Bipolar Therapy for Client of Korean Decent Ancestry
Which decision did you select?
For discussion one; I chose Seroquel XR 100 orally HS because it is a typical antipsychotic,
serotonin-dopamine antagonist. Secondly; it has been cited by FDA as the most anti-depressant
drug in the market which makes it an ideal choice bipolar therapy.
According to clinical pharmacology studies; Seroquel extended release capsules are supposed to be
administered 300mg once daily on day1, then 600mg once daily on day 2, then 400-800mg once daily
starting on day 3. Seroquel XR 100mg is to be administered without regard to food and extended release
tablets should be swallowed whole and should not be chewed or crushed. Seroquel has a half life of 6-7
hours, it is rarely legal and non habit forming.
Why did you select this decision?
The reason why I selected this decision is because seroquel has so far proved to be the most
reliable anti-depressant as approved by the FDA and has fewer side effects compared to other
anti-depressants. Another major reason why I selected this decision is because Seroquel XR 100
orally HS is generation antipsychotic and also a mood stabilizer (Chen, et.al, 2015). It is
commonly prescribed for acute mania and bipolar maintenance. By making this decision; I was
hoping to achieve absolute recovery of the patient in three weeks and be able to assist the patient
in handling the situation conclusively.
From the case study; it is evident that the patient in this scenario suffers from the following things:
1: Biopolar I Disorder
2: Hyperactivity
3: Insomnia
4: Experiencing acute mania
From the above symptoms; the reason why I selected this decision (Seroquel XR 100mg HS) is because
based on my experience and research this medication is used to treat the aforementioned issues. For
example; people experiencing acute mania like the patient in this scenario can use this Seroquel XR 100
mg HS to improve their mood, improve negative symptoms and reduce mania. (
) states that many
bipolar patients have a reduction of symptoms by 50% or more and it not only decreases mania but it
also stops recurrences of mania in Bipolar. (
) goes on to say that psychotic symptoms can improve
within 1 week and it may take several weeks for full effect on behavior, cognition and affective
stabilization.
Another reason why I chose Seroquel XR is because prescribing it at night may cause sedation at
bedtime and have a positive outcome on the patient’s complaints of insomnia. The patient admits that
she only sleeps about 5 hours per night. (
) states that decreased amounts of sleep can cause mixed
states of mania and increased amounts of stress can cause mania relapse. It was also the only
medication choice prescribed as an extended release which means that the effectiveness of the
medication is constant and would last longer due to the slow release of the medication throughout the
day. Lastly; the main reason why I have selected Seroquel XR 100mg is because it will help the patient in
restoration and balance of serotonin and dopamine in the brain. Seroquel blocks dopamine 2 receptors
which help to reduce positive symptoms of psychosis and stabilizes affective symptoms. It also blocks
serotonin 2A causing increase of dopamine release in certain brain regions reducing motor side effects.
Why I did not choose Lithium ?
I did not choose Lithium because for unknown reasons the patient was non-complaint with her
prescribed medication regimen. She admits she stopped taking it since her discharge from the hospital
21 days ago. Lithium would have been my choice for decision #1 because it is used as a first line
medication for Bipolar I. Lithium is classified as a mood stabilizer and is used to treat bipolar disorder.
The action of Lithium works by changing cation transport in the nerves and muscle then it influences
reuptake of neurotransmitters. Its therapeutic effect lowers the chance of manic episodes. However, the
patient in this cases study stopped taking her lithium medication two weeks ago after being discharged
from the hospital. The patient is exhibiting manic signs and symptoms so Seroquel XR now becomes my
first choice. While we are not aware why the patient stopped taking her Lithium medication in this case I
would advise the patient to follow her prescribed medication regimen and to avoid skipping or
decreasing her medication without supervision going forward.
Why I did not choose Risperdol?
I did not chose Risperdol because the patient is of Korean decent and genetic testing revealed she tested
positive for CYP2D6*10 allele. The metabolism of Risperadol is dependent on CYP2D6 and the
CYP2D6*10 allele is essential to regulate the activity of that enzyme. However Seroquel XR is mostly
metabolized by P450 CYP3a4 enzyme system which makes it a better choice for this patient.
The CYP2D6*10 Aelle enzyme being a common CYP enzyme is usually involved in more than
a few important drug interactions (Sit, et.al, 2017). For example; CYP is a system of enzymes in
the liver important for metabolism because it metabolizes all types of drugs in the liver.
Basically; this means the drugs that are metabolized by CYP2D6 to inactive metabolites,
CYP2D6 inhibitors may result in toxicity. CYP2D6*10 Aelle enzyme can be categorized in
many groups such as patients with poor metabolizers or those with ultrarapid metabolizers. It
must be also acknowledged that ethnic differences exist in CYP2D6 activity
What were you hoping to achieve by making this decision?
Imperative medical research reveals that people are different and may respond to drugs
differently. Currently; there is no specific scientific time frame that can distinctively say how
long it takes for seroquel XR to works because according to numerous psychological researches
it comes down to what you are taking. For example; if you are using therapeutic dose (150mg300mg) it may take one up to three weeks for the drug to work effectively. Alternatively; there
are higher mixed episodes or mania such as the ones the patient in this case demonstrates and
that may need a higher dosage of up-to 400mg + which may differ in time difference with the
patient being administered therapeutic dose (150mg-300mg) (Yatham, et.al, 2016).
Like any other psychiatric mental health nurse practitioner (PMHNP) one of the main things I was hoping
to achieve by making this decision was to achieve a decrease in manic behavior, manic episodes and a
decrease in signs of depression. I also want to improve the patient’s mood and sleeping habits.
(Murphy & Rhodes, 2015) states that labs should be monitored including: AST, ALT, total cholesterol,
triglycerides, fasting blood glucose, serum prolactin, CBC, and WBC. (Murphy & Rhodes, 2015) also
explains that the patient’s weight should be assessed and BMI throughout therapy due to the
medication’s increased risk for weight gain. I expected to see the patient’s labs to continue to be of
normal values. I also expected to see the disappearance of mania, insomnia and maintenance of Bipolar
I disorder.
Explain any difference between what you expected to achieve with Decision #1 and the results of the
decision. Why were they different?
In decision #1 it was evident that the decision to choose Seroquel XR 100mg HS was to eliminate current
symptoms as well as prevent future reoccurrence while I would later find the results of decision #1 were
a bit different than what I expected. I was aware that Seroquel is a medication that is known to cause
weight gain but I expected for the patient to continue to maintain a healthy weight and normal
laboratory results. I predicted that the patient’s insomnia and mania would be resolved due to the
sedating and long lasting effect of extended release Seroquel.
The patient returned in 4 weeks and stated that Seroquel XR was effective and the client returned to the
clinic and she admits sleeping more at bedtime and she also admits she is in a really good mood.
However she has complaints of a weight gain of 2 or 3 pounds, constipation and a dry mouth.
(Wegmann, 2012) states that side effects of Seroquel XR include dry mouth, constipation, weight gain,
sedation, dizziness and diabetes. Seroquel antagonizes histamine H2 receptors and alpha adrenergic
receptors. The results were different than what I expected because I found that according to
(Wegmann, 2012).it is common for patients prescribed Seroquel to experience weight gain due to the
blocking of histamine 1 receptors in the brain. I also learned it is common for patients to experience dry
mouth, constipation and sedation due to the blocking of muscarinic 1 receptors. So even though the
Seroquel has proven to be effective in treating the patients Bipolar I and Acute manic episode she is
requesting to be placed on a different medication because of the weight gain.
Descision #2 Which decision did you select?
Geodon is classified as an antipsychotic (serotonin dopamine antagonist) and mood stabilizer, it is used
to treat acute mania with mixed episodes associated with Bipolar I disorder. It is also used for
maintenance treatment of Bipolar I disorder as adjunct to Lithium. (Murphy & Rhodes, 2015) explains it
works by antagonizing dopamine type 2 (D2) and serotonin type 2 (5HT2) and A2 adrenergic receptors.
This reduces positive symptoms of psychosis and reduces motor side effects. (Murphy & Rhodes, 2015)
also explains that 60% of the drug is absorbed during oral administration and 100% is absorbed from
intramuscular sites. Geodon has an oral half life of 7 hours and an intramuscular half life of 2-5 hours.
Why did you select this decision?
Based on this case the patient was experiencing the following undesired symptoms:
1: Weight gain
2: Dry mouth
3: Constipation
So for decision #2 I decided to discontinue Seroquel and start Geodon 40 mg orally BID; and administer
it with a 500 calorie meal. It made sense to choose Geodon 40 mg because it has the same classification
and actions as Seroquel which was proven to be effective in resolving the patient’s current symptoms
and mania reoccurrence. Geodon and Seroquel are both used to treat Bipolar I and acute mania
however Geodon has a lower risk of weight gain for the patient. (Murphy & Rhodes, 2015) explains that
weight gain for patients who are prescribed Geodon is unusual. The reason why weight gain is less
frequent is because Geodon mechanism of action does not block histamine 1 receptors in the brain. The
medication Geodon also does not block muscarinic 1 receptors which contributes to dry mouth,
constipation and sedation. Another reason why I chose Geodon is because it is metabolized by CYP 450
3A4 this means it should not have an issue being metabolized by the patient who has tested positive for
CYP2D6*10 allele..
What were you hoping to achieve by making this decision?
By making this decision I was hoping to achieve is to continue to manage Bipolar I disorder and acute
mania with Geodon medication. The main thing I was hoping to achieve is to maintain a reduction in
mania and for the patient to experience an overall improvement of 50% or more. I also want to achieve
a decrease the patient’s weight by switching the medication to Geodon and administering it with a 500
low calorie meal.
Explain any difference between what you expected to achieve with Decision #2 and the results of the
decision. Why were they different?
In decision #2 The decision to choose Geodon 40mg orally with a 500 calorie meal was to continue to
maintain control of Bipolar I and manic symptoms as well as prevent future reoccurrence. The client
returned to the clinic in 4 weeks and demonstrates a 50% decrease in score on the young mania rating
scale (from 22 to 11). The Young Mania Rating Scale (YMRS) is a commonly utilized rating scales to
assess and rate manic symptoms. The scale consists of 11 items that are based on the patient’s
subjective report of his or her clinical condition over a span of 48 hours. It is used to evaluate manic
symptoms at the starting point and overtime in patients with mania.
The client had experienced weight gain with the use of Seroquel however she denies any additional
weight gain or side effects while using Geodon. The results of decision # 2 was what I expected which
was the medication Geodon was effective in treating and maintaining the patients Bipolar I diagnosis
and acute mania. The results were different than before because the patient was compliant with the
medication regimen and she did not experience any additional weight gain or side effects.
Decision #3 Which did you select?
For decision #3 I chose to continue the same dose and reassess in 4 weeks.
Why did you select this decision?
I chose the decision to continue the same dose and reassess in 4 weeks the patient because the
medication Geodon has proven to be effective in the case of this patient. The patient admits to being in
a good mood, denies additional weight gain, denies adverse side effects, insomnia is resolved, mania
symptoms are resolved and there is a decrease in the patients young mania score. I decided it is
important for the patient to stay on the same dose because psychotic symptoms can improve within one
week but it may take several weeks for full effect on behavior as well as cognition and affective
stabilization (
). (
) states that many bipolar patients may experience a reduction of symptoms
by half or more.
What were you hoping to achieve by making this decision?
I was hoping to achieve a continued effective response. The main goal is to manage her Bipolar, acute
mania and depressive episodes which were achieved. I would encourage the patient to stay on
medications and not to decrease or stop any mediation without medical supervision to prevent
reoccurrence of symptoms. I wanted the patient to maintain a good mood and healthy weight, I would
encourage the patient to exercise and eat healthy on a regular basis. The patient would be encouraged
to increase water intake and fluids to prevent dry mouth and increase fiber to prevent constipation. The
patient should be reassessed in 4 weeks to monitor weight, BMI, labs, symptoms, side effects, mental
status and medication effectiveness.
Explain any difference between what you expected to achieve with Decision #3 and the results of the
decision. Why were they different?
There was no difference in what I expected to achieve with Decision # 3 and the results of the decision.
The results were as expected.
Lastly; there are more than a few things that can define how ethical considerations might
impact your treatment plan and communication with clients. For example; any physician ought
to consistent with their patients’ treatment plan which would help them in gaining their trust
and improve communication between the caretaker and the patient. Secondly; one should
apply the beneficence rue which mean they need to do what is good and for the best interest of
the patient. (Walshaw, et.al, 2017) Thirdly and lastly; one should take precautions to ensure
total confidentiality when it some sot a patients’ records and especially when using technology
such as computers, electronic mail among others.
Conclusion
In conclusion, it is clear that there is no evidence indicated how long patients with Bipolar I and acute
mania should be treated with Geodon. Based on this research it is clear that Geodon have demonstrated
some effectiveness in this case. One thing that remains clear is that patients need to be periodically
reassessed to assist with maintenance treatment and the correct dose and monitoring of side effects.
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Murphy, P., Rhoads, J., (2015). Clinical Consult to Psychiatric Nursing for Advanced Practice.
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