Abstract

Abstract

Abstract

Due to the well-defined risks of abrupt discontinuation of certain psychiatric medications, such as withdrawal and worsening symptoms, guideline recommendations describe evidence-based strategies for tapering some psychiatric medications, such as antidepressants. Despite widespread use of acetylcholinesterase inhibitor (ACHEI) therapy in the management of dementia, guideline recommendations for discontinuation of these therapies are very inconsistent. Specifically, studies and evidence-based recommendations for discontinuing ACHEIs in patients with dementia with Lewy bodies (DLB) are severely lacking. This deficit is problematic in that emerging reports suggest several adverse outcomes, such as worsening cognition and behavioral symptoms, are associated with abrupt switching and discontinuation of ACHEI therapy in this population. A case of rapid cognitive and functional decline following both abrupt switch and discontinuation of donepezil in a patient diagnosed with DLB is presented. A literature review of outcomes following changes in ACHEI therapy in DLB is also presented.

Abstract

Angioedema is characterized by marked swelling of the subcutaneous or submucosal tissue and may affect various parts of the body, including the face, mouth, and extremities. Angioedema has specifically been associated with the use of several antipsychotic agents, including clozapine, olanzapine, iloperidone, haloperidol, quetiapine, paliperidone, ziprasidone, risperidone, and chlorpromazine. A 67-year-old African American male with a past medical history significant for hypertension, coronary artery disease requiring stent placement, mitral insufficiency, hyperlipidemia, tobacco use disorder, and schizophrenia presented with altered mental status and disorientation in the setting of clozapine nonadherence, which prompted acute hospitalization for clozapine reinitiation. During clozapine titration, the patient developed edema, erythema, and pruritus on his face and arms along with lip swelling characteristic of angioedema. Upon discontinuation of clozapine, the patient was trialed on several other antipsychotic medications to help manage acute psychosis and subsequently developed angioedema symptoms with trials of both olanzapine and quetiapine. Following these 3 distinct events of angioedema, the clinical decision was made to no longer trial atypical antipsychotics for the patient, and loxapine was cautiously initiated. The patient responded well to loxapine and continued to tolerate loxapine therapy for years. This case report identifies angioedema cross-reaction linked with 3 second-generation antipsychotics. Given the potentially life-threatening nature of angioedema, awareness of recurrent angioedema should be undertaken when trialing antipsychotics following an episode of angioedema correlated to antipsychotic use, particularly when trialing antipsychotics from the same generation and with similar chemical structures.

Abstract

Long-term use of lithium is a known risk factor for hypercalcemia often due to involvement of the parathyroid gland. Because of this, lithium-induced hypercalcemia typically occurs simultaneously with abnormal parathyroid hormone concentrations. This case report describes a 54-year-old white male who has received lithium therapy intermittently for more than 10 years. During admission to an acute inpatient psychiatric unit, the patient experienced hypercalcemia with normal parathyroid hormone concentrations and no other discernible cause. Based on the Naranjo algorithm, lithium was determined to be the probable cause of hypercalcemia. Current literature suggests that lithium-induced hypercalcemia occurs secondary to hyperparathyroidism; however, this case may provide evidence of another, unidentified cause.

Abstract

Akathisia is a relatively common adverse effect that may emerge during treatment with antipsychotics and other medication classes. We present a case of akathisia that may have been induced by the abrupt discontinuation of varenicline and review existing literature related to this phenomenon. A 46-year-old female with a past psychiatric history of bipolar disorder and borderline personality disorder was admitted to the acute psychiatric services department for suicidal ideation after 3 weeks of a new course of varenicline. This was prescribed for smoking cessation and titrated to 1 mg twice daily. Upon admission, the varenicline was discontinued. Roughly 3 days later, the patient began to complain of akathisia. The patient had experienced akathisia previously while taking antipsychotics for her bipolar disorder and was able to recognize its emergence. As the akathisia worsened, propranolol 10 mg 3 times daily was ordered and was effective in relieving her symptoms. A PubMed search using the terms varenicline, akathisia, withdrawal, and discontinuation was conducted. No literature of this phenomenon was found; however, reports of other extrapyramidal symptoms were noted. Considering the timing of varenicline's discontinuation and its mechanism, a pharmacological link between its use and akathisia is possible. Akathisia is a severely uncomfortable sequela of medications that may produce severe outcomes, such as suicidal ideation. In this case, it is possible that the discontinuation of varenicline after 3 weeks of therapy led to akathisia, which was successfully treated with propranolol.

Abstract

One mechanism involved in the pathophysiology of posttraumatic stress disorder (PTSD) is increased noradrenergic stimulation. Prazosin, a commonly utilized treatment for PTSD nightmares, works to block noradrenergic stimulation of the alpha-1 adrenoreceptor. Dual antagonism of this receptor would be expected to increase risk of adverse effects. Carvedilol has both alpha-1 adrenergic and nonselective beta-adrenoreceptor antagonist activity. To our knowledge, there is no clinical guidance on use of prazosin in patients concomitantly prescribed carvedilol for hypertension. This case describes the successful titration of prazosin for PTSD symptoms in a 49-year-old male concurrently prescribed carvedilol for hypertension. This patient had a previous unsuccessful prazosin trial due to adverse effects. His second trial of prazosin was efficacious and well tolerated using individualized titration with close monitoring by mental health clinical pharmacy specialists in the pharmacist-managed prazosin titration clinic. This case details the importance of utilizing caution and close follow-up in prazosin dose titration in patients prescribed concomitant alpha-1 antagonists. This appears to be the first case report describing the successful dose titration of prazosin for PTSD in a patient on a concurrent alpha-1 antagonist antihypertensive agent.

Abstract

Drug rash with eosinophilia and systemic symptoms (DRESS) is a serious adverse drug reaction with a high mortality rate. Discontinuation of the causative agent is the primary treatment. History of DRESS may put patients at higher risk of future episodes; however, cross-reactivity between various medications is not well established. An 18-year-old African American male with a history of bipolar I disorder with psychotic features was admitted for mania on his home dose of divalproex. After 1 week, olanzapine was added for refractory symptoms, but due to elevated creatinine phosphokinase (CPK), it was subsequently discontinued, and he was started on lorazepam and lithium. One week later, the patient was transferred to the intensive care unit with elevated CPK, fever, thrombocytopenia, elevated serum creatinine, hypotension, diarrhea, mild rigidity, bilateral inducible ankle clonus, and a rash. All medications were discontinued except for lorazepam. The skin pathology report was consistent with a drug eruption, and he was started on prednisone. Given continued symptoms of mania, carbamazepine was initiated. After clinical and laboratory improvement, the patient was discharged on hospital day 59 with instructions to continue carbamazepine and lorazepam. A MEDLINE search revealed no published case reports of the successful use of carbamazepine in a patient with a history of DRESS. Information regarding cross-reactivity between medications is limited primarily to aromatic antiepileptics. In our case report, carbamazepine was successfully used in a patient with a recent episode of DRESS during olanzapine, lithium, and valproate use.