Reply to the 2 posts
Post 1:
If your LAST name begins with the letters K through R please address Case Study #2: Antipsychotic Case Study #2.docx
1. Why might breakthrough symptoms be more likely when switching between these particular medications? (Consider receptors)
According to Stahl (2021), Zyprexa is a second-generation antipsychotic that binds at several other receptors stronger than it does to D2 receptors. It acts as an antagonist at dopamine D2 and serotonin 5-HT2A receptors along with histamine H1, alpha-adrenergic, and muscarinic receptors. Lithium acts on numerous neurotransmitter systems such as glycogen synthase kinase-3 and serotonin receptor sensitivity. Klonopin is a benzodiazepine that acts on GABA which leads to increased inhibitory neurotransmission. Aripiprazole is a partial agonist at D2 receptors. It also includes 5HT2A antagonists actions, 5HT1A partial agonists actions (Stahl, 2021).
In the case study, the 14-year-old, experienced paranoia when he switched from Zyprexa to Abilify when coming off Lithium and Klonopin. According to Stahl (2021), differences in receptors and downstream effects between medications can cause paranoia and other psychotic symptoms. Zyprexa blocks dopamine 2 receptors which reduces positive symptoms and stabilizing affective symptoms. It also blocks serotonin 2A receptors that reduce motor side effects and improve cognitive symptoms. Individual responses and underlying psychiatric conditions may also play a role in how individuals respond to medication changes. It is important for the healthcare provider to weigh all patients, get baseline personal and family history of diabetes and blood pressure, and to get a fasting lipid profile (Stahl, 2021).
2. If the patient begins struggling with catatonia, what might the clinician prescribe?
According to Smith & Holmes (2023), the first line treatment for catatonia is benzodiazepines such as lorazepam. Usually, lorazepam is administered IV. A lower dose can be repeated within 10 minutes if the results are vague. If an individual is not responding to benzodiazepine treatment, or if a benzodiazepine is contraindicated, the NMDA receptor antagonists memantine or amantadine can be used. Memantine is usually started at 5mg BID and titrated up to 10mg BID for a few days. Amantadine is usually started at 100 mg daily and increased by 100 mg every few days for a total of 400 mg daily. If catatonia is because of psychosis, starting an antipsychotic may be beneficial. Usually, a second-generation antipsychotic with a lesser D2 affinity should be used instead of higher potency drugs. Antipsychotics such as olanzapine and quetiapine are preferred. If catatonia is unrelated to psychosis, antipsychotics should be avoided (Smith & Holmes, 2023).
3. Which antipsychotics are FDA approved in children and adolescents? What are their indications?
Risperdone: According to Stahl (2021), Risperdal has favored use in maintenance and schizophrenia in age 13 and older and bipolar mania/maintenance for ages 10 and older. It also approved for treatment for children and adolescents with irritability related to autistic disorder. It can be used in particular for symptoms of aggression, tantrums, self-injury, and quickly changing moods (Stahl, 2021).
Paliperidone: According to Stahl (2021), Invega is approved for schizophrenia/maintenance in ages 12 and older. Invega is more tolerable with less sedation however, it has a moderate risk for weight gain. The main pro of utilizing Invega is the long-acting injectable is easier to load and dose.
Aripiprazole: According to Stahl (2021), Abilify is effective in treating schizophrenia/maintenance ages 13 and older and agitation along with bipolar/maintenance for ages 10 and older. It is also used for children and adolescents with irritability related to autism and Tourette syndrome in ages 6 to 18.
Quetiapine: According to Stahl (2021), Seroquel is approved for schizophrenia/maintenance for ages 13 and older and for mania/maintenance for 10 and older. It does not cause any motor side effects, however, it puts the individual at risk for moderate weight gain.
4. Many patients take antipsychotic medications for years. What are the most recent monitoring guidelines for metabolic issues? You may display your answer in a chart.
Metabolic monitoring guidelines as proposed by various organizations
| US Consensus |
BAP Guidelines[32 |
|---|
| Links to an external site.] | |||
|---|---|---|---|
| Weight | At 4 wk, 8 wk, and 12 wk after initiating or changing SGA therapy, then quarterly | BMI weekly for the first 4–6 wk, then every 2–4 wk for up to 12 wk. At a minimum, once every 4 wk for the first 12 wk, then at 6 mo and at least annually | |
| Blood glucose | Assessed fasting plasma glucose at 3 mo, then annually | Assessed fasting or random plasma glucose in the initial weeks and glycated hemoglobin at 12 wk, 6 mo, and then annually | |
| Lipid profile | At 3 mo, then repeated at 5-yr intervals if normal | At 12 wk, 6 mo, and then annually. The total cholesterol/high-density lipoprotein cholesterol ratio should be required. | |
| Blood pressure | At 3 mo, then annually | At 12 wk, 6 mo, and then annually |
US consensus: Consensus proposed by American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, and North American Association for the Study of Obesity[32
]; BAP guidelines: Guidelines proposed by the British Association for Psychopharmacology[
Links to an external site.]; SGA: Second-generation antipsychotics; BMI: Body mass index.
5. What are the options for a patient that has gained a significant amount of weight on an antipsychotic? List three different options (at least one should be the addition of a medication).
According to Chang et al., (2021), lifestyle interventions are imperative, switching to another antipsychotic with a lower propensity for weight gain can also be effective, and adding adjunctive medication to mitigate metabolic changes. Dietary interventions such as a balanced diet along with physical activity, can help the individual promote weight loss. If lifestyle interventions are not helpful, switching to another antipsychotic can be effective. Medications such as Metformin, Topiramate, Amantadine, Abilify, and Fluvoxamine can be used for low metabolic risk and weight gain. Metformin is used to help with weight gain related to antipsychotics. Topiramate is an antiepileptic medication, but it is also treatment for weight loss in individuals with antipsychotic induced weight gain. Abilify has lower rates of weight gained compared to other antipsychotics. All interventions should be monitored because individuals respond differently and unpredictable results can occur (Chang et al., 2021).
References
Chang, S. C., Goh, K. K., & Lu, M. L. (2021). Metabolic disturbances associated with antipsychotic drug treatment in patients with schizophrenia: State-of-the-art and future perspectives. World Journal of Psychiatry, 11(10), 696–710. https://doi.org/10.5498/wjp.v11.i10.696
Smith, A., & Holmes, E. (2023). Catatonia: A Narrative Review for Hospitalists. American Journal of Medicine Open, 10(1000059). https://doi.org/10.1016/j.ajmo.2023.100059
Stahl, S. M. (2021a). Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press.
Stahl, S. M. (2021b). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (5th ed.). Cambridge University Press.
Post 2:
Case Study 3
- Considering the patient’s symptoms, what type of antipsychotics would be most appropriate? (Think dopamine). Please explain your choice.
The patient presents with psychotic features such as visual and auditory hallucinations. He reports that a demon has been following him and, in some cases, the demon has commanded him to kill himself. The patient is currently experiencing intermittent hallucinations, anxiety, poor concentration, and insomnia. He has been diagnosed with a psychotic disorder, not otherwise specified, and marijuana dependence. It is important to recognize that the symptoms occurred at the same time that he has been using marijuana more frequently, hence a diagnosis of substance-induced psychosis should be considered.
The best intervention is to start him on a second-generation antipsychotic agent such as lurasidone (Tandon & Shariff, 2019). Lurasidone blocks the receptors for the neurotransmitter dopamine hence improving the patient’s symptoms. Dysregulation in the dopaminergic pathway is one of the neurobiological factors that are linked to psychosis (Tandon & Shariff, 2019). Also, typical antipsychotic agents like haloperidol are dopamine 2 receptor antagonists and D2 blockade is associated with extrapyramidal side effects (Tandon & Shariff, 2019). Lurasidone is an appropriate antipsychotic agent given that marijuana dependence can lead to low dopamine levels hence lurasidone can increase dopamine levels and mitigate the psychotic features (Ricci et al., 2022).
- Can substance-induced psychosis be treated with antipsychotics?
As mentioned earlier, substance-induced psychosis can be treated with antipsychotic agents such as lurasidone (Tandon & Shariff, 2019). A case report involving four patients with cannabis-induced psychosis showed that all the patients’ recovery was positive, not only with the remission of positive and negative symptoms but also regarding disruptive behavior with the return to functioning (Ricci et al., 2022).
- Would an LAI (long-acting injectable) be appropriate for this patient? Please explain why or why not.
A long-acting injectable is considered for patients with schizophrenia who fail to adhere to the prescribed oral medications despite being educated on the benefits of the medication (Riboldi et al., 2022). These long-acting injectables can last for even three months, therefore, in this patient’s case, their use might not be warranted since the psychotic features can abate in a few days or weeks once the marijuana effects wear off. An oral antipsychotic agent should be considered since the patient understands that there is something wrong and he voluntarily sought medical attention.
- Let’s pretend Seroquel was prescribed for this patient. Explain how and why Seroquel can have a different effect at different doses.
Different doses of Seroquel are associated with different effects. At lower doses, Seroquel affects histaminergic and adrenergic (alpha 1 and 2) receptors and this leads to sedation which indicates that the medication can be used to treat insomnia (Modesto-Lowe et al., 2021). At moderate to high doses, Seroquel has an additive affinity for serotonin receptors and dopamine 2 receptors hence leading to mood stabilization and improving psychosis and anxiety (Modesto-Lowe et al., 2021). At high doses, Seroquel can mitigate the patient’s hallucinations and anxiety.
- Antipsychotics are often prescribed “off label” (to treat symptoms for which they do not have FDA approval). Choose any antipsychotic and research why it is used “off-label.” Locate a peer-reviewed article that offers evidence in support or against using that antipsychotic for this reason.
- Risperidone for the management of behavioral and psychological symptoms in patients with Alzheimer’s disease.
- Yunusa, I., & El Helou, M. L. (2020). The use of risperidone in behavioral and psychological symptoms of dementia: A review of pharmacology, clinical evidence, regulatory approvals, and off-label use. Frontiers in Pharmacology, 11, 485120. https://doi.org/10.3389/fphar.2020.00596
- Links to an external site.
References
Modesto-Lowe, V., Harabasz, A. K., & Walker, S. A. (2021). Quetiapine for primary insomnia: Consider the risks. Cleveland Clinic Journal of Medicine, 88(5), 286-294. https://doi.org/10.3949/ccjm.88a.20031
Riboldi, I., Cavaleri, D., Capogrosso, C. A., Crocamo, C., Bartoli, F., & Carrà, G. (2022). Practical guidance for the use of long-acting injectable antipsychotics in the treatment of schizophrenia. Psychology Research and Behavior Management, 15, 3915–3929. https://doi.org/10.2147/PRBM.S371991
Ricci, V., Martinotti, G., De Berardis, D., & Maina, G. (2022). Lurasidone use in Cannabis-Induced Psychosis: A novel therapeutic strategy and clinical considerations in four cases report. International Journal of Environmental Research and Public Health, 19(23), 16057. https://doi.org/10.3390/ijerph192316057
Tandon, R., & Shariff, S. M. (2019). Substance-induced psychotic disorders and schizophrenia: pathophysiological insights and clinical implications. American Journal of Psychiatry, 176(9), 683-684. https://doi.org/10.1176/appi.ajp.2019.19070734