How should the medication regimen be optimized for a patient with hyperthyroidism, aggression, and EPS?

Medication Optimization for Hyperthyroidism with Aggression and EPS

The medication regimen should be optimized by discontinuing atomoxetine, starting beta-blocker therapy (propranolol 20-40mg TID), continuing benztropine for EPS, reducing quetiapine to once daily dosing at night, and considering gradual tapering of polypharmacy.

Assessment of Current Medication Issues

The patient presents with three key issues that need to be addressed:

1. Hyperthyroidism - Requires specific management as it can worsen psychiatric symptoms and EPS
2. Extrapyramidal symptoms (EPS) - Currently being treated with benztropine
3. Aggression - Multiple medications being used that may contribute to or treat this symptom

Current Medication Analysis

• Problematic medications:

  • Atomoxetine - Should be discontinued as it can worsen hyperthyroidism symptoms through adrenergic stimulation 1
  • Multiple antipsychotics/sedatives - Polypharmacy increases risk of side effects
  • Ingreeza (atomoxetine by another name) - Should not be started for the same reasons

• Potentially beneficial medications:

  • Benztropine - Appropriate for EPS management
  • Quetiapine - Can help with aggression but current split dosing may be problematic
  • Valproate (Depakote) - Helpful for mood stabilization

Step-by-Step Optimization Plan

1. Address Hyperthyroidism First

• ADD beta-blocker therapy - Propranolol 20-40mg TID is the first-line treatment for hyperthyroidism symptoms including agitation and cardiovascular manifestations 2, 3
• STOP Atomoxetine and do NOT start Ingreeza (same medication) as stimulants can worsen hyperthyroidism symptoms and increase adrenergic tone 1
• Refer for endocrinology consultation to initiate anti-thyroid medications (not specified in current regimen)

2. Optimize EPS Management

• CONTINUE Benztropine 1mg PO + 2mg qHS - Appropriate for managing EPS 4
• SIMPLIFY antipsychotic regimen - Consolidate Quetiapine dosing to once daily at night (100-125mg qHS) to reduce daytime sedation while maintaining efficacy 5

3. Address Aggression

• CONTINUE Valproate ER 500mg PO BID - Effective mood stabilizer for aggression
• CONTINUE Sertraline 150mg PO qHS - May help with irritability/aggression
• CONSIDER REDUCING Gabapentin from 900mg TID to 600mg TID if sedation is an issue
• MAINTAIN Prazosin 1mg PO qHS for nighttime symptoms

4. Reduce Polypharmacy

• CONSOLIDATE PRN medications:
  • Maintain clonidine 0.1mg PRN for breakthrough agitation
  • Consider tapering hydroxyzine as it may contribute to anticholinergic burden with benztropine

Rationale for Changes

1. Beta-blockers are first-line for hyperthyroidism symptoms

   • Propranolol specifically addresses the adrenergic hyperactivity that causes many psychiatric manifestations of hyperthyroidism 2, 3
   • Helps control tachycardia, tremor, anxiety, and agitation associated with hyperthyroidism 6

2. Atomoxetine/Ingreeza contraindication

   • Stimulant-like effects can worsen hyperthyroidism symptoms 1
   • May increase risk of cardiovascular complications in hyperthyroid patients

3. Antipsychotic simplification

   • Once-daily dosing of quetiapine at night (100-125mg) provides better tolerability while maintaining efficacy 5
   • Morning doses of quetiapine (25mg) contribute to daytime sedation without significant benefit for aggression

4. Benztropine continuation

   • Appropriate for managing EPS symptoms 4
   • The current dosing regimen is standard practice

Monitoring Recommendations

• Weekly monitoring of thyroid function tests until stabilized
• Regular assessment of EPS symptoms using standardized scales
• Vital sign monitoring with focus on heart rate and blood pressure
• Evaluate for signs of thyroid storm which requires immediate intervention

Common Pitfalls to Avoid

• Overlooking hyperthyroidism as a primary driver of psychiatric symptoms
• Adding more medications before optimizing current regimen
• Continuing stimulant medications in patients with hyperthyroidism
• Excessive anticholinergic burden from multiple medications with anticholinergic properties (benztropine, hydroxyzine, quetiapine)

By addressing the hyperthyroidism first with beta-blocker therapy, discontinuing stimulants, and simplifying the antipsychotic regimen, this approach targets the underlying medical condition while optimizing psychiatric symptom management.