Immediately after Mr. Z’s discharge from the cardiology unit, we readmit him to inpatient psychiatry. His parents and case manager say he is again becoming preoccupied with his brief college relationship. He has been off clozapine for 5 days.
The authors’ observations
The American Psychiatric Association27 (see http://www.psych.org/psych_pract/treatg/pg/SchizPG-Complete-Feb04.pdf) recommends maximizing 1 medication for at least 2 to 4 weeks to assess schizophrenia symptom response and urges clinicians to consider adverse effects, medical comorbidities, and patient preference before continuing the medication.
These recommendations highlight the challenges of treating medication-resistant schizophrenia. Relapse is common after a serious reaction to clozapine, and combining 2 or more other antipsychotics could lead to significantly greater side effects. A time-limited trial with an antipsychotic and an adjunctive agent might be attempted while carefully weighing the combination’s risks and benefits.27
Clozapine reduced Mr. Z’s psychosis, but rechallenge would likely cause his potentially fatal cardiomyopathy to re-emerge. His sensitivity to adverse antipsychotic effects discourages polypharmacy and further complicates our decision.
‘These tests are needed’:
How to convince other specialists
How to convince other specialists
Many physicians are reluctant to pursue additional tests or procedures—and risk a confrontation with a consultant, insurer, or ER physician—especially when the risk of abnormality is extremely low. Advocating for cardiac workup in patients with vague symptoms is challenging, particularly if the suspected side effect is rare.
Taking the path of least resistance can increase the risk of a serious—albeit rare—adverse event. Failure to test could prolong a potentially harmful treatment, and the test results—even if negative—could be critical to planning care.
Calmly but firmly spell out the risks of missing a suspected cardiac problem (death, proceeding with potentially harmful treatment). Tell the ER manager or consultant, “I realize this is a very rare side effect, but not catching it could be life-threatening.”
Be circumspect when pleading your case—an overaggressive approach might cause the ER doctor to “dig in his heels” and reject your request. Use a medically focused response such as, “This is a known complication of this medicine with this common time course and presentation.”
TREATMENT: Another trial
We start olanzapine, 5 mg/d, and titrate to 20 mg/d over 1 week. We add sustained-release bupropion, 200 mg bid, for associated dysphoria.
Mr. Z’s symptoms and paranoia gradually decline, and he tolerates off-unit passes with friends and family before discharge. Staff works closely with him to develop cognitive-behavioral strategies to manage residual paranoia and hallucinations, such as assessing evidence for his delusional beliefs and developing tools to distract him from remaining “voices.” He reports no cardiac symptoms and continues taking enalapril, 2.5 mg bid.
We discharge Mr. Z after 1 week, at which point he shows no suicidal or homicidal thoughts. Follow-up echocardiogram 2 weeks later shows ejection fraction has improved to 60%, suggesting absence of cardiomyopathy.
Related resource
- Clozapine safety information.
www.clozaril.com/.
- Bupropion • Wellbutrin
- Chlorpromazine • Thorazine
- Clozapine • Clozaril
- Enalapril • Vasotec
- Fluphenazine • Prolixin, Permitil
- Haloperidol • Haldol
- Lithium • Eskalith, others
- Olanzapine • Zyprexa
- Propranolol • Inderal
- Quetiapine • Seroquel
- Risperidone • Risperdal
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.