CENTRE FOR ADDICTION AND MENTAL HEALTH
Pharmacy Care Plan
Patient: RM
MRN: xxx542
DOB: 15/4/75 Sex: F
Working Dx: I. SCZ
Allergies: haloperidol ?( possible EPS)
Med Condition(s); mild leukopenia
Current Drug-related
Problem
Treatment
Goals
(1) pat. is still psychotic &
delusional (experiencing
auditory hallucination,
religiously preoccupied),
c/o many somatic sx
likely caused by meds
1.treat psychotic
sx without
significant
adverse effects
Date: ____________________
*PLEASE AFFIX TO CHART*
Current Medication
Regular
Risperidone 4mg bid
Paroxetine 20mg qam
Benztropine 2mg qam
Lorazepam 2mg bid
Special
Considerations
Assessment of
Options
1.mild leukopenia
1.Is she compliant?
2.Non-compliance with
medication, treatment
2. increase dose of
risperidone (up to
12mg/day)
3. add high potency
typical antipsychotics
such as haloperidol
(up to 10mg/day),
perphenazine (up to
32mg/day) or
loxapine ( up to
50mg/day) as
augmentation
4. switch to other
atypical antipsychotics
such as
Olanzapine (start with
5mg qhs up to
20mg/day), zydis
Quetiapine
(start with 100mg bid
up to 1000mg/day)
* clozapine-not an
option because of
leukopenia
5. switch to depot
clopixol decanoate
(200mg im q2w, up to
400mg im q2w,
clopixol acetate
400mg, 5 doses in total
as chemical restraint
PRN
Lorazepam 2mg po/im q1hx3,anxiety,agitation
Loxapine 25mg po/im x3,agitation
Clopixol acetate 50mg q48h,severe agitation, as
chemical restraint
Therapeutic
Recommendations
1.Wait and see, the
dose is high enough
2.monitor EPS/
akathisia closely
3. switch benztropine
to biperidine (up to
16mg/day) to
minimize peripheral
anticholinergic
adverse effects
4. increase
lorazepam
(up to 8mg/day) for
akathisia
Monitoring
Plan
Date
Follow Up
1.Check the pat.
after each dose
2.observe
psychotic
symptoms daily
3. evaluate the
efficacy and
adverse effects
of antipsychotics,
adjust the dose,
add, or switch
medications if
neccessary
4. monitor adverse
effects (esp.EPS,
akathisia) daily
5. add propranolol
(up to 40mg tid monitor bp ) or,
5. monitor
hypotension
6. add diphenhydramine (up to
150mg/d)
4. 6. monitor
excess dizziness,
drowsiness and
6. toxic delirium
Need oral supplement
which may be tapered
off in 10-20 weeks
(Takes 5 T1/2 to reach
steady state)
risperidone depot
coming in Jan 2003
Start with low
dose, increase
slowly while
monitor EPS and
other side effects.
Loading dose for
quick onset
Pharmacist (Print name & degree) _____________________________________________________
Nov/01
Current Drug-related
Problem
Treatment
Goals
Special
Considerations
Assessment of
Options
Therapeutic
Recommendations
Also, requires consent
for tx.
Clopixol 200mg im
q2w =20mg po /day
= risperidone 4mg/day
Flupenthixol decanoate
(start with25mg im q4w,
up to 80mg q2w)
Flupenthixol 50mg im
q2w = risperidone
4mg/day
Pipotiazine palmitate
(start with25mg im q2w,
up to 250mg q4w), or
Pipotiazine 25mg im
q2w = risperidone
4mg/day
Fluphenazine
decanoate
(start with 12.5mg im
q2w, up to 200mg im
q2w)
Fluphenazine 25mg im
q4w = risperidon
4mg/day
Monitoring
Plan
(2) Does this pat. require
paroxetine? – not
depressed, rather
manicky?
Is this for panic or
anxiety attack?
Minimize drug
induced adverse
effects such as
insomnia, anxiety
nausea,
akathsia,
constipation,
headache, and
drug induced
mania
discontinue paroxetine
Tapering off to
minimize the possible
withdrawal symptoms
Monitor dizziness,
lethargy, malaise
insomnia,nausea,
headache, fever,
electric -shock-like
sensation x48hrs
after d/c of
paroxetine
(3) pat. c/o insomnia,
day time drowsiness,
dizziness
resolve the
problem without
worsening of
psychosis or
adverse effects
1.Educate and counsel
the pat. for sleep
hygiene
1.avoid nap/ caffeine,
take hot bath and
drink hot milk before
go to bed
Monitor day time
drowsiness,
dizziness closely
2. Cut morning dose of
Lorazepam,
Risperidone, and
increase
Evening dose
2. warn the pat. reg.
Postural hypotension
(advise to get up
slowly)
3. Add other Bz,
zopiclone or chloral
hydrate for insomnnia
3. might worsen the
day time drowsiness,
dizziness
Date: ____________________
Date
Follow Up
Monitor sleep
pattern daily after
each adjustment
Pharmacist (Print name & degree) _____________________________________________________
Nov/01
Current Drug-related
Problem
Treatment
Goals
Date: ____________________
Special
Considerations
Assessment of
Options
Therapeutic
Recommendations
Monitoring
Plan
Date
Pharmacist (Print name & degree) _____________________________________________________
Follow Up
Nov/01
(4) pat.c/o nausea,
indigestion
(5) pat. c/o anxiousness,
occassional anxiety
attack
resolve the
problem without
worsening of
psychosis or
adverse effects
resolve the
problem without
worsening of
psychosis or
adverse effects
1.Possible adverse
effect from med
or somatic delusion
Monitor sx daily
2.Pat. education
Advise to take with
food
3.Maalox prn
15-30ml prn, separate
from other meds at
least 1 hr apart to
avoid interaction
1.Possible adverse
effect from risperidone
and paroxetine
(akathisia, EPS)
-> increase dose of
Lorazepam up to
12mg/day,
if not working well
Add diphenhydramine
Or propranolol
2. part of the illness
3. switch lorazepam to
other long acting Bz.
(clonazepam, diazepam)
4. Buspirone
takes long time,
ineffective as prn,
can’t cover withdrawal
sx. of Bz.
2. increase the dose of
antipsychotic
3. Lorazepam 2mg
=clonazepam 0.5mg
=diazepam 5mg
2.Monitor EPS &
other adverse
effects closely
3. monitor efficacy
after each change
is made
4. start with 10mg bid
up to 40mg/day
Anticholinergic effects
1.Pat.education and
counseling
(6) pat.c/o dry mouth
resolve the
problem without
worsening of
psychosis or
adverse effects
2. Oracare D spray
1. advise to drink more
water, sour juice,
chew sugarless gum,
brush teeth more
often
Monitor sx daily
2. coconut flavor,
use freely
Date: ____________________
Pharmacist (Print name & degree) _____________________________________________________
Nov/01
Current Drug-related
Problem
(7) pat. c/o mild
constipation
Treatment
Goals
resolve the
problem without
worsening of
psychosis or
adverse effects
(8) pat. c/o headache,
back pain
(9) pat. c/o back pain,
stiffness in legs
(10) pat. c/o missing
periods
Special
Considerations
Assessment of
Options
Anticholinergic effects
1.Pat.education and
counseling
2. lactulose
3. prodiem,
metamucil
4. docusate cal/ sod.
5. Bisacodyl tab/supp.
6. fleet enema
Monitoring
Plan
1.advise to take more
fiber, fruit, vegetable
prune juice
2. 15-60ml regularly
3. 5-10g regularly
15-30g regularly
4. prn basis
5. prn basis
6. reserve for the worst
Monitor sx daily
Use mild med first
1.could be part of
somatic delusion or
simple headache
1.Acetaminophen
500mg prn up to
4g/day
2.NSAIDS
2. adverse effect from
paroxetine or other
meds?
decrease the dose or
d/c unnecessary med
possible EPS
1.increrase dose of
benztropine for stiffness
1.up to 8mg/day
2. switch to other
antiparkinsonian agents
if benztropine is not
working well
2. amantadine
biperidine
ethopropazine
procyclidine
trihexyphenidyl
diphenhydramine
pat. counseling
probably due to
increased prolactin
caused by risperidone,
1.decrease the dose
1.may worsen
psychosis
2. not an option
because of leukopenia
3. less to similar risk
2.switch to clozapine?
3.switch to olanzapine or
quetiapine
Date: ____________________
Therapeutic
Recommendations
Date
Follow Up
monitor sx daily
(AIMS),
cogwheeling
and other sx.
Observe sx
closely
Pharmacist (Print name & degree) _____________________________________________________
Nov/01
Current Drug-related
Problem
(11) pat. worries about
possible weight gain
(12) pat. wants some
OTC allergy pills
Treatment
Goals
resolve the
problem without
worsening of
psychosis or
adverse effects
Recommend
appropriate
product that
dosen’t have
drug interaction
or affect the
efficacy of other
meds that she
takes
Special
Considerations
Assessment of
Options
Therapeutic
Recommendations
1.pat education and
counseling reg. diet,
exercise and weight
watch
Monitoring
Plan
Date
Follow Up
Measure body
weight weekly
Ask pat. to make a
list of what she
eats
2. switch to quetiapine?
risk of inducing weight
gain is similar to that of
risperidone,
clozapine or
olanzapine also has
high risk
3. switch to loxapine,
ziprasidone
or molindone
ziprasidone is an
Investigational drug
Molindone is not
available in Canada
1.old H1 receptor
antagonists such as
Diphenhydramine,
Pseudoephedrine
Or chlorpheniramine
may increase
sedation, drowsiness
and risk of collapse.
Advise not to drive,
get up slowly.
Also, increase the
risk of anticholinergic
toxic delirium.
Monitor closely
Advise to consult
with a pharmacist
or an MD before
taking any of
these meds to
avoid harmful
effects/ drug
interaction
2.non-drowsy H1receptor
antagonists such as
Cetirizine, or
Fexofenadine
3. steroid nasal spray
(13) pat. wants high dose
mega vitamins and
herbal medications
Educate and
counsel the pat.
Reg. appropriate
use of these
meds
Date: ____________________
1.high dose mega
vitamins
1.intake of excessive
amount of high dose
mega vitamin may
induce toxic adverse
effects
The efficacy for
schizophrenia
is not established
2. herbal medications
2. safety, efficacy and
quality of these
products are not well
established
Pharmacist (Print name & degree) _____________________________________________________
Nov/01