Particularly after her PANSS test results, the client in this case has been diagnosed with schizophrenia, paranoid type, in which positive symptoms like delusions are prevalent. The purpose of this paper is to clarify three key psychopharmacological treatment decisions made on behalf of the client. Goals of all three decisions are symptom reduction and the promotion of the client’s mental health and psychosocial functioning.
The decision was to give the patient Invega Sustenna (paliperidone palmitate) 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter, instead of either Zyprexa (olanzapine) or Abilify. The reasoning is based primarily on the fact that Invega Sustenna is a long-acting injectable with fewer compliance complications than orally administered drugs. Although Abilify has been available as a long-acting injectable, Invega Sustenna is recommended in this case because it presents fewer side effects than either Zyprexa or Abilify, particularly those the client has been concerned about such as weight gain (Khanna et al., 2016). Moreover, Invega Sustenna is a second-generation antipsychotic known to be “better tolerated and have fewer adverse neurological side effects” than first-generation drugs (Park, et al., 2013, p. 651).
The client returned to the clinic for follow-up four weeks after the initial injection of Invega Sustenna. The PANSS was re-administered and the client’s score decreased by 25%, revealing improvement. The client reports no troublesome side effects from the medication, although she complains of immediate pain at the injection site that lasts for several hours as well as some weight gain. However, neither of these are serious complications. The husband has agreed to take the client for further injections. It is believed that the switch from orally administered antipsychotics will be beneficial for this client, and it is strongly recommended that the client stay with Invega Sustenna given the promising initial results of the PANSS test.
Because the client expressed concern over not being able to sit or walk comfortably after the injection, it was recommended that the administering nurse inject at the deltoid site instead. As pain at the injection site is a concern due to the need to maintain patient compliance with the medication schedule, switching the site should not be a problem.
This decision worked well, as the client directly told the nurses that the pain was much less problematic at the arm site. However, the client has gained more weight — up again from the first injection to now a total of 4.5 pounds over two months. The client claims that “her husband might not like it,” referring to the weight gain, but he was not consulted directly on the matter. However, the client does admit that that she feels good on the drug. Her PANNS score is actually down 50% since her initial test. The client has requested the nurses to look for a drug that offers similarly promising results without the weight gain.
After investigating the literature, it was determined that Invega Sustenna is actually no worse and perhaps superior to alternative antipsychotics in terms of weight gain — a common side effect for both typical and atypical antipsychotics (Amiaz, Rubenstein, Czerniak, et al., 2016; Zheng, et al., 2015). Rather than switching the client away from a medication that works and yields no deleterious effects, it is strongly recommended that the client instead engage in a lifestyle regime that includes diet and fitness. Amiaz, Rubenstein, Czerniak, et al. (2016) found “patients with schizophrenia are capable of adhering to a diet and fitness program and successfully lose weight, regardless to taking typical or atypical medications,” (p. 112). If necessary, the client may be able to try metabolic drugs like Metformin, as a meta-analysis “suggests that adjunctive metformin is an effective, safe, and reasonable choice for antipsychotic-induced weight gain and metabolic abnormalities,” (Zheng, et al., 2015, p. 499). Metformin is studied more extensively than other weight loss interventions like Qsymia specifically for the purpose of helping patients like this one, who experience relatively minor weight gain as a result of taking antipsychotics (Zheng, et al., 2015).
Switching to the next-best option antipsychotic, Abilify, would not be advisable given that Khanna et al. (2016) found that weight gain was significantly greater in people receiving aripiprazole than other atypical antipsychotics (p. 2). Weight gain is all but inevitable with antipsychotics and a meta-analysis of clinical trials on the weight gain associated with antipsychotics shows that “the rational of switching antipsychotics to achieve weight reduction may be overrated,” (Bak, et al., 2014, p. 1). Therefore, the client should be counseled on how to best manage her weight through dietary and exercise interventions, rather than switching her from a drug that is otherwise working. Lifestyle counseling is also an ideal option because it may help increase medication compliance in the long run. It is worth noting that one study did show “consistently greater improvements were observed with aripiprazole once-monthly 400 mg vs. paliperidone palmitate across all measures,” but given that the client has shown significant PANNS score improvements after two months on paliperidone palmitate, a switch at this stage is not recommended (Potkin, et al., 2016, p. 1). If, however, the client’s symptoms should change or worsen, then a switch in antipsychotics might be recommended in the future.
Amiaz, R., Rubenstein, K., Czerniak, E. et al. (2016). A Diet and Fitness Program Similarly Affects Weight Reduction in Schizophrenia Patients Treated with Typical or Atypical Medications. Pharmacopsychiatry 49(3): 112-116.
Bak, M., et al. (2014). Almost All Antipsychotics Result in Weight Gain: A Meta-Analysis. PLoS ONE 9(4): e94112. doi:10.1371/journal.pone.0094112
Khanna, et al. (2016). Aripiprazole versus other atypical antipsychotics for schizophrenia. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD006569. DOI: 10.1002/14651858.CD006569.pub5.
Park, E.J. et al. (2013). Long-acting injectable formulations of antipsychotic drugs for the treatment of schizophrenia. Archives of Pharmacal Research 36(6): 651-659.
Potkin, S.G. et al. (2016). Multidimensional Assessment of Functional Outcomes in Schizophrenia: Results From QUALIFY, a Head-to-Head Trial of Aripiprazole Once-Monthly and Paliperidone Palmitate. International Journal of Neuropsychopharmacology. DOI: http://dx.doi.org/10.1093/ijnp/pyw093
Zheng, W. et al. (2015). Metformin for Weight Gain and Metabolic Abnormalities Associated With Antipsychotic Treatment: Meta-Analysis of Randomized Placebo-Controlled Trials. Journal of Clinical Psychopharmacology 35(5): 499-509.
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