Clinical Assessment and Therapeutic Intervention
Urgent assessment of serum concentrations of APs at admission was conducted. Serum concentrations of ziprasidone, risperidone, aripiprazole, sulpiride, olanzapine, and clozapine were at 174.34 ng/mL, 62.29 ng/mL, 986.91 ng/mL, 6551.00 ng/mL, 83.78 ng/mL, and 336.52 ng/mL. Physical examination (including blood, urine, stool tests, and head Magnetic Resonance Imaging (MRI)) showed no abnormality, and her vital signs were stable. An electrocardiogram (ECG) showed sinus rhythm, incomplete right bundle branch block, and partial T-wave changes. Admission assessment of psychiatric symptoms showed the existence of delusion, aprosexia, retardation, hypobulia, and lack of insight. The scores of Scale for Assessment of Negative Symptoms (SANS), Scale for Assessment of Positive Symptoms (SAPS), and Treatment Emergent Symptom Scale (TESS) were 47, 23, and 0. Pharmacogenomic examination is shown in Supplementary Table 1 .
The patient was diagnosed with “schizophrenia, drug intoxication”, an infusion of 2000 ml isotonic solution was given daily to accelerate drug excretion with vital signs were closely monitored. Medication was adjusted to “risperidone 6 mg/day, clozapine 300 mg/day, trihexyphenidyl 4 mg/day, propranolol 20 mg/day, and vitamin complex 3 tablets”. Serum concentrations of sulpiride, olanzapine, and aripiprazole decreased to <10 ng/mL, 12.61 ng/mL, and 414.91 ng/mL at the fourth day, and infusion and monitoring was stopped.
Since reducing the dose of medication, clinical symptoms were weekly assessed by clinical scales, the results showed that symptoms did not decrease at the first two weeks. And the patient started to become anxious and worried that her symptoms would worsen. And she had no bowel movements for 3 days. We added sertraline 50mg daily to treat her anxiety, and then the dose was increased to 100 mg/day due to poor effect at the next week. Lactulose oral solution (20 mL/day) was administered for short-term bowel movements.
At discharge, her condition was stable and the medication regime was “risperidone 6 mg/day, clozapine 275 mg/day, sertraline 100 mg/day, trihexyphenidyl 4 mg/day, and propranolol 20 mg/day”. Three months later, she came to the clinic for review. Details of drug doses are “risperidone 6 mg/day, clozapine 275 mg/day, sertraline 150 mg/day, trihexyphenidyl l4 mg/day, and propranolol 20 mg/day”. The scores of SANS, SAPS, TESS, Hamilton Anxiety Scale (HAMA), and Bech-Rafaelsdn Mania Rating Scale (BMRS) were 18, 4, 4, 14, and 2. Sertraline dose was increased to 175 mg/day for anxiety symptoms.