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Psychopharmacology for the Clinician

The information in this column is not intended as a definitive treatment strategy but as a suggested approach for clinicians treating patients with
similar histories. Individual cases may vary and should be evaluated carefully before treatment is provided. The patient described in this column
gave informed consent for its publication.

Successful management of free of psychotic symptoms as well as in rodents has been shown to be associ-
clozapine adverse effects with of adverse effects of the medications. ated with less risk for vacuous chewing
extended (alternate day) The caregivers had also stopped giv- movements (proxy for tardive dyskin
antipsychotic dosing in a ing lactulose syrup and ispaghula esia in humans) than continuous expos
patient with schizophrenia husk. The alternate day regimen was ure.11 Continuous antipsychotic expos
continued after educating the caregiv- ure has been associated with increased
Vijaya Kumar, MD; Lavanya Sharma, ers about the early warning signs of tolerance to antipsychotics, loss of
MBBS, DPM; Srikanth Madival, MD; relapse. The dose of olanzapine was a ntipsychotic response and super-
Ganesan Venkatasubramanian, MD, PhD gradually decreased to 10 mg every sensitivity psychosis.1214 On the other
alternate day over the next 9 months, hand, nondaily dosing for patients with
A 57-year-old woman with treatment- and the dose of clozapine continued a chronic illness like schizophrenia may
resistant schizophrenia was started on at 300 mg every alternate day. After pose adherence-related problems.15
clozapine as augmentation to her on- 10 months the patient remained For some patients, extended antipsy-
going treatment with olanzapine largely asymptomatic on the new chotic dosing may be a beneficial alter-
(15 mg/d). Her psychotic symptoms regimen without any adverse effects native to conventional antipsychotic
started improving, as the dose of clo- of medications. Her fasting glucose dosing. Systematic research should ad-
zapine was gradually increased to levels and lipid profile have also re- dress various aspects of extended anti-
300 mg/d over a period of 4 weeks mained largely unchanged. psychotic dosing, including the impact
(average increase of 10 mg/d). An Higher doses of antipsychotics are as- of interindividual v ariability in phar-
attempt to decrease the dose of olan- sociated with greater adverse effects, macokinetics of antipsychotics.
zapine to 12.5 mg/d led to worsening emphasizing the need for lower thera-
of psychotic symptoms and hence, it peutic doses in maintenance treat- Affiliations: Department of Psychiatry,
National Institute of Mental Health and
was again increased to 15 mg/d. The ment.1,2 Advances in psychotropic for-
Neurosciences (NIMHANS), Bangalore,
patients psychotic symptoms re- mulations have helped to decrease some Karnataka, India.
solved completely after 2 months of of the adverse effects.3 Extended (alter-
Competing interests: None declared.
regular treatment; however, she had nate day) antipsychotic dosing is one of
significant adverse effects, such as the strategies for preventing exposure to
DOI: 10.1503/jpn.150132
hypersalivation throughout the day, higher doses of antipsychotics.4
constipation (passing stools once in The peripheral pharmacokinetics of
45days despite dietary modification, medications remain an important fac- References
exercise and taking ispaghula husk tor when deciding dosing for antipsy-
and lactulose syrup) and sedation chotics.5 But preliminary evidence sug- 1. Ray WA, Chung CP, Murray KT, et al.
Atypical antipsychotic drugs and the
lasting up to 1214 hours/d. After dis- gests that central receptor occupancy risk of sudden cardiac death. N Engl J
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Long-term antipsychotic treatment and
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without consulting the physicians. to be effective.7,8 Studies with depot 4. Remington G, Fervaha G, Foussias G, et
The patient was given 15mg of olan- antipsychotics also have indicated that al. Antipsychotic dosing: found in transla-
tion. J Psychiatry Neurosci 2014;39:223-31.
zapine and 300mg of clozapine on al- they would be effective even if D2 re- 5. Preskorn SH. The recommended dosage
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ing between the 2 agents instead of 65% before the next administration.9 A would it ever be exceeded? J Psychiatr
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in severity in a week and completely with schizophrenia showed extended plasma kinetics with antipsychotics.
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7. Seeman P, Tallerico T. Antipsychotic drugs
new regimen. A month later, during a dosing in the prevention of relapse.10 which elicit little or no parkinsonism bind
visit to the physician, the patient was Transient exposure to antipsychotics more loosely than dopamine to brain D2

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J Psychiatry Neurosci 2016;41(1) E1

Kumar et al.

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