamide, lamotrigine, rufinamide, zonisamide, ezogabine, gabapentin, felbamate, and phenobarbital.
- Chronic lithium use is associated with ataxia that is often permanent. Symptom onset tends to occur after infection, dehydration, or renal dysfunction.
- Ataxia secondary to selective serotonin reuptake inhibitor use has been reported.
- Tacrolimus and cyclosporine are associated with mild and transient ataxia.
- Cytarabine-induced ataxia tends to occur 2-4 days after first dose and typically resolves within weeks.
- Metronidazole – High doses associated with ataxia and development of cerebellar hyperintensities in T2 sequences on MRI.
- Piperazine (antihelmintic agent) can cause ataxia in children.
- Most common toxin producing ataxia in a midline cerebellar pattern, characterized by ataxia of the legs and gait with relative sparing of the arms.
- Carbon tetrachloride, heavy metals, phencyclidine (PCP), and toluene may cause cerebellar ataxia.
Medications commonly implicated in peripheral neuropathy include:
Cardiovascular agents
- Statins and amiodarone may cause a reversible peripheral neuropathy.
- Chemotherapy-induced peripheral neuropathy (CIPN) is a well-described entity and may be caused by various agents.
- Vincristine, paclitaxel, cisplatin, and bortezomib are common causes of CIPN.
- Isoniazide can cause a reversible peripheral neuropathy.
- Metronidazole may cause a reversible peripheral neuropathy.
- Nucleoside reverse transcriptase inhibitors such as stavudine contribute to polyneuropathy in patients with human immunodeficiency virus (HIV).
- Vitamin B6 (pyridoxine) in high doses can cause peripheral neuropathy. However, pyridoxine supplementation can prevent neuropathy in patients on isoniazid therapy.
Codes
ICD10CM:R27.0 – Ataxia, unspecified
SNOMEDCT:
20262006 – Ataxia
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Basilar migraine
- Cerebellar metastasis
- Acute cerebellar ataxia or acute cerebellitis (especially in children)
- Cerebellar abscess
- Labyrinthitis
- Vitamin E deficiency – sensory ataxia
- Cerebellar stroke
- Cerebellar hemorrhage
- Vascular malformation
- Paraneoplastic syndrome (especially neuroblastoma in children; lung cancer in adults)
- Multiple sclerosis
- Miller-Fisher variant of acute inflammatory demyelinating polyneuropathy – sensory ataxia
- Chiari malformation
- Post-concussive syndrome
- Episodic ataxias (type 1, type 2, types 3 and 4)
- Spinocerebellar ataxias
- Fragile X-associated tremor ataxia syndrome
- Friedreich ataxia – sensory ataxia
- Ataxia telangiectasia (consider in children)
Best Tests
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:12/18/2018
Last Updated:10/28/2021
Last Updated:10/28/2021