NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry
NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry

BACKGROUND INFORMATION

The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weights 110 lbs. and is 5’ 5”

SUBJECTIVE

Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

MENTAL STATUS EXAM

The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Decision Point One

Select what you should do:

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngBegin Lithium 300 mg orally BID

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-blue.pngBegin Risperdal 1 mg orally BID

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-yellow.pngBegin Seroquel XR 100 mg orally at HS

Decision Point One

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngBegin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
Today’s presentation is similar to the first day you met her
Decision Point Two

Select what you should do next:

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngIncrease Lithium to 450 mg orally BID

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-blue.pngAssess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-yellow.pngSwitch to Depakote ER 500 mg orally at HS

Decision Point One

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngBegin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
Today’s presentation is similar to the first day you met her
Decision Point Two

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngIncrease Lithium to 450 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client returns reports that she is still taking the medication when she feels that she needs it
She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night
Decision Point Three

Select what you should do next:

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NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry
NURS 6630 Bipolar Therapy Client of Korean Descent or Ancestry

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngAssess for rationale for non-compliance and educate client

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-blue.pngConsider hospitalization

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-yellow.pngChange to abilify 10 mg orally at HS

Decision Point One

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngBegin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
Today’s presentation is similar to the first day you met her
Decision Point Two

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngIncrease Lithium to 450 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client returns reports that she is still taking the medication when she feels that she needs it
She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night
Decision Point Three

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngAssess for rationale for non-compliance and educate client

Guidance to Student
You should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, you needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ You need to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client.

Decision Point One

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-blue.pngBegin Risperdal 1 mg orally BID

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
Client’s mother explains that “she has been like this since about a week after the last office visit”
Decision Point Two

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngDiscontinue Risperdal and start Lithium sustained release 300 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client no longer lethargic after the end of the first week
Client has a slight decrease in her Young Mania Rating Scale (from 22 to 19)
Client reports that her sleep is again decreasing, but that overall, she is happy
Decision Point Three

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngIncrease Lithium SR to 450 mg orally BID

Guidance to Student
Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic/sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. You could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, you can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, you would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy.

Decision Point One

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-yellow.pngBegin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client is reporting that she sleeps a bit more at bedtime
Client states that she has gained about 2 or 3 pounds, which she does not like
Client also reports that she has been constipated since starting this medication
Client is also complaining of dry mouth which she does not like.
Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18
Client is reporting really good mood, but is asking for a different medication because of the weight gain
Decision Point Two

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngIncrease Seroquel XR to 300 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client reports that her constipation is worse and that she has now gained a total of 7 pounds since starting this drug
Client feels that you are not listening to her concerns and is very upset
Client’s Young Mania Rating Scale has decreased from 18 to 14
Decision Point Three

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/img/pill-red.pngIncrease Seroquel XR to 400 mg orally daily

Guidance to Student
The client is becoming frustrated and feels that you do not hear her concerns about weight gain and constipation, which can be causing a rupture in the therapeutic relationship. In addition, after 8 weeks, the client still has significant manic symptoms despite the fact that they have decreased, they are still present.

You could discontinue the Seroquel XR and begin Geodon. This may be an appropriate choice as Geodon is cleared by approximately one third through the CYP-3A4,1A2 alleles and the remaining two-thirds of the drug are cleared through aldehyde oxidase, which means that it should not cause the same adverse effects as Seroquel. Although this drug is metabolized through 2D6, you need to remember that this is a minor pathway for metabolism and 3A4 is the major pathway through which this drug is metabolized. Geodon must be administered with a 500 calorie meal in order to assure adequate absorption.

In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. You should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

Decreasing Seroquel as suggested in the third choice may result in a decrease in side effects, but addition of Depakote can also result in weight gain- which is one of the side effects that the client has found objectionable.