Lurasidone in Antipsychotic Therapy – A Case Study of a Virtual Patient from the Laurie Project

Introduction

The aim of this interactive case study was to educate regarding the indication and administration of lurasidone, its prescription restrictions, initial and maximum dosage for acute treatment, dosage adjustment for patients with renal failure, and switching from another antipsychotic to lurasidone. Although the case involved a 'virtual' patient, the case study was based on real clinical practice.

Case Description and Course

The initial situation involved the transfer of a patient from the acute admission department of a nearby psychiatric hospital due to congenital renal dysplasia with chronic renal failure, albeit of a mild degree. The patient had a rich pharmacological history, including quetiapine p.o. at a daily dose of 300 mg, clonazepam p.o. at a daily dose of 1.5 mg, and additional clonazepam i.m. as needed, up to 1 ampoule 3 times a day.

Following the initial psychiatric examination, a diagnosis of acute schizophreniform psychotic disorder was made, although the patient also complained of weakness and dizziness. Therefore, basic somatic examinations (BP, ECG, biochemistry, blood count, urine analysis, and urine toxicology) were indicated. These revealed hypotension (90/60 mmHg), mild sinus tachycardia (112/min), and signs of renal failure.

Workshop participants decided to change the treatment to another preparation, rather than titrating quetiapine, due to the risk of collapse with hypotension. Initially, risperidone was indicated, titrated to a daily dose of 4 mg. After 2 weeks of this therapy, the patient's condition improved, but auditory hallucinations persisted, and the patient continued to speak of his 'grand plans.' He also complained of nipple pain, and laboratory tests revealed elevated prolactin levels. Given the adverse effects of risperidone, a cross-tapering to lurasidone to a daily dose of 37 mg was decided (thus, the dose of the original drug was gradually reduced, and the dose of lurasidone simultaneously increased to the target dose over several days).

After just one week, an improvement in the patient's condition was observable, with a noticeable reduction in formal thought disorders. However, the patient still described occasional auditory hallucinations and mentioned his 'grand plans.' After another week, the daily dose of lurasidone was increased to 74 mg, further improving the patient's condition. During conversations, occasional paralogies were noticeable, but the patient described that the 'spirits' were speaking to him minimally. The patient's parents, who visited him, also joyfully described his improvement but noted it still wasn't 'their Honza.'

In the following week, an MRI examination for differential diagnosis was performed, which was without pathological findings. However, the patient's parents began to be nervous, and given the residual symptoms, the daily dose of lurasidone was further increased to 111 mg. After another week, the patient's condition improved again, with a complete disappearance of auditory hallucinations and formal thought disorders.

Two weeks later, the patient developed unpleasant sensations in his legs, compelling him to continually move and stretch his legs. Given the kidney disease, a control examination of kidney function was indicated, revealing moderate renal failure.

In the context of psychopharmacological therapy, it was decided to consult a clinical pharmacologist, who recommended a lurasidone dose of 18.5–74 mg once daily for moderate renal failure. Therefore, the dose was reduced to 74 mg, and after 2 days, no side effects were present. The patient was stabilized on this dose and discharged to outpatient care after 3 weeks.

Conclusion

The lecturer concluded that the real patient, who was the basis for this virtual case study, underwent a successful kidney transplant, did not relapse into psychotic illness, and continues to do well on lurasidone medication.

The interactive case study captures the decision-making process in clinical practice as faithfully as possible – in this case, the conversion to lurasidone therapy and the subsequent dosage titration to achieve the optimal therapeutic dose, including possible complications in a patient with somatic comorbidity.

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Source: Bartečků E. Laurie – virtual patient v2. Interactive case studies inspired by real patients. Symposium 'A Look at Schizophrenia Treatment in the 21st Century.' XIV Congress of the Psychiatric Society of the CLS JEP, Mikulov, 16 June 2022. Available at: www.youtube.com/watch?v=2y2ulTy1Ck0