Case outcome: interim follow-ups through one month

The patient is seen weekly because of her symptoms

• – Records are requested but do not arrive

• – Several medications are presented and the patient states she has a negative tolerability history with many of them

• – States divalproex sodium (Depakote) has worked well but she fears re-emergence of hyperammonemia

• – Feels that risperidone (Risperdal) was helpful too but caused weight gain and movement disorder

After the following informed consent she agrees to a trial of paliperidone (Invega)

• – Is the atypical in the class that least requires p450 metabolism

• – Is primarily renally excreted

• – Can be titrated easily to allow adequate monitoring and treatment of emergent extrapyramidal symptoms

• – She is at risk for TD again, but this can be monitored closely and removed if needed

• – Has 52 weeks of data showing minimal metabolic impact

• – It is approved to treat schizophrenia but its D2 receptor antagonism might alleviate mania and mixed features

Paliperidone (Invega) 3 mg/d is initiated, which is subtherapeutic but should limit adverse effects initially. On day 4, the patient states she has more insomnia and dysphoric lability post dose, but is better able to focus and concentrate during the daytime

Dosed next at 6 mg/d, which is not tolerated due to agitation and gastrointestinal (GI) issues. There were no EPS side effects, however

Patient states that the typical antipsychotic thiothixene (Navane) had helped at one hospitalization and asked to try this instead, and it was dosed now at 5–10 mg/d

Now allowed to take diphenhydramine (Benadryl) 50 mg for insomnia or emergent EPS as needed

Considering her current use of a typical antipsychotic, what clinical monitoring would you suggest?

Routine monitoring for treatment-emergent TD/EPS is needed as she reports a history of movement disorder, which appears to include dystonias and dyskinesias involving tic-like features

• – Consider AIMS testing frequently

• – Provide clear informed consent regarding emergence of TD and its possible permanence

Is routine measurement of weight, abdominal girth, blood pressure, blood lipids, and glucose warranted due to metabolic risks?

• – The typical antipsychotics do not carry metabolic risk warnings like the atypical antipsychotics

• – Thiothixene (Navane) and other high-potency typicals are not clinically well documented to cause AAWG; therefore, this type of monitoring may not be necessary

• – If lower-potency typicals (chlorpromazine [Thorazine], thioridazine [Mellaril]) are to be used, they clearly promote weight gain and likely metabolic disorder, and monitoring similar to that utilized during atypical antipsychotic use should occur

If records can be obtained and if her EPS

• – Appear more dystonic, then prophylactic use of anticholinergics (diphenhydramine [Benadryl], benztropine [Cogentin]) are warranted

• – Appear more akathisia-based, then as needed-or even prophylactic beta-blocker or BZ use may be warranted

This patient has a tenuous history of tolerating medications

• – Being diligent about side, effect monitoring is worthwhile clinically

• – Utilizing antidotes for side effects is imperative

• – Additionally, being patient and supportive with numerous complaints may be good for rapport building, medication compliance, and ultimately allow better outcomes due to the ability to obtain better dosing