From the Guidelines
For a patient with alcohol-induced psychosis who is non-adherent to their aripiprazole and thiamine regimen due to a lupus flare-up and Ehlers-Danlos Syndrome (EDS), I strongly recommend a multidisciplinary approach to manage their complex condition, prioritizing their psychiatric stability, lupus activity, and EDS symptoms.
Management Strategies
- Consult with both psychiatry and rheumatology to coordinate care, ensuring that the patient's psychiatric and autoimmune conditions are managed concurrently.
- Consider temporarily adjusting the aripiprazole dosage rather than discontinuing it completely, perhaps starting at a lower dose (2.5-5mg daily) and gradually increasing as tolerated, to minimize the risk of psychosis exacerbation 1.
- Thiamine (100mg daily) should be continued if possible, as its deficiency during alcohol withdrawal can lead to serious neurological complications like Wernicke's encephalopathy, and it is recommended for prevention and management of Wernicke encephalopathy 1.
- For the lupus and EDS flare, address pain management with non-sedating options like acetaminophen or low-dose NSAIDs if not contraindicated, to avoid exacerbating the patient's condition.
- Ensure the patient understands that stopping psychiatric medications abruptly can worsen psychosis symptoms, and emphasize the importance of adherence to their medication regimen.
- Physical therapy and gentle movement may help manage EDS symptoms while maintaining medication adherence, and regular follow-ups should monitor both psychiatric symptoms and autoimmune disease activity to balance treatment needs for these complex, interacting conditions.
Key Considerations
- The patient's lupus flare-up and EDS symptoms should be managed in conjunction with their psychiatric condition, to prevent exacerbation of any of these conditions.
- The use of corticosteroids and immunosuppressive therapy may be necessary to manage the patient's lupus activity, and their potential impact on the patient's psychiatric condition should be carefully considered 1.
- The patient's alcohol withdrawal symptoms should be managed with a comprehensive approach, including thiamine supplementation, fluids, and electrolytes, to prevent complications like Wernicke's encephalopathy 1.
From the Research
Management Strategies for Alcohol-Induced Psychosis
Given the complexities of the patient's condition, including a lupus flare-up and Ehlers-Danlos Syndrome (EDS), management strategies should focus on addressing the underlying causes of non-adherence to the aripiprazole (Abilify) and thiamine (Vitamin B1) regimen.
- Consider the potential for Wernicke's encephalopathy, a condition that can mimic neuropsychiatric symptoms in patients with systemic lupus erythematosus (SLE) 2.
- Thiamine deficiency should be considered as a differential diagnosis in SLE patients with neuropsychiatric signs and symptoms, especially when risk factors for thiamine deficiency are present 2, 3.
- Treatment with thiamine has been shown to result in significant improvement in patients with Wernicke's encephalopathy 2, 4, 5, 6, 3.
Addressing Non-Adherence
- The patient's non-adherence to their medication regimen may be due to various factors, including the lupus flare-up and EDS.
- Healthcare providers should work closely with the patient to identify the underlying causes of non-adherence and develop strategies to improve adherence.
- This may involve simplifying the medication regimen, providing education on the importance of adherence, and addressing any concerns or side effects the patient may be experiencing.
Treatment of Wernicke-Korsakoff Syndrome
- Treatment of Wernicke-Korsakoff syndrome is based on the administration of thiamine, which should be started early and parenterally at the appropriate doses 3.
- Thiamine treatment can be effective in improving symptoms, such as cognitive impairment, but early diagnosis and treatment are crucial 5.
- In some cases, treatment with thiamine tetrahydrofurfuryldisulphide (TTFD) may also be considered, as it has been shown to produce a greater increase in erythrocyte transketolase activity than thiamine alone 4.