Describe your clinical decision making. What is your rationale for choosing this medication?

Based on the case study, answer the following questions.

Identification of target symptoms/problems
What information, if any, would you like to know that was not included in the case?
– Family psych history
– Any previous episode
– Depression episodes
– Any other medical condition
– Child abuse history

Which psychiatric symptoms are a treatment priority for this case?
– Suicidal/homicidal ideation
– Auditory hallucinations
– Substance abuse psychosis
– Treat if any withdrawal or overdose

What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?
1. Substance abuse

Medication Choice 1
List one medication that would be appropriate for this case. Include the name and starting dose.
– Ziprasidone  20mg BID

Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.

I chose the medication ziprasidone which is a class of medications called atypical antipsychotic and the reason to choose ziprasidone because this medication can work very well with this patient’s case as he is having auditory and visual hallucinations including delusions and paranoid psychosis and this medication works well and helping to clear and organized the thoughts and helps him auditory and visual hallucinations, also patient would have has less issues with metabolic problems and with weight gain as compared with other atypical antipsychotic olanzapine or Seroquel (Stahl, 2008).

So the mode of action ziprasidone works by altering the activity of neurotransmitters in the brain and dopamine is the primary neurotransmitter affected by antipsychotic medication and it has been proposed that this drug’s efficacy in schizophrenia is mediated through a combination of dopamine type 2 (D2) and serotonin type 2 (5HT2) antagonism (Stahl, 2008). Ziprasidone function as antagonist at the D2, 5 HA more 5-HT1D receptors, and as an agonist at the 5-HT1A receptor (Golan D, 2011).

Ziprasidone inhibited synaptic reuptake of serotonin and norepinephrine. It was postulated that overactive Bromaline neurotransmitter could be the one cause of auditory and visual hallucinations including delusions in psychotic patients (Schmidt AW, 2001). Studies showed that human liver microsomes and recombinant enzymes indicate that CYP3A4 is the major CYP contributing to the oxidative metabolism of ziprasidone (Ziprasidone (Geodon). Product Insert. Pfizer Inc. New York, NY. 2014¬).

What laboratory testing/monitoring is needed for safely prescribing this medication?
As most antipsychotic medications affects metabolic changes especially atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular/cerebrovascular risk, including hyperglycemia, dyslipidemia, and weight gain so Would need to monitor CBC, COMP, Lipid panel and hemoglobin A1c (Stahl, 2008). Also, some antipsychotic can cause possibility Leukopenia, neutropenia, and agranulocytosis. We must be careful with patients who have a pre-existing low white blood cell count (WBC) or a history of leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy (Stahl, 2008).

Are there any contraindications or safety issues associated with this medication?
We should be careful while starting psychotic medication in patients with a known history of QT prolongation and with the patients who recently had acute myocardial infarction. (Golan D, 2011). We also must be very careful with patients who have a history of congestive heart failure or uncompensated heart failure. we should not use ziprasidone patient had a previous episode of known hypersensitivity to ziprasidone (Stahl, 2008).
Non pharmacologic Interventions

What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complimentary and holistic therapies?

– Cognitive Behavior Therapy (Haddock G, 1999).
– yoga therapy (Mehta UM, 2016).
– complimentary interventions such as vitamin D or folic acid supplements
– Personal Therapy, CBT (Psycho-social treatments) (Haddock G, 2009).
– Electro-Convulsive Therapy (ECT)
– Antioxidant Vitamins (C, E, Alpha Lipoic Acid, etc)
– Vitamin E and Other Antioxidants (for Tardive Dyskinesia)
– A Healthy Diet Helps in Schizophrenia Recovery (Stahl, 2008).
– EPA Omega-3 Fish Oils

Safety Risk Assessment
What are the safety concerns, if any, associated with this case? How will you address safety?

– Known history of QT prolongation
– Patients with recent acute myocardial infarction
– Patients with uncompensated heart failure
– In combination with other drugs that have demonstrated QT prolongation
– Known hypersensitivity to ziprasidone
– Potential for cognitive and motor impairment – patients should use caution when operating machinery
– Suicide – closely supervise high-risk patients
– Dysphagia – esophageal dysmotility and aspiration possible
– Metabolic changes – include hyperglycemia, dyslipidemia, and weight gain.
– Leukopenia, neutropenia, and agranulocytosis – patients with a pre-existing low white blood cell count (WBC) or a history of leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy
– Seizures – use cautiously in patients with a history of seizures or with conditions that lower seizure threshold (Golan D, 2011).

When would you follow up with this patient?
At this time patient will be follow-up for the first time in a week to see if his hallucinations are better, in case these hallucinations are not better, will start a combination of another antipsychotic medication or will switch to clozapine for the resistant symptoms.

After that patient will be seen in 2 weeks and then follow-up 4 weeks, and when patient will be established and is stable then will continue medication for 4 to 6-month then will taper the dose and will monitor for relapses.

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