delusional disorders pakistani female with delusional thought processes
Decision Point One
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- A decrease in PANSS score of 25% is noted at this visit
- Client seems to be tolerating medication
- Client’s husband has made sure she makes her appointments for injections (one thus far)
- Client has noted a 2 pound weight gain but it does not seem to be an important point for her
- Client complains of injection site pain telling the PMHNP that she has trouble siting for a few hours after the injections and doesn’t like having to walk around for such a long period of time
Decision Point Two
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client’s PANNS has reduced by a total of 50% from the initiation of Invega sustenna
- When questioned about injection site pain, client states it is much better in the arm
- Client’s weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2 month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself
- Client likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gain
Decision Point Three
Guidance to Student
Weight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.
Abilify Maintena is a good option for someone who has good response to abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less affective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication first before administering the first injection. Also a disadvantage to Abilify Maintena is a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.
Qsymia is a weight loss medication that is a combination of Phenteramine and Topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme†or “severe†obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable and weight gain is not one of those scenarios. Secondly, Phenteramine has a lot of cardiovascular toxicities (such as elevated BP, HR, increased workload on the heart).
