What suggestions are there for optimizing the medication regimen of a 17-year-old female patient with Attention Deficit Hyperactivity Disorder (ADHD), depression, anxiety, self-harming, and suicide attempts, currently taking Pristiq (desvenlafaxine) 100mg daily, lamotrigine 200mg twice a day (BID), buspirone 15mg BID, Lybalvi (olanzapine and samidorphan) 15mg every morning (QPM), Naltrexone 50mg QPM, trazodone 50mg every night at bedtime (QHS), and Ritalin (methylphenidate) 5mg daily, due to concerns about polypharmacy?

Optimizing Medication Regimen for Adolescent with Multiple Psychiatric Conditions

A medication regimen review with strategic deprescribing is urgently needed for this 17-year-old patient with significant polypharmacy that increases her risk of adverse effects, drug interactions, and potentially worsens her clinical outcomes. 1

Current Medication Analysis

The patient is currently taking 7 medications:

• Pristiq (desvenlafaxine) 100mg daily for depression/anxiety
• Lamotrigine 200mg BID for unknown reason
• Buspirone 15mg BID for anxiety
• Lybalvi (olanzapine/samidorphan) 15mg QPM for unknown reason
• Naltrexone 50mg QPM for self-harming impulses
• Trazodone 50mg QHS for sleep
• Ritalin (methylphenidate) 5mg daily for ADHD

Key Medication Concerns

1. Drug-Drug Interactions:

   • Lybalvi (contains samidorphan, an opioid antagonist) and naltrexone represent duplicate opioid antagonist therapy 2
   • Multiple CNS depressants (Lybalvi, trazodone) increasing sedation risk
   • Multiple serotonergic agents (Pristiq, buspirone, trazodone) increasing serotonin syndrome risk

2. Unclear Indications:

   • Lamotrigine 200mg BID (high dose without clear indication)
   • Lybalvi (olanzapine/samidorphan) without documented psychosis or bipolar I disorder

3. Age-Inappropriate Medications:

   • Lybalvi is only FDA-approved for schizophrenia and bipolar I disorder, neither of which are documented in this patient 3

Recommended Medication Optimization Plan

1. First Priority: Address Duplicate Mechanisms

   • Discontinue naltrexone since Lybalvi already contains samidorphan (opioid antagonist) that can help with impulse control 2

2. Second Priority: Evaluate Antipsychotic Need

   • If no psychosis or bipolar disorder is present, taper and discontinue Lybalvi as it carries significant metabolic risks without clear indication 1
   • If mood stabilization is needed, rely on the lamotrigine which is already at a therapeutic dose

3. Third Priority: Simplify Anxiety Treatment

   • Consolidate to one primary anxiolytic - either:
     • Maintain Pristiq at current dose and discontinue buspirone, OR
     • If buspirone is particularly effective, maintain it and reduce Pristiq dose to 50mg daily 3

4. Fourth Priority: Address Sleep

   • Consider discontinuing trazodone if sleep improves after reducing other sedating medications
   • Implement non-pharmacological sleep hygiene interventions

5. Fifth Priority: Clarify Lamotrigine Use

   • Evaluate lamotrigine indication - if for mood stabilization, continue at current dose
   • If no clear benefit is documented, consider gradual dose reduction to 200mg daily (standard dose)

6. Maintain ADHD Treatment

   • Continue Ritalin 5mg daily as this is a low dose appropriate for ADHD management

Implementation Strategy

1. Sequenced Approach:

   • Make one medication change at a time with 2-3 weeks between changes
   • Start with discontinuing naltrexone (redundant with samidorphan in Lybalvi)
   • Next address the Lybalvi if no clear indication exists

2. Monitoring Parameters:

   • Assess for withdrawal symptoms with each medication change
   • Monitor for changes in mood, anxiety, sleep, and self-harming behaviors
   • Document response to each medication adjustment

3. Patient Engagement:

   • Explain the rationale for medication changes to the patient and family
   • Set clear expectations about the timeline for seeing benefits
   • Emphasize that reducing medications often improves outcomes by reducing side effects

Cautions and Considerations

• Withdrawal Risk: Avoid abrupt discontinuation of any psychotropic medication; all changes should be gradual 1
• Suicide Risk: Maintain close monitoring during medication changes given history of suicide attempts
• Developmental Context: Consider that adolescent brain is still developing and minimize exposure to medications with long-term metabolic effects 1
• Documentation: Clearly document the rationale for each medication, target symptoms, and response to justify the regimen

This approach systematically addresses polypharmacy concerns while maintaining treatment for the patient's core psychiatric conditions, with the goal of improving safety, adherence, and overall outcomes.