Should a 75-year-old female with psychosis, currently on Fluphenazine (Fluphenazine) 1 milligram twice daily, have her dose increased or be switched to an atypical antipsychotic?

From the Guidelines

For a 75-year-old female experiencing psychosis while on Fluphenazine 1 mg twice daily, switching to an atypical antipsychotic would be preferable to increasing the Fluphenazine dose, as this approach aligns with the American Psychiatric Association's practice guideline for the treatment of patients with schizophrenia, which emphasizes the importance of minimizing morbidity and mortality associated with antipsychotic therapy 1.

Key Considerations

• Atypical antipsychotics are generally more appropriate for elderly patients due to their reduced risk of extrapyramidal side effects and tardive dyskinesia compared to typical antipsychotics like Fluphenazine.
• The APA recommends (1A) that patients with schizophrenia be treated with an antipsychotic medication and monitored for effectiveness and side effects 1.
• Consider transitioning to quetiapine (starting at 25 mg at bedtime, gradually increasing to 100-200 mg daily as tolerated) or risperidone (starting at 0.25-0.5 mg daily, gradually increasing to 1-2 mg daily if needed).

Implementation and Monitoring

• When switching, overlap medications briefly while tapering off Fluphenazine over 1-2 weeks to prevent withdrawal symptoms.
• Monitor for orthostatic hypotension, sedation, metabolic changes, and QTc prolongation.
• Regular follow-up within 1-2 weeks of medication changes is essential to assess response and side effects, with particular attention to fall risk and cognitive function in this elderly patient.

Rationale

• The APA suggests (2C) options for managing side effects such as parkinsonism, akathisia, and tardive dyskinesia associated with antipsychotic therapy, including lowering the dosage, switching to another antipsychotic, or adding specific medications 1.
• The goal is to enhance the treatment of schizophrenia, reducing mortality, morbidity, and significant psychosocial and health consequences of this condition 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Depending on the severity and duration of symptoms, total daily dosage for adult psychotic patients may range initially from 2. 5 mg to 10 mg and should be divided and given at 6 to 8 hour intervals. For geriatric patients, the suggested starting dose is 1 mg to 2.5 mg daily, adjusted according to the response of the patient.

The patient is currently taking 2 milligrams daily (1 milligram twice daily), which is within the suggested starting dose for geriatric patients.

• The current dose is 2 mg daily.
• The suggested starting dose for geriatric patients is 1 mg to 2.5 mg daily. Since the patient's current dose is already at the higher end of the suggested starting dose for geriatric patients, and there is no information that directly supports increasing the dose or switching to an atypical antipsychotic, no change in medication or dose is recommended 2.

From the Research

Dose Increase or Switch to Atypical Antipsychotic

• The patient is currently taking Fluphenazine (Fluphenazine) 1 milligram twice daily for psychosis 3.
• According to the study on emergency treatment of psychotic symptoms, if the patient is currently taking antipsychotic medication when the emergency situation occurs, it is usually adequate to increase the dose of antipsychotic drug 3.
• However, the study on using antipsychotic agents in older patients suggests that for older patients with psychosis, atypical antipsychotics such as risperidone, quetiapine, and olanzapine may be preferred due to their more favorable side effect profiles 4.
• A study comparing fluphenazine with atypical antipsychotics found no significant differences in clinical response and mental state between fluphenazine and amisulpride, risperidone, quetiapine, or olanzapine, but noted that atypical antipsychotics may have a lower risk of extrapyramidal symptoms 5.
• Another study found that atypical antipsychotics were associated with fewer extrapyramidal side effects than typical antipsychotics, and were an excellent choice as add-on therapy to mood stabilizers for the treatment of patients with mania 6.

Considerations for Switching to Atypical Antipsychotic

• The patient's age and medical history should be taken into consideration when deciding whether to switch to an atypical antipsychotic 4.
• Atypical antipsychotics may have a lower risk of extrapyramidal symptoms, but can still cause these symptoms in some patients 7.
• The study on atypical presentations of atypical antipsychotics highlights the importance of monitoring patients for extrapyramidal symptoms, even when using atypical antipsychotics 7.
• The decision to switch to an atypical antipsychotic should be based on the individual patient's needs and medical history, and should be made in consultation with a healthcare professional 4, 3, 5, 7, 6.