Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.
Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”
She weights 110 lbs. and is 5’ 5”
SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.
Genetic testing reveals that she is positive for CYP2D6*10 allele.
Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.
MENTAL STATUS EXAM
The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.
The Young Mania Rating Scale (YMRS) score is 22
RESOURCES
§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6
Lithium 300mg orally twice a day
Risperdal 1mg orally bid
Seroquel XR 100mg orally at bedtime
• Decision #1
o Which decision did I select? Lithium 300mg orally twice a day
o Why did I select this decision? Patient was previously on Lithium. Support your response with evidence and references to the Learning Resources.
o What did I hope to achieve by making this decision? Decrease in symptoms of mania. Support your response with evidence and references to the Learning Resources.
o Was the outcome of the decision expected? Client returns to clinic in four weeks. Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”. Today’s presentation is similar to the first day I met her
• Decision #2
o Why did I select this decision? Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology. Support your response with evidence and references to the Learning Resources.
o What did I hope to achieve by making this decision? Patient understanding the risks vs benefits from starting and stopping Lithium abruptly. Support your response with evidence and references to the Learning Resources.
o Was the outcome of the decision expected? Client returns to clinic in four weeks. Client states that the drug makes her nauseated and gives her diarrhea. Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again
• Decision #3
o Why did I select this decision? Change Lithium to sustained release preparation at same dose and frequency. Support your response with evidence and references to the Learning Resources.
o What did I hope to achieve by making this decision? Eliminate diarrhea and nausea. Support your response with evidence and references to the Learning Resources.
o Was the outcome of the decision expected? Student Guidance Response: In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.
Resources
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press. Chapter 4 & 5
Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3
Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6
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