Examine this Case Study and make three decisions concerning the medication to prescribe to this patient

Case study of a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her when she was 9 years old). She presents following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month. Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control,” which resulted in his calling the police and her subsequent admission to an inpatient psych unit. During today’s assessment, she appears quite calm and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She says she knows this because the television is telling her so.She currently weighs 140 lbs., and she is 5’ 5.
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.
A review of her hospital records shows that she received a medical workup from physician, who reported her to be in overall good health. Lab studies were all within normal limits. Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.
MENTAL STATUS EXAM
The client is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and, at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect is constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.
You administer the PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Diagnosis: Schizophrenia, paranoid type
DICISION POINT ONE
Select what you should do:
1-Start Zyprexa(Olanzapine) 10mg orally at bedtime
2-Start Invega Sustenna 234mg IM X1 followed by 156mg IM on day 4 and monthly there after.
3-Start Abilify(Aripiprazole) 10mg orally at bedtime.
Examine this Case Study and make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
QUESTIONS:
1-Introduction to the case (1 page)
•Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
2-Decision #1 (1 page)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
3-Decision #2 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
4-Decision #3 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
5-Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Decision #1

The decision was made to start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day four and monthly thereafter. This medication was selected because it blocks dopamine two receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms, blocks serotonin 2A receptors, causing the enhancement of dopamine release in specific brain regions and thus reducing motor side effects and possibly improving cognitive and affective symptoms, and serotonin seven antagonist properties may contribute to antidepressant actions. Psychotic symptoms can improve within one week, but it may take several weeks for full effect on behavior and cognition. Classically recommended to wait at least 4–6 weeks to determine drug efficacy, but in practice, some patients may require up to 16–20 weeks to show a good response, especially cognitive symptoms (Stahl, S., 2014b). My goal was to reduce the patient’s psychosis and delusions of persecution. When the patient returned, her symptoms improved, with her only complaint being irritated at the injection site, a common complaint of IM injectable medications. The pharmaceutical company developed the medication to dissolve slowly after deep intramuscular injection before being hydrolyzed to paliperidone and absorbed into the systemic circulation. The pharmacokinetic (PK) profile of the INVEGA SUSTENNA® formulation is biphasic. Comprised of an initial relatively fast zero-order input, this allows rapid attainment of therapeutic concentrations without oral supplementation; and a subsequently maintained second-stage, first-order input, allowing for once-monthly administration (Procyshyn, R., Lamoure, J., Katzman, M., Skinner, P., & Sherman, S., 2019). Having the advantage of not needing to worry if the patient receives the correct dose in the face of her significant psychiatric instability, this medication is the best choice. With Zyprexa and Abilify as alternate options, both were oral. Given how ill the patient was, neither of those medications would be in her best interest for compliance reasons. The best choice was the IM Invega Sustenna, which is why it was selected for this patient.

 

Decision #2

I chose to continue the same dose but instead changing the location of the site to the deltoid. By changing the site, my goal was to decrease soreness in the patient’s IM site. When the patient returned in four weeks for a follow-up, the result was the patient continued to have improved, with a 50% reduction in symptoms. She reported an additional 2.5 pounds of weight gain and was concerned about this. Considering the pharmacokinetics, Paliperidone palmitate is a benzoxazole derivative that is hydrolyzed to the active moiety, paliperidone, and absorbed into the systemic circulation. The palmitate ester of paliperidone is an aqueous suspension that utilizes nanoparticle technology. The resulting increased surface area leads to a rapid release of medication and a relatively short time to steady-state. Following an injection, active paliperidone plasma levels have been detected from day 1; therefore, coadministration with oral paliperidone on the initiation of therapy is not required. Following the intramuscular administration of single doses in the deltoid muscle, on average, a 28% higher peak concentration is observed compared with injection in the gluteal muscle (U.S. National Library of Medicine, 2020). At this point, adding additional medications would not be appropriate. Alternate options included adding Haldol and Abilify to the Invega Sustenna. Given that Invega had positive results, other than the injection site’s discomfort, the best choice was to remain on the same dose and change the injection locations.

 

Decision #3

 

I chose to remain on the same dose of Invega Sustenna due to its efficacy and the fact that the patient has been on the medication for less than six months. A referral to a dietician was made for the patient to counsel her on proper nutritional needs and exercise regimen now that her negative symptoms have subsided. The patient is to follow up in one month. If she is still having untoward symptoms after six months, Abilify Maintena will be considered for the patient at that time. Any other medications would be unnecessary at this time.

Legal and ethical considerations for the patient include that her negative symptoms of schizophrenia affected her quality of life and possibly her safety. With the immediate need to protect the patient and ensure she received her medication in the proper doses, the injection mediation was best. Having her husband as an advocate also helped ensure the patient’s success.

 

 

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