Post 1 Why might breakthrough symptoms be more likely when switching between these particular medications? (Conside

Post 1

1. Why might breakthrough symptoms be more likely when switching between these particular medications? (Consider receptors)

While olanzapine and aripiprazole are both second generation antipsychotics, differences in their pharmacological profiles make it likely for the occurrence of breakthrough symptoms to occur when switching between them. Olanzapine is an antagonist to 5HT2A and dopamine D2 receptors, it also has a higher affinity to muscarinic M1 receptors than aripiprazole so switching between them may result in cholinergic withdrawal symptoms (Obayashi et al, 2020). Aripiprazole is a dopamine D2 receptor partial agonist, and it has a more potent D2 binding affinity than most other antipsychotics. The differences in the mechanisms of actions between these two medications is what leads to the breakthrough symptoms. Attempts to minimize breakthrough symptoms can be made by tapering down one antipsychotic while gradually increasing a new one instead of discontinuing one abruptly (Stahl, 2020).

1. If the patient begins struggling with catatonia, what might the clinician prescribe?

It is important that patients be monitored for signs and symptoms of catatonia. Untreated catatonia can lead to bedsores, painful muscle contractions, deep vein thrombosis, and urinary tract infection. Benzodiazepines such as lorazepam are the recommended first line of treatment. Electroconvulsive therapy may be another treatment options in cases that are resistant to other treatment methods (Takács et al, 2021).

1. Which antipsychotics are FDA approved in children and adolescents? What are their indications?

Aripiprazole is approved for the treatment of schizophrenia in adolescents, it can also be used for the treatment of manic episodes related to bipolar 1 disorder, depressive disorder, and aggression related to autistic disorders (Orsolini et al., 2016).

Olanzapine is approved for the treatment of schizophrenia in adolescents, it can also be used for the treatment of manic episodes related to bipolar 1 disorder (Orsolini et al., 2016).

Quetiapine is approved when used as monotherapy in the treatment of manic or mixed episodes related to bipolar 1 in children and adolescents (Orsolini et al., 2016).

Risperidone is approved for treatment of schizophrenia in adolescents and when used as monotherapy it can be used to treat aggression related to autism disorder in children (Orsolini et al., 2016).

1. 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.

Problems such a obesity, hyperglycemia, dyslipidemia, and type 2 diabetes related to antipsychotic medication develop faster in children than in adults so it is important that they are monitored closely. Olanzapine is associated with having the highest risk for developing obesity while aripiprazole is associated with the lowest risk of developing obesity (De Hert & Detraux, 2018). Weight/Body mass index, fasting triglycerides, fasting glucose, ,and blood pressure should be taken at baseline and monitored closely after initiating treatment to watch for metabolic issues (Stahl, 2020).

1. 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).

Trying to recommend and incorporated health lifestyle choices to treat the patients weight gain is one option, although it has been found that due to the nature of illness most patients in this population are facing that lifestyle modifications are often not sustainable. The used of pharmacological interventions is currently viewed as the best treatment option (Correll et al., 2020).

The addition of metformin to current pharmacologic treatment may help to fight obesity. Metformin’s ability to aid in weight loss is not completely understood but it is known to help improve insulin sensitivity as well as preventing fat storage in liver, skeletal muscle, and adipose tissue. Switching from an antipsychotic associated with a high risk for weight gain such as olanzapine to that of lower risk such as aripiprazole may help to reduce weight as well (Correll et al., 2020). Using the lowest effective dose possible when prescribing medications may also help to prevent unnecessary weight gain (Stroup & Gary, 2018).

Post 2

 Considering the patient’s symptoms, what type of antipsychotics would be most appropriate? (Think dopamine). Please explain your choice.

Schizophrenia is thought to be caused by hyperactivity of dopamine in the mesolimbic dopamine pathway.  Antipsychotics that block the D2 receptors of the prefrontal cortex, but spare the other dopamine receptors, would be the best choice for pharmacological therapy.  Atypical antipsychotics are D2 antagonists that can lessen positive symptoms of schizophrenia, while lessening the chance of extrapyramidal symptoms (Stahl, 2013). 

Can substance induced psychosis be treated with antipsychotics?

Substance abuse has been linked to the pleasure/reward center of the brain.  When this system is not functioning inadequately, the patient can display anhedonia and/or drug abuse (Stahl, 2013).  Drug abuse is common in patients with schizophrenia, especially if they are taking antipsychotics that block D2.  D2 receptors can cause a sense of pleasure when activated. When an antipsychotic medication blocks D2, the patient can experience loss of motivation and joy, apathy, and anhedonia (Stahl, 2013).  Avoiding antipsychotics in substance-induced psychosis can help lessen the risk of increased substance use.

Would a LAI (long acting injectable) be appropriate for this patient? Please explain why or why not.

The patient does not have a history of noncompliance with medications and has never taken an antipsychotic.  LAIs can improve treatment adherence, but due to the long action time, I would not recommend that this be the first line of treatment because it is uncertain how he would react to the medication.

Let’s pretend Seroquel was prescribed for this patient. Explain how and why Seroquel can have a different effect at different doses.

Quetiapine (seroquel) has the ability to bind to many neurotransmitter receptors.  Depending on the dosage, it is able to treat psychosis, depression, and insomnia.  The higher the dose, the more D2 receptors are occupied.  At the highest dose, most types of receptors are effected.  At the middle range, it is more selective, only binding to a select amount of receptors that act on depression.  At the lowest dosage, it acts on histamine.  This patient would require a high dosage of quetiapine to treat his psychosis.

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.

Antipsychotic medication use in the elderly with dementia, especially those who reside in a community setting is considered low-value care in the eyes of Medicare.  Although this is frowned upon, the use of this class of medication remains to occur in this setting.  Antipsychotic medications in patients with dementia, without a diagnosis of severe mental illness, has been shown to be dangerous.  They have an increased risk of death and adverse side effects (Nili et al., 2018).  The FDA even issued an off-label warning for the use of antipsychotics in the elderly with dementia and no severe mental illness (Nili et al., 2018).  Nili et al., (2018) found that patients that had both dementia and depression were more likely to be treated with antipsychotic medication, with the highest incidence in the Midwest.