This case study deals with treating a 26-year-old woman of Korean descent hospitalized for 21days due to acute mania. She had been diagnosed with bipolar 1 and had been prescribed lithium drugs. She also has CYP2D6*10 allele (common among people of Asian descent) and displays various manic symptoms, but overall health is fine. The allele will affect the pharmacodynamics of CYP2D6 metabolized drugs such as Risperidone (Risperdal 1 mg orally BID) (Seripa et al., 2018). Therefore, this gene will be an essential determinant in the treatment plan since it is responsible for adverse side effects and therapeutic failure in CYP2D6 metabolized drugs.
Decision #1
The first step is to initiate a treatment regimen that will improve the patient's mental health and alleviate her maniac symptoms. The medicine selected is Lithium 300 mg orally BID, which works well in treating bipolar disorder (Stahl, 2017). It is also not a CYP2D6 metabolized drug; hence will have little or no side effects or complications (Seripa et al., 2018). The dosage will be taken orally every day without fail. The initial dosage aligns with medical guidelines, which stipulate that a patient should be introduced to a lower dosage, which can then be increased if the condition does not improve. Stahl (2013) says that the patient's progress should be monitored so that the physician can have vital information to analyze the side effects and decide whether to increase the dosage or switch to another medication altogether.
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Lithium 300 mg oral dose is expected to improve at least two bipolar symptoms after the first four weeks (Stahl, 2013). The expectations are that the dosage should positively impact the patient's symptoms compared to the period before medication began. The patient is expected to be calmer, more peaceful, and less active. However, the results after the initial four weeks were not as optimistic. The patient still exhibited the same degree of symptoms as initially when she came for treatment. Such could be partially attributed to the client's inconsistent administration of the medicine as she confesses to taking medicine only when "she feels like she needs it." However, considering that there was no change whatsoever prompts the need to try a different solution in the second decision.
Decision #2
A moderate treatment plan is required when treating the patient's bipolar condition and should, therefore, be the primary consideration of each choice the physician takes. As such, the patient is switched to Depakote ER 500mg oral dose HS. The reason for this choice is its effectiveness of Valproate (Depakote ER) in treating bipolar disorder, bipolar depression, and acute manic symptoms (Stahl, 2017). Symptoms are expected to improve in a short period, usually 1-3 weeks.
Increasing the lithium dosage to 450mg was a consideration, but upon reviewing the persistence of the patient's symptoms, that idea was discarded. Failure to contain the bipolar state early enough could result in adverse and tragic outcomes. The patient had reported symptoms such as abnormal dressing, sleeplessness, and fast speech. Depakote ER 500mg HS is effective in improving mood disorders and relieving seizures. Therefore, it would be expected to enhance the mood of the patient and thus impact those symptoms.
Depakote ER 500mg HS is expected to improve patient symptoms. The patient's Young Mania Rating Scale (YMRS) of 22 is expected to improve and weight gain after four weeks of using this medication. The patient comes back after four weeks, her YMRS has reduced to 11, and there is an increase in weight. There is also gradual improvement in her maniac symptoms, as provided by Stahl (2015). The patient asks if she can stop the medication after a further four weeks but is encouraged to continue with the treatment due to its positive impact. As Stahl (2017) notes, weight gain is a common side effect. The patient should be educated on the significance of sticking with this regimen due to its effectiveness in treating her.
Decision #3
The final decision involves the long-term treatment plan for the patient. Valproate (Depakote ER) is effective in the maintenance phase of treating bipolar and ensure complete remission of symptoms (Stahl, 2017). She is educated on a proper diet to help her manage her weight gain and encouraged her to continue with the Depakote ER 500mg HS due to its effectiveness and to ensure complete recovery.
The patient will be encouraged to continue with the same dosage despite the weight gain and adjust to better nutrition practices and appropriate diet to cope with the weight gain (Weiss & Connery, 2011). The patient's fear of weight gain should not interrupt the treatment plan. This is because switching to Zyprexa 15 mg orally daily at HS would also result in continued weight gain.
It is expected that the patient will stick to the dosage, and her bipolar disorder will improve gradually. She is also expected to manage her weight gain by improving her dieting and following proper nutritional guidelines offered by her PMHNP. The PMHNP should be aware that the weight gain may be a real concern for the patient, but she should be encouraged to maintain the drug and keep up with the dosage. Reducing the dosage or the client missing to take medicine may help in weight reduction and regression of her bipolar condition. Fountoulakis (2014) offers that where diet management is ineffective in dealing with weight loss, Zyprexa could gradually manage weight gain.
Ethical Considerations
Communication is a key aspect of designing a proper treatment plan for patients. Regardless of the severity of the bipolar condition, there should be clear communication between the PMHNP and the patient when choosing the appropriate drug and dosage to administer. This should be followed in the onset of decision 1.
Proper administration of dosage should be followed. The patient should be given the correct guidelines and be encouraged to adhere to it. A taper dose should be administered if the drug is to be discontinued. When modifying dosage or switching drugs, great care should be taken to ensure the patient's response is monitored to inform the choice of modification (Stahl, 2013). This avoids serious side effects that the patient should be well informed of before any modification occurs as chosen in decision 2.
Patient education is also an important ethical factor that should be undertaken in decision 3. Patients should be given sufficient information about the treatment plan, such as expected results, side effects, and dietary or other guidelines they should adhere to when following a treatment regime.
Conclusion
In deciding the drug to use, the PMHNP should consider the pharmacodynamics caused by the CYP2D6 genome. The patient's progress was closely followed, and when no improvements occurred was switched to Depakote ER 500mg. The improvements observed under this drug necessitated its continued use despite the weight gain concerns of the patent, which was educated on the best nutritional guidelines to manage the weight gain.
References
Fountoulakis, K. N. (2014). Bipolar disorder: An evidence-based guide to manic depression . Springer.
Seripa, D., Lozupone, M., Miscio, G., Stella, E., La Montagna, M., Gravina, C., Urbano, M., Di Mauro, L., Daniele, A., Greco, A., Logroscino, G., Panza, F., & Bellomo, A. (2018). CYP2D6 genotypes in revolving door patients with bipolar disorders. Medicine , 97 (37), e11998. https://doi.org/10.1097/md.0000000000011998
Stahl, S. M. (2013). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications . Cambridge University Press.
Stahl, S. M. (2017). Prescriber's guide: Stahl's essential psychopharmacology (6th ed.). Cambridge University Press.
Weiss, R. D. & Connery, H. S. (2011). Integrated group therapy for bipolar disorder and substance abuse . Guilford Press.
