A 32-year-old woman with bipolar disorder comes to the office for follow-up. The patient was diagnosed and treated for a manic episode at age 29 and has been stable on a combination of lithium and risperidone. Her mood has been "fine" overall, but she has been stressed about work. After a staff meeting a few weeks ago, her supervisor said she appeared angry because she was repeatedly frowning while others were presenting. Since then, the patient has been increasingly self-conscious and has started eating lunch alone at her desk. Temperature is 37.0 C (98.6 F), blood pressure is 132/78 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable except for occasional grimacing and slow inversion and tapping movements of her right foot. Lithium level is 0.9 mEq/L (normal: 0.6-1.2). Which of the following is the most appropriate next step in pharmacological management?

Question

A 32-year-old woman with bipolar disorder comes to the office for follow-up.  The patient was diagnosed and treated for a manic episode at age 29 and has been stable on a combination of lithium and risperidone.  Her mood has been "fine" overall, but she has been stressed about work.  After a staff meeting a few weeks ago, her supervisor said she appeared angry because she was repeatedly frowning while others were presenting.  Since then, the patient has been increasingly self-conscious and has started eating lunch alone at her desk.  Temperature is 37.0 C (98.6 F), blood pressure is 132/78 mm Hg, pulse is 72/min, and respirations are 14/min.  Physical examination is unremarkable except for occasional grimacing and slow inversion and tapping movements of her right foot.  Lithium level is 0.9 mEq/L (normal: 0.6-1.2).  Which of the following is the most appropriate next step in pharmacological management?

Quizplus · Accepted Answer

11ec25c8_d80f_978b_bc81_d1c8ed656b5f_MD0003_00 This patient's facial grimacing combined with foot tapping and inversion movements are most likely signs of tardive dyskinesia (TD) caused by exposure to risperidone, a second-generation antipsychotic (SGA) used in the treatment of bipolar and psychotic disorders. Although most commonly associated with first-generation antipsychotics and antiemetic metoclopramide, TD may also occur with some SGAs. The risk of TD varies significantly within the SGA class; risperidone is among the highest-risk SGAs whereas clozapine and quetiapine are among the lowest-risk SGAs. Patients receiving maintenance antipsychotic medication should be assessed for TD at regular intervals and the causative medication tapered and discontinued if feasible. This patient has been stable (ie, no recurrent mood episodes for 3 years) and may not require maintenance risperidone because lithium may adequately control her symptoms. Therefore, a gradual taper and discontinuation of risperidone is the most appropriate initial management. When antipsychotic dose reduction or discontinuation is not feasible, treatment options include switching to a lower-risk agent (eg, clozapine) or treatment with a vesicular monoamine transporter 2 inhibitor (eg, valbenazine, deutetrabenazine). (Choice A) Anticholinergic drugs (eg, benztropine) are ineffective and may worsen TD. Benztropine is indicated in the treatment of acute dystonia. (Choice B) Propranolol has been used in the treatment of akathisia, a type of extrapyramidal symptom characterized by inner restlessness and inability to sit still. It is ineffective in treating TD. (Choice C) Lithium is not the causative agent of this patient's TD and should be maintained. Switching to valproic acid would risk destabilizing the patient. (Choice D) Continued exposure to risperidone would likely exacerbate the patient's TD. (Choice E) This patient is not in a major depressive episode. Adding an antidepressant (eg, fluoxetine) may have destabilizing effects in a bipolar patient and would not treat TD. Educational objective: Tardive dyskinesia is characterized by abnormal involuntary movements of the face, lips, tongue, trunk, or extremities that develop as a result of prolonged exposure to antipsychotic medication. If feasible, the causative medication should be tapered and discontinued. References: Epidemiology, prevention, and assessment of tardive dyskinesia and advances in treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29022654) Tardive dyskinesia risk with first- and second-generation antipsychotics in comparative randomized controlled trials: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/30192088)

A 32-Year-Old Woman with Bipolar Disorder Comes to the Office