What would you recommend for a patient with schizophrenia who is on Latuda (lurasidone) 80 mg once a day in the morning and Seroquel (quetiapine) extended release 200 mg in the evening who has now begun experiencing hallucinations?

From the Guidelines

For a patient with schizophrenia experiencing hallucinations despite being on Latuda 80 mg in the morning and Seroquel XR 200 mg in the evening, I would recommend consulting with their psychiatrist about increasing the Seroquel XR dose to 300-400 mg at bedtime while maintaining the current Latuda dose. The timing of Latuda should also be adjusted to be taken with a meal of at least 350 calories to improve absorption and efficacy, as suggested by the general principles of pharmacotherapy in schizophrenia 1. If hallucinations persist after these adjustments, adding a different antipsychotic like aripiprazole 5-10 mg daily could be considered, taking into account the potential benefits and risks of antipsychotic polypharmacy 1. The emergence of hallucinations suggests the current regimen is providing inadequate dopamine D2 receptor blockade. Quetiapine has dose-dependent receptor binding, with higher doses needed for antipsychotic effects, while ensuring it's taken at night helps minimize daytime sedation. Regular monitoring for metabolic side effects (weight, blood glucose, lipids) and extrapyramidal symptoms is essential with any antipsychotic adjustment, as emphasized by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. The patient should also be assessed for medication adherence, substance use, and stressors that might be contributing to symptom breakthrough, considering that non-adherence is a significant problem in the treatment of schizophrenia and is often under-recognized 1.

Some key points to consider in the management of this patient include:

• Ensuring adequate treatment duration and dosage before considering treatment resistance
• Assessing and addressing potential factors contributing to symptom breakthrough, such as medication non-adherence or substance use
• Carefully evaluating the risks and benefits of antipsychotic polypharmacy, considering the potential for increased side effects and the need for regular monitoring
• Prioritizing patient-centered care and involving the patient in treatment decisions, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1.

Overall, the goal of treatment should be to minimize symptoms, improve quality of life, and reduce the risk of morbidity and mortality associated with schizophrenia, while also considering the potential risks and benefits of different treatment approaches.

From the FDA Drug Label

2.8 Switching from Antipsychotics There are no systematically collected data to specifically address switching patients with schizophrenia from antipsychotics to quetiapine fumarate tablets, or concerning concomitant administration with antipsychotics

The patient is already on Seroquel (quetiapine) and Latuda (lurasidone), and has begun experiencing hallucinations.

• The Seroquel label does not provide guidance on managing hallucinations in patients already on the medication.
• The label also does not provide information on adjusting the dose of Seroquel in response to hallucinations.
• It is recommended to consult with a healthcare professional to determine the best course of action, as the label does not provide sufficient information to make a decision 2.

From the Research

Patient's Current Medication Regimen

The patient is currently taking Latuda (lurasidone) 80 mg once a day in the morning and Seroquel (quetiapine) extended release 200 mg in the evening for schizophrenia.

Hallucinations as a Symptom

• Hallucinations are a common symptom of schizophrenia, and the patient has begun experiencing them despite being on medication.
• According to 3, antipsychotic medication is the first treatment option for hallucinations in schizophrenia, and it can induce a rapid decrease in severity.

Treatment Options for Hallucinations

• The patient is already taking two antipsychotic medications, Latuda and Seroquel, which are both effective against hallucinations 3.
• If the current medication regimen is not providing adequate improvement, it may be necessary to switch or adjust the medication after 2-4 weeks of treatment 3.
• Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication to reduce the emotional distress associated with auditory hallucinations 3.
• Transcranial magnetic stimulation (TMS) is also a potentially useful treatment method for auditory hallucinations, but it should be used in combination with antipsychotic medication 3.

Lurasidone (Latuda) Efficacy and Safety

• Lurasidone has been shown to be efficacious and tolerable in the treatment of schizophrenia, with a recommended dose of 40-80 mg/day 4, 5.
• The patient is currently taking 80 mg/day, which is within the recommended dose range.
• Lurasidone has a favorable metabolic profile and is associated with minimal weight gain and no clinically meaningful alterations in glucose, lipids, prolactin, or the ECG QT interval 5, 6.

Considerations for Treatment Adjustment

• The patient's current medication regimen may need to be adjusted or switched if the hallucinations persist or worsen.
• The choice of antipsychotic medication should be based on the patient's individual needs, tolerability, and comorbidities 7.
• Lurasidone has been shown to be effective in delaying time to relapse in persons with schizophrenia, and it may be a good option for long-term treatment 7.