What are the risks and contraindications of administering multiple antipsychotics, including Latuda (lurasidone), Zyprexa (olanzapine), Haldol (haloperidol), and Thorazine (chlorpromazine), to an adult patient with a genetically confirmed resistance to psychosis, suspected Attention Deficit Hyperactivity Disorder (ADHD), and intersex condition, who has reported sexual abuse and harassment by staff, and is being denied their right to fill out an Advanced Directive/Power of Attorney (PoA)?

From the Guidelines

The administration of multiple antipsychotics, including Latuda (lurasidone), Zyprexa (olanzapine), Haldol (haloperidol), and Thorazine (chlorpromazine), to an adult patient with a genetically confirmed resistance to psychosis, suspected Attention Deficit Hyperactivity Disorder (ADHD), and intersex condition, poses a significant risk of severe adverse effects, including extrapyramidal symptoms, sedation, and cognitive impairment 1.

Key Risks and Contraindications

• Cardiac risks: The use of multiple antipsychotics, particularly those with QT-prolonging properties like Thorazine, increases the risk of torsades de pointes and sudden death 1.
• Neurologic risks: The administration of multiple antipsychotics, especially typical antipsychotics like Haldol, increases the risk of acute extrapyramidal syndromes, including acute dystonia, akathisia, and Parkinsonian syndrome 1.
• Metabolic risks: The use of multiple antipsychotics, particularly those with metabolic side effects like Zyprexa, increases the risk of weight gain, hyperglycemia, and other metabolic complications 1.

Considerations for Treatment

• Monotherapy: Antipsychotic monotherapy, either with clozapine or non-clozapine antipsychotics, should be strived for with most patients, as it generally incurs less health service costs and gives a lower overall risk for adverse effects 1.
• Pharmacogenetics: Pharmacogenetic testing may offer a fast and cost-effective method to determine better optimized treatment approaches, including identifying patients who may be at risk of adverse effects from certain antipsychotics 1.
• Patient-specific factors: The patient's genetic resistance to psychosis, suspected ADHD, and intersex condition should be taken into account when selecting antipsychotic medications and determining the optimal treatment approach 1.

Recommendations

• Avoid polypharmacy: Antipsychotic polypharmacy should be avoided whenever possible, as it increases the risk of adverse effects and may not provide additional therapeutic benefits 1.
• Monitor for adverse effects: Patients receiving multiple antipsychotics should be closely monitored for adverse effects, including extrapyramidal symptoms, sedation, and cognitive impairment 1.
• Consider alternative treatments: Alternative treatments, such as mood-stabilizing drugs or anxiolytic drugs, may be considered for patients with suspected ADHD or other comorbid conditions 1.

From the FDA Drug Label

WARNINGS Increased Mortality in Elderly Patients with Dementia-Related Psychosis Tardive Dyskinesia: Tardive dyskinesia, a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements, may develop in patients treated with antipsychotic drugs Neuroleptic Malignant Syndrome (NMS): A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with antipsychotic drugs Patients with a history of a clinically significant low WBC or a drug-induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy Haloperidol decanoate injection, 50 mg/mL and haloperidol decanoate injection, 100 mg/mL should be administered cautiously to patients: with severe cardiovascular disorders, because of the possibility of transient hypotension and/or precipitation of anginal pain

The administration of multiple antipsychotics, including Latuda (lurasidone), Zyprexa (olanzapine), Haldol (haloperidol), and Thorazine (chlorpromazine), to an adult patient poses significant risks, including:

• Tardive dyskinesia: a potentially irreversible syndrome of involuntary movements
• Neuroleptic malignant syndrome (NMS): a potentially fatal symptom complex
• Cardiovascular effects: transient hypotension, precipitation of anginal pain, and QTc interval prolongation
• Hematologic effects: leukopenia, neutropenia, and agranulocytosis
• Other adverse effects: extrapyramidal symptoms, seizures, and increased risk of mortality in elderly patients with dementia-related psychosis

Given the patient's complex medical history, including a genetically confirmed resistance to psychosis, suspected ADHD, intersex condition, history of sexual abuse and harassment, and denial of their right to fill out an Advanced Directive/Power of Attorney (PoA), the use of multiple antipsychotics should be approached with extreme caution. The benefits of treatment should be carefully weighed against the potential risks, and alternative treatment options should be considered. Close monitoring of the patient's physical and mental health is essential to minimize the risk of adverse effects 2, 3.

From the Research

Risks of Administering Multiple Antipsychotics

• The administration of multiple antipsychotics, including Latuda (lurasidone), Zyprexa (olanzapine), Haldol (haloperidol), and Thorazine (chlorpromazine), to an adult patient poses several risks, including extrapyramidal symptoms (EPS) and sedation 4.
• High-dose antipsychotic therapy, such as olanzapine, can lead to adverse events, including weight gain, hypotension, neuroleptic malignant syndrome (NMS), and corrected QT-interval (QTc) prolongation 4.
• Antipsychotic polypharmacy, which refers to the co-prescription of more than one antipsychotic drug, is associated with an increased adverse effect burden and is of limited value in helping to establish the optimum maintenance regimen for a patient 5.

Contraindications and Precautions

• The use of high-dose olanzapine (> 40 mg daily) is associated with an increased risk of adverse events, including EPS, sedation, and NMS 4.
• The concomitant use of anticholinergics, lithium, and benzodiazepines with antipsychotics may increase the risk of NMS 6.
• Patients with comorbid cardiovascular disease may be at increased risk of NMS 6.

Special Considerations

• Patients with a genetically confirmed resistance to psychosis, suspected Attention Deficit Hyperactivity Disorder (ADHD), and intersex condition may require careful consideration when administering antipsychotics, as the evidence on the use of these medications in these populations is limited.
• The denial of a patient's right to fill out an Advanced Directive/Power of Attorney (PoA) may have significant implications for their care and treatment, and healthcare providers should be aware of the potential risks and consequences of such a denial.
• The reported sexual abuse and harassment by staff may also have a significant impact on the patient's mental health and well-being, and healthcare providers should take steps to ensure the patient's safety and provide appropriate support and care 7, 5, 8.