From the Guidelines
The administration of high doses of antipsychotic medications, including Latuda (lurasidone) and Zyprexa (olanzapine), combined with Haldol (haloperidol) and Benadryl (diphenhydramine), to a patient with no signs of psychosis, but rather Attention Deficit Hyperactivity Disorder (ADHD), and a genetically confirmed resistance to hallucinations or psychosis, is a potentially dangerous and ill-advised treatment approach.
Key Concerns
- The use of high-dose antipsychotics in a patient without psychosis can lead to severe sedation, respiratory depression, and extrapyramidal symptoms 1.
- The combination of these medications can increase the risk of anticholinergic toxicity and excessive sedation 1.
- The patient's genetic characteristics and lack of psychosis symptoms suggest that this treatment approach may be inappropriate and potentially harmful.
Treatment Guidelines
- The American Academy of Child and Adolescent Psychiatry recommends that antipsychotic medications be used with caution in children and adolescents, and only when other treatments have failed 1.
- The British Journal of Psychiatry suggests that antipsychotic medications should be used at the lowest effective dose and for the shortest duration necessary to achieve therapeutic goals 1.
Alleged Mistreatment
- The alleged mistreatment of the patient based on their intersex status, genetic characteristics, and religious affiliation warrants immediate attention and investigation.
- The denial of the patient's right to complete an Advanced Directive is a serious concern that requires further review.
Recommendations
- A thorough review of the patient's medical history and current treatment plan is necessary to determine the best course of action.
- The patient's treatment plan should be revised to prioritize their safety and well-being, and to ensure that their rights are respected.
- Further education and training on the appropriate use of antipsychotic medications and the importance of respecting patients' rights and dignity are necessary to prevent similar incidents in the future.
From the FDA Drug Label
Chronic antipsychotic treatment should generally be reserved for patients who suffer from a chronic illness that, 1) is known to respond to antipsychotic drugs, and, 2) for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate In patients who do require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically. If signs and symptoms of tardive dyskinesia appear in a patient on antipsychotics, drug discontinuation should be considered
The administration of high doses of antipsychotic medications, including Latuda (lurasidone) and Zyprexa (olanzapine), combined with Haldol (haloperidol) and Benadryl (diphenhydramine), to a patient with no signs of psychosis, but rather Attention Deficit Hyperactivity Disorder (ADHD), is a potentially dangerous and ill-advised treatment approach.
- Key considerations:
- Antipsychotic treatment should be reserved for patients with a chronic illness known to respond to antipsychotic drugs.
- Alternative, equally effective, but potentially less harmful treatments should be considered.
- The smallest dose and shortest duration of treatment should be sought.
- The need for continued treatment should be reassessed periodically.
- Risks associated with antipsychotic treatment:
From the Research
Administration of High Doses of Antipsychotic Medications
- The administration of high doses of antipsychotic medications, including Latuda (lurasidone) and Zyprexa (olanzapine), combined with Haldol (haloperidol) and Benadryl (diphenhydramine), to a patient with no signs of psychosis, but rather Attention Deficit Hyperactivity Disorder (ADHD), and a genetically confirmed resistance to hallucinations or psychosis, may be potentially dangerous and ill-advised 4, 5.
- High-dose antipsychotic therapy has been associated with an increased risk of adverse effects, including extrapyramidal symptoms, sedation, weight gain, hypotension, neuroleptic malignant syndrome, and corrected QT-interval (QTc) prolongation 4.
- The use of antipsychotic polypharmacy, which refers to the co-prescription of more than one antipsychotic drug, has been identified as a major contributor to high-dose prescribing and is associated with an increased adverse effect burden 6.
Risks and Benefits of Antipsychotic Polypharmacy
- The evidence on the risks and benefits of antipsychotic polypharmacy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry 6.
- Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments have been exhausted, and with monitoring of the clinical response and adverse effects 6.
- The use of dopamine partial agonists, such as aripiprazole and cariprazine, may offer a more favorable side effect profile and could potentially be used to replace, rather than enhance, the D2 antagonism of other antipsychotic agents 7.
Considerations for Treatment Approach
- The treatment approach should be individualized and based on the patient's specific needs and circumstances, taking into account the potential risks and benefits of antipsychotic therapy 8, 5.
- Clinicians should be aware of the potential for adverse effects and be prepared to act appropriately if toxic effects occur, including treatment cessation if serious adverse events arise 4.
- Further research is needed to develop more effective psychotropic drugs with minimal side effects, and to improve cognition, adherence, and long-term outcomes in patients with schizophrenia or other major psychiatric illnesses 5, 7.