Antipsychotics
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Tardive dyskinesia and its worsening: case report An adult woman [exact age not stated] developed tardive dyskinesia (TD) following treatment with cariprazine, paliperidone, quetiapine and risperidone, which worsened following use of ziprasidone and aripiprazole for bipolar I disorder [not all routes and dosages stated; time to reaction onset not stated]. The woman was transferred from an alternate facility (at the age of 38 years) for percutaneous endoscopic gastrostomy (PEG) tube placement because of poor nutritional status secondary to persistent orofacial dyskinesias. She had a history of bipolar I disorder. Also, she had TD related to atypical antipsychotic use. Due to her geographic healthcare disparities and complexities of her comorbid conditions, she was often referred at numerous tertiary care facilities for the treatment. Hence, she lacked adequate psychiatric access for appropriate treatment of her bipolar I disorder. Previously, she showed adequate nutrition after gastric bypass prior to the development of TD symptoms, and she had been monitored by a bariatric nutritionist. Due to the lingual protrusions, she had lost ability to tolerate oral intake including oral fluids and medications leading to decrease in serum albumin and profound hypernatraemia. It was reported that she had been trialed on various atypical antipsychotics for bipolar I disorder with auditory hallucinations between 2010–2016 including risperidone, IM paliperidone monthly, oral quetiapine 400mg twice a day (September 2016–October 2016), oral cariprazine 1.5mg/day(September–October 2016) and oral ziprasidone 20mg twice a day (9 December–15 December 2018). Due to her treatment at various healthcare facilities detailed medication history was difficult. Based on her chart review, it was suspected that she might started developing TD symptoms [exact age at reaction onset not stated] following catheter embolisation for the treatment of a cerebellar arteriovenous malformation related to superior cerebellar haemorrhage and subarachnoid haemorrhage in the quadrigeminal plate in November 2018. As she was unable to effectively communicate, history taking was difficult. Her family member reported that the symptoms started after the use of cariprazine, which later worsened after taking ziprasidone. Upon presentation (current presentation), she received oral aripiprazole 10 mg/day on the basis of medication reconciliation. She was unable to communicate at admission. Physical examination revealed truncal tremors, extensive akathisia, orofacial dyskinesia and lingual protrusions, which worsened her oral challenge and speech. Due to akathisia she was unable to write, perform meaningful commands or point to responses on a communication board. Laboratory tests revealed mild anaemia and serum albumin concentration of 2.6 g/dL. Fiberoptic endoscopic evaluation of swallowing (FEES) showed aspiration with severely impaired swallowing because of orofacial dyskinesia. For nutrition, a temporary enteral access was started, then PEG was performed. Despit
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