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Haloperidol/olanzapine/paliperidone Mania, lack of efficacy and metabolic-side effects: case report

A man in his 20s [exact age at reaction onset not stated] developed mania during treatment with paliperidone for schizophrenia. He additionally exhibited lack of efficacy during treatment with haloperidol and experienced metabolic side effects during treatment with olanzapine [not all routes, durations of treatments to reactions onsets and outcomes stated]. The man was diagnosed with paranoid schizophrenia 6 years ago. Initially, he presented with referential, persecutory, and nihilistic delusions. In addition to that, he experienced social and emotional withdrawal. He started with oral haloperidol 20mg, but no improvement was seen in his psychotic symptoms. Therefore, haloperidol was switched to olanzapine 15 mg/day. During follow-up visits, the dose of olanzapine was reduced to 10 mg/day due to metabolic side effects of olanzapine. He was in 2 years remission. However, due to poor treatment compliance with olanzapine, worsening of his symptoms was observed. He was hospitalised with an increase in the dose of olanzapine. His psychotic symptoms reduced with that treatment regime and he was undergoing remission while receiving the olanzapine until 2018. However, worsening of his psychotic symptoms occurred, once again due to poor medication compliance, which led to his involuntary hospitalisation. He was recommended on long-acting paliperidone due to poor compliance to oral medications. He was commenced on treatment with oral paliperidone 6 mg/day and it was planned to provide treatment with paliperidone [paliperidone palmitate] injection on 10th day of treatment with oral paliperidone. On day 15 after the initial injection of paliperidone, oral paliperidone was discontinued. For the first treatment, the initial dose was 150mg, which was then decreased to 100mg, finally, the maintenance dose of 100mg was decided for the first month. In view of the ongoing symptoms after the maintenance dose of 100mg, the next injection of paliperidone was set at 150mg, with the addition of oral paliperidone 6 mg/day to the treatment regime until the next injection. He started to experience logorrhoea, euphoria, decreased sleep requirements, psychomotor agitation and grandiosity after the one week of the treatment. The score obtained on the Young Mania Rating Scale (YMRS) was 30. The man was prescribed clonazepam to control the manic symptoms. His sleep improved with a decrease in mobility; however, he continued to experience grandiosity. Sodium valproate was initiated and the dose was gradually increased. His YRMS decreased to 26, 3 weeks after addition of sodium valproate. He discontinued the paliperidone injections and oral paliperidone, and started receiving clozapine. His manic symptoms decreased by the third week of clozapine treatment, and his YRMS improved to 16. The dose of clozapine was gradually increased and his last YMRS score obtained was 6 before discharge from the hospital. He was continued treatment with clozapin