Curbside consults


         First question                                                               Second question


Question 1:

I have been treating a now 49-year-old patient for years diagnosed with schizophrenia. The medications that have best stabilized him are fluphenazine 40 mg/d and risperidone 4 mg twice daily. He also takes escitalopram 5 mg/d for depression. All trials thus far to alter this combination have led to decompensation. He and family are aware that using two antipsychotics is polypharmacy and they have approved this combination. Within the last six weeks I decided to try one agent, risperidone, and started to carefully cross titrate medications. Prior to any changes a serum risperidone level was taken and results indicated that his risperidone dose was similar to a 16mg dose. I was at first perplexed by this and then realized that fluphenazine is a potent inhibitor of 2D6 and read recently that patients with elevated C-reactive protein (CRP) can have elevated serum levels of antipsychotics. His CRP was tested as normal. He is unwilling to use a depot medication which in itself might not offer any advantages. He is unwilling to do a trial of clozapine because of the initial weekly CBC for the first six months. He is closely monitored by a cardiologist and has a pacemaker. His lipids and hemoglobin A1C are normal. He has a trifascicular bundle branch block. QTc is mildly prolonged. The family and the patient don't want to change the current combination because "this is the most stable he has been in years". I welcome any suggestions on continued treatment.

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Delusion is the literal interpretation of metaphor. 

Otto Dorr MD

Contemporary Chilean psychiatrist

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