I have a patient on the long term ward who transferred from a local short term ward, presented with persisting persecutory delusions and command hallucinations with accompanying violence risk, dx was schizophrenia. He came in on Risperidone 4mg BID, had previously been on Haloperidol, Olanzapine, Aripiprazole, and Lurasidone, Didn't want to up the Risperdal because anecdotally I haven't seen much success with doses above 8mg.
Given he had failed multiple antipsychotics and the fact he was violent multiple times a week I decided on Clozapine, titrated him to 300mg over 3 weeks, tested plasma levels and decided to up it to 400mg and sit there. After a month saw about a 20% reduction in PANSS scores, patient was still agitated. Decided to augment with Haloperidol 10mg BID, when that failed I added Divalproex Sodium (Depakote) and titrated up to therapeutic plasma levels, no change. Swapped out the Haloperidol for 3mg Cariprazine (I wanted to try a partial agonist but patient had horrible akathisia on aripiprazole so I decided on Cariprazine,) no change after a month.
I reviewed the diagnosis, got a good history with the help of family members and sent the patient in for a neurological eval to make sure we were dealing with a psychiatric illness. I came to the conclusion that schizophrenia was the correct diagnosis, neuro eval came back normal.
I have used Clozaril a good bit as a doctor but have never had someone fail Clozaril + augmentations, so I'm basically wondering what other options I have. ECT is an option (and the patient is on a court order so he doesn't really have a choice) but I want to make sure I tick every box. Any and all advice is appreciated.
Given he had failed multiple antipsychotics and the fact he was violent multiple times a week I decided on Clozapine, titrated him to 300mg over 3 weeks, tested plasma levels and decided to up it to 400mg and sit there. After a month saw about a 20% reduction in PANSS scores, patient was still agitated. Decided to augment with Haloperidol 10mg BID, when that failed I added Divalproex Sodium (Depakote) and titrated up to therapeutic plasma levels, no change. Swapped out the Haloperidol for 3mg Cariprazine (I wanted to try a partial agonist but patient had horrible akathisia on aripiprazole so I decided on Cariprazine,) no change after a month.
I reviewed the diagnosis, got a good history with the help of family members and sent the patient in for a neurological eval to make sure we were dealing with a psychiatric illness. I came to the conclusion that schizophrenia was the correct diagnosis, neuro eval came back normal.
I have used Clozaril a good bit as a doctor but have never had someone fail Clozaril + augmentations, so I'm basically wondering what other options I have. ECT is an option (and the patient is on a court order so he doesn't really have a choice) but I want to make sure I tick every box. Any and all advice is appreciated.