Psychotic patient with high cardiometabolic risk – interactive case report

The patient is a 44-year-old woman, single, childless, living in an apartment with her boyfriend. She graduated from a vocational secondary school and worked as a seamstress. She has been on long-term disability due to a psychotic disorder.

From her medical history, it is important to note that she is being treated for type 2 diabetes mellitus (taking oral antidiabetics), dyslipidemia (treated with statins), and has had recurrent thromboembolic events. She is obese and smokes. From a cardiometabolic perspective, she is therefore highly at risk.

The diagnosis of paranoid schizophrenia was made in 2005 during hospitalization at a psychiatric clinic. She was treated with ziprasidone at a dose of 160 mg per day. Due to persistent negative symptoms and residual auditory hallucinations, she was switched to aripiprazole 15 mg per day. She then remained in a stable condition for 10 years, after which a relapse occurred. Olanzapine was prescribed at a maximum dose of 30 mg per day, temporarily combined with haloperidol up to 6 mg per day. Due to dominant negative symptoms, weight gain, and dyslipidemia, a change to cariprazine 6 mg per day was done via slow cross-titration. This resulted in a reduction of negative symptoms and an improvement in metabolic parameters.

Upon the incipient relapse, therapy with olanzapine 20 mg per day in combination with risperidone 1 mg per day was reintroduced. While positive symptoms subsided under this treatment, negative symptoms became dominant once again. The patient complained of sedation and significant sexual dysfunction. There was a substantial weight gain (10 kg) and worsening of metabolic parameters. The estimated vascular age of the patient was 68 years (!).

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The patient was repeatedly instructed on a healthy lifestyle (dietary measures, exercise, smoking cessation), but she was unable to follow these principles.

Weight gain, worsening of metabolic parameters, sedation, and sexual dysfunction appeared in connection with olanzapine administration. Therefore, a slow cross-titration to a metabolically sparing antipsychotic was implemented.

Tab.  The relative risk of developing cardiometabolic symptoms with different antipsychotics

We opted to introduce lurasidone at a dose of 74 mg instead of risperidone. Subsequently, we gradually reduced the dose of olanzapine over several weeks and increased lurasidone to the target dose of 148 mg per day. Due to the insufficient effect of aripiprazole in the patient's history and unsuccessful attempts to switch to cariprazine, we chose to treat with lurasidone. Lurasidone is an antipsychotic from the group of serotonin and dopamine antagonists (SDA), which is metabolically sparing and suitable for a patient prone to sedation, with the presence of sexual dysfunction, and with a history of recurrent relapses.

Currently, the patient has been maintained on monotherapy with lurasidone 148 mg per day for 10 months. There has been a weight loss of 15 kg and significant improvement in metabolic parameters (glucose levels and lipid profiles within normal ranges). Sedation and sexual dysfunction have resolved. The medication is effective in long-term maintenance therapy for relapse prevention.

Prof. MUDr. Jiří Masopust, Ph.D.
Psychiatric Clinic, Faculty of Medicine, Charles University and University Hospital Hradec Králové