What medication should be reduced first in a 65-year-old male patient with dementia and behavioral disturbances, currently on Geodon (ziprasidone) 40mg QHS (every night), clonazepam 0.5mg BID (twice a day), Nuedexta (dextromethourphan and quinidine) 20-10mg BID, memantine 10mg BID, Depakote (valproate) Sprinkles 500mg BID, and melatonin 3mg QHS, with thrombocytopenia and hypernatremia?

From the Guidelines

I strongly recommend reducing Depakote Sprinkles first due to the patient's low platelet count of 96, as valproic acid is known to cause thrombocytopenia, as noted in the guidelines for managing Alzheimer's disease 1. The patient's current medication regimen includes multiple CNS-active medications, and any changes should be made gradually to avoid withdrawal symptoms or behavioral decompensation. Consider decreasing the dose from 500mg BID to 250mg BID initially, with close monitoring of platelet levels, as suggested by the guidelines for managing behavior and mood disorders in Alzheimer's disease, which recommend monitoring platelets, prothrombin time, and partial thromboplastin time as indicated for divalproex sodium (Depakote) 1. Key points to consider when reducing Depakote Sprinkles include:

• Close monitoring of platelet levels to assess the effect of the dose reduction
• Gradual reduction of the dose to avoid withdrawal symptoms or behavioral decompensation
• Reassessment of platelet counts within 1-2 weeks after adjusting the Depakote dose
• Further reduction or discontinuation of Depakote may be necessary if platelets don't improve
• Ensuring adequate hydration to address the hypernatremia, which is less likely to be directly medication-related and more likely due to dehydration or other factors. The guidelines for managing Alzheimer's disease also recommend using low dosages of antipsychotic agents, such as risperidone, olanzapine, and quetiapine, and avoiding typical antipsychotic agents due to their significant side effects 1. However, in this case, the primary concern is the patient's low platelet count, and reducing Depakote Sprinkles is the most appropriate initial step.

From the FDA Drug Label

Ziprasidone capsules are not approved for the treatment of patients with dementia-related psychosis Elderly patients with a diagnosis of psychosis related to dementia treated with antipsychotics are at an increased risk of death when compared to patients who are treated with placebo (a sugar pill).

The patient is a 65-year-old male with dementia and is currently taking Geodon (ziprasidone) 40mg QHS. Given the information from the drug label, Geodon (ziprasidone) should be reduced first, as it is not approved for the treatment of patients with dementia-related psychosis and may increase the risk of death in elderly patients with dementia-related psychosis 2.

From the Research

Medication Reduction Considerations

The patient is currently taking multiple medications, including Depakote Sprinkles 500mg BID, which contains valproate. The patient's platelet count is 96, and sodium level is 150.

• The patient's low platelet count may be related to valproate therapy, as studies have shown that valproate can cause thrombocytopenia 3, 4, 5, 6.
• Advanced age, female gender, and high doses of valproate are risk factors for the development of thrombocytopenia 4, 5.
• Although the patient is male, his age and valproate dose may still contribute to the risk of thrombocytopenia.
• Reducing the dose of Depakote Sprinkles may help alleviate the patient's thrombocytopenia, as studies have shown that platelet counts can return to normal after withdrawal or reduction of valproate 3, 6.
• It is essential to monitor the patient's platelet count and sodium level after reducing the medication dose to assess the effectiveness of the reduction and potential need for further adjustments.

Valproate Formulation

• The patient is currently taking Depakote Sprinkles, which has been shown to have a slower absorption rate compared to valproic acid syrup 7.
• This formulation may be contributing to the patient's thrombocytopenia, and reducing the dose or switching to a different formulation may be considered.

Next Steps

• Consider reducing the dose of Depakote Sprinkles to alleviate the patient's thrombocytopenia, taking into account the patient's age, valproate dose, and other risk factors 4, 5.
• Monitor the patient's platelet count and sodium level after reducing the medication dose to assess the effectiveness of the reduction and potential need for further adjustments.