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Orally disintegrating olanzapine for the treatment of a manic patient with esophageal stricture plus chronic pharyngitis
Progress in Neuro-Psychopharmacology & Biological Psychiatry 31 (2007) 541 – 542 www.elsevier.com/locate/pnpbp
Case report
Orally disintegrating olanzapine for the treatment of a manic patient with esophageal stricture plus chronic pharyngitis Yu-Chih Shen a,b,c,⁎, Mei-Ying Lee a , Chaucer C.H. Lin a,b,c , Chia-Hsiang Chen a,b,c a
c
Department of Psychiatry, Tzu-Chi General Hospital, Hualien City, Taiwan, ROC b Department of Psychiatry, Tzu-Chi University, Hualien City, Taiwan, ROC Graduate Institute of Human Genetics, Tzu-Chi University, Hualien City, Taiwan, ROC
Received 5 July 2006; received in revised form 6 September 2006; accepted 7 September 2006 Available online 6 October 2006
Abstract An orally disintegrating tablet formulation of olanzapine (ODT olanzapine) is designed to dissolve rapidly upon contact with saliva. We describe a manic patient who has an esophageal stricture and chronic pharyngitis, two conditions that impede the swallowing of medications. She was successfully treated for her mania with this orally disintegrating formulation. This case report shows that ODT olanzapine may be useful in the psychiatric management of manic and other patients for whom olanzapine is appropriate, and who have an underlying medical condition that impedes swallowing oral medications. © 2006 Elsevier Inc. All rights reserved. Keywords: Chronic pharyngitis; Esophageal stricture; Olanzapine
1. Introduction
2. Case report
Antipsychotic medications are the treatment of choice for psychosis, and are frequently part of the treatment regimen for mood disorder (Yatham et al., 2005). Currently, numerous atypical antipsychotic agents such as risperidone, olanzapine, quetiapine and aripiprazole are approved for the treatment of acute manic episodes (Yatham et al., 2005). Although these agents all show some degree of efficacy, problems may arise with non-compliance in taking them. An orally disintegrating tablet formulation of olanzapine (ODT olanzapine) is designed to dissolve upon contact with saliva and provides an alternative method of administering an antipsychotic to patients whose noncompliance is due to difficulty in swallowing (Citrome, 2004; Freudenreich, 2003). The case report below shows ODT olanzapine to be helpful in the treatment of a non-compliant manic patient with an esophageal stricture complicated by chronic pharyngitis that impeded the swallowing of medications.
Ms. L, a 20-year-old woman, was admitted to the hospital because her relatives were worried about her “unusual behavior.” She was convinced that a particular man she knew from long before was communicating with her to express his love. A psychiatric examination revealed racing thoughts, and speech that was circumstantial, partly incomprehensible, and not directed. Her mood was elated and sometimes irritable. She was unusually self-confident, showed psychomotor agitation, and reported a decreased need of sleep. These symptoms had developed within a few days and had now lasted for about 2 weeks. Clearly, she was suffering from a manic episode with psychotic features. During hospitalization, Ms. L was treated initially with controlled-release valproate (1000 mg/day) and risperidone (2 mg/ day). The patient, however, exhibited non-compliant behavior, including failure to swallow pills and expulsion of the pills from her mouth. In addition to refusing to swallow the pills, Ms. L also complained of solid-food and liquid dysphagia. An internist was therefore asked to evaluate the possibility of an esophageal stricture. A double-contrast esophagram showed the patient to have a partial obstruction due to a stricture in the upper thoracic
⁎ Corresponding author. Department of Psychiatry, Tzu-Chi General Hospital, 707, Sec. 3, Chung Yang Rd, Hualien 970, Taiwan. Tel.: +886 3 8561825; fax: +886 3 8577161. E-mail address: [email protected] (Y.-C. Shen). 0278-5846/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pnpbp.2006.09.003
542
Y.-C. Shen et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry 31 (2007) 541–542
esophagus. Diagnostic endoscopy and tissue pathology were next performed in order to rule out the possibility that the stricture was caused by a malignancy. An otolaryngologist who was also consulted diagnosed, in addition, the existence of chronic pharyngitis due to frequent regurgitation of stomach acid. After these diagnoses, liquid formulations of valproate and risperidone were prescribed instead to treat the manic symptoms, but the patient still could not be persuaded to swallow, because of her oropharngeal irritation and dysphagia. A parenteral atypical antipsychotic medication, olanzapine 20 mg/day, was next used for the following 2 weeks. Although the manic symptoms improved and the patient's score on the Young Mania Rating Scale (YMRS) decreased from 48 to 34, the frequent injections made her muscles stiff. Therefore, oral treatment with rapidly-dissolving olanzapine was substituted for the parenteral preparation. Because of the rapid oral dissolution of this preparation, no difficulty was encountered with its administration. Treatment with ODT olanzapine, combined with behavior therapy, resulted in gradual improvement of her manic symptoms over a period of 1 month, and a further decrease in the YMRS, from 34 to 20, occurred. Her chronic pharyngitis was treated, successfully, with local antibacterial oral inhalation. After her mania subsided, the esophageal stricture was treated with bougie dilation and adjunctive use of acid-suppressing medications.
and Donner, 1987). The majority of benign strictures are acidrelated (Marks and Richter, 1993). Benign strictures are best managed by esophageal dilation with the addition of acidsuppressing medications if the stricture is thought to be caused by acid reflux (Levine and Rubesin, 2005; Patterson et al., 1983). If dysphagia recurs, repeat dilation should be performed. There are also a variety of interventions for refractory strictures, such as injection of intra-lesional corticosteroids, temporary placement of self-expanding plastic stents, and surgery (Levine and Rubesin, 2005). 4. Conclusion In conclusion, the case presented here suggests that the ODT olanzapine is helpful for the treatment of an acute manic episode, when medication non-compliance is the result of difficulty in swallowing due to an esophageal stricture accompanied by chronic pharyngitis. Currently, numerous psychotropic agents such as risperidone, aripiprazole, mirtazapine, citalopram, alprazolam and clonazepam are available with orally disintegrating tablets. These quickly dissolving formulations may be useful for the treatment of our psychiatric patients with non-compliance behaviors and who have an underlying medical condition which impedes taking oral medications. References
3. Discussion Many factors influence compliance, including those that affect patients' beliefs about their illness and the benefits of treatment (e.g., insight into illness, belief that medication can ameliorate symptoms), perceived costs of treatment (e.g., medication side effects), and barriers to treatment (e.g., ease of access to treatment, degree of family or social support) (Perkins, 2002). To our knowledge, this is the first description of medication noncompliance as a result of esophageal stricture plus chronic pharyngitis in a manic patient. It appears that the ODT olanzapine may be helpful for the treatment of this kind of patient. Taken together, our case and previous reports of ODT olanzapine for the treatment of acutely ill non-compliant patients with schizophrenia or schizoaffective disorder (Kinon et al., 2003), and psychotic and behavioral disturbances associated with dementia (Reeves and Torres, 2003), suggest that this formulation could facilitate antipsychotic medication compliance. To follow the example described here, a patient with frequent solid food or liquid dysphagia should be evaluated for the presence of an esophageal stricture (Castell and Donner, 1987). A combination of a barium esophagram and endoscopy can differentiate whether the strictures is benign or malignant (Castell
Castell DO, Donner MW. Evaluation of dysphagia: a careful history is crucial. Dysphagia 1987;2:65–71. Citrome L. Re: treatment noncompliance with orally disintegrating olanzapine tablets. Can J Psychiatry 2004;49:413. Freudenreich O. Treatment noncompliance with orally disintegrating olanzapine tablets. Can J Psychiatry 2003;48:353–4. Kinon BJ, Hill AL, Liu H, Kollack-Walker S. Olanzapine orally disintegrating tablets in the treatment of acutely ill non-compliant patients with schizophrenia. Int J Neuropsychopharmacol 2003;6:97-102. Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology 2005;237:414–27. Marks RD, Richter JE. Peptic strictures of the esophagus. Am J Gastroenterol 1993;88:1160–73. Patterson DJ, Graham DY, Smith JL, Schwartz JT, Alpert E, Lanza FL, et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 1983;85:346–50. Perkins DO. Predictors of noncompliance in patients with schizophrenia. J Clin Psychiatry 2002;63:1121–8. Reeves RR, Torres RA. Orally disintegrating olanzapine for the treatment of psychotic and behavioral disturbances associated with dementia. South Med J 2003;96:699–701. Yatham LN, Kennedy SH, O'Donovan C, Parikh S, MacQueen G, McIntyre R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.
Case report
Orally disintegrating olanzapine for the treatment of a manic patient with esophageal stricture plus chronic pharyngitis Yu-Chih Shen a,b,c,⁎, Mei-Ying Lee a , Chaucer C.H. Lin a,b,c , Chia-Hsiang Chen a,b,c a
c
Department of Psychiatry, Tzu-Chi General Hospital, Hualien City, Taiwan, ROC b Department of Psychiatry, Tzu-Chi University, Hualien City, Taiwan, ROC Graduate Institute of Human Genetics, Tzu-Chi University, Hualien City, Taiwan, ROC
Received 5 July 2006; received in revised form 6 September 2006; accepted 7 September 2006 Available online 6 October 2006
Abstract An orally disintegrating tablet formulation of olanzapine (ODT olanzapine) is designed to dissolve rapidly upon contact with saliva. We describe a manic patient who has an esophageal stricture and chronic pharyngitis, two conditions that impede the swallowing of medications. She was successfully treated for her mania with this orally disintegrating formulation. This case report shows that ODT olanzapine may be useful in the psychiatric management of manic and other patients for whom olanzapine is appropriate, and who have an underlying medical condition that impedes swallowing oral medications. © 2006 Elsevier Inc. All rights reserved. Keywords: Chronic pharyngitis; Esophageal stricture; Olanzapine
1. Introduction
2. Case report
Antipsychotic medications are the treatment of choice for psychosis, and are frequently part of the treatment regimen for mood disorder (Yatham et al., 2005). Currently, numerous atypical antipsychotic agents such as risperidone, olanzapine, quetiapine and aripiprazole are approved for the treatment of acute manic episodes (Yatham et al., 2005). Although these agents all show some degree of efficacy, problems may arise with non-compliance in taking them. An orally disintegrating tablet formulation of olanzapine (ODT olanzapine) is designed to dissolve upon contact with saliva and provides an alternative method of administering an antipsychotic to patients whose noncompliance is due to difficulty in swallowing (Citrome, 2004; Freudenreich, 2003). The case report below shows ODT olanzapine to be helpful in the treatment of a non-compliant manic patient with an esophageal stricture complicated by chronic pharyngitis that impeded the swallowing of medications.
Ms. L, a 20-year-old woman, was admitted to the hospital because her relatives were worried about her “unusual behavior.” She was convinced that a particular man she knew from long before was communicating with her to express his love. A psychiatric examination revealed racing thoughts, and speech that was circumstantial, partly incomprehensible, and not directed. Her mood was elated and sometimes irritable. She was unusually self-confident, showed psychomotor agitation, and reported a decreased need of sleep. These symptoms had developed within a few days and had now lasted for about 2 weeks. Clearly, she was suffering from a manic episode with psychotic features. During hospitalization, Ms. L was treated initially with controlled-release valproate (1000 mg/day) and risperidone (2 mg/ day). The patient, however, exhibited non-compliant behavior, including failure to swallow pills and expulsion of the pills from her mouth. In addition to refusing to swallow the pills, Ms. L also complained of solid-food and liquid dysphagia. An internist was therefore asked to evaluate the possibility of an esophageal stricture. A double-contrast esophagram showed the patient to have a partial obstruction due to a stricture in the upper thoracic
⁎ Corresponding author. Department of Psychiatry, Tzu-Chi General Hospital, 707, Sec. 3, Chung Yang Rd, Hualien 970, Taiwan. Tel.: +886 3 8561825; fax: +886 3 8577161. E-mail address: [email protected] (Y.-C. Shen). 0278-5846/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.pnpbp.2006.09.003
542
Y.-C. Shen et al. / Progress in Neuro-Psychopharmacology & Biological Psychiatry 31 (2007) 541–542
esophagus. Diagnostic endoscopy and tissue pathology were next performed in order to rule out the possibility that the stricture was caused by a malignancy. An otolaryngologist who was also consulted diagnosed, in addition, the existence of chronic pharyngitis due to frequent regurgitation of stomach acid. After these diagnoses, liquid formulations of valproate and risperidone were prescribed instead to treat the manic symptoms, but the patient still could not be persuaded to swallow, because of her oropharngeal irritation and dysphagia. A parenteral atypical antipsychotic medication, olanzapine 20 mg/day, was next used for the following 2 weeks. Although the manic symptoms improved and the patient's score on the Young Mania Rating Scale (YMRS) decreased from 48 to 34, the frequent injections made her muscles stiff. Therefore, oral treatment with rapidly-dissolving olanzapine was substituted for the parenteral preparation. Because of the rapid oral dissolution of this preparation, no difficulty was encountered with its administration. Treatment with ODT olanzapine, combined with behavior therapy, resulted in gradual improvement of her manic symptoms over a period of 1 month, and a further decrease in the YMRS, from 34 to 20, occurred. Her chronic pharyngitis was treated, successfully, with local antibacterial oral inhalation. After her mania subsided, the esophageal stricture was treated with bougie dilation and adjunctive use of acid-suppressing medications.
and Donner, 1987). The majority of benign strictures are acidrelated (Marks and Richter, 1993). Benign strictures are best managed by esophageal dilation with the addition of acidsuppressing medications if the stricture is thought to be caused by acid reflux (Levine and Rubesin, 2005; Patterson et al., 1983). If dysphagia recurs, repeat dilation should be performed. There are also a variety of interventions for refractory strictures, such as injection of intra-lesional corticosteroids, temporary placement of self-expanding plastic stents, and surgery (Levine and Rubesin, 2005). 4. Conclusion In conclusion, the case presented here suggests that the ODT olanzapine is helpful for the treatment of an acute manic episode, when medication non-compliance is the result of difficulty in swallowing due to an esophageal stricture accompanied by chronic pharyngitis. Currently, numerous psychotropic agents such as risperidone, aripiprazole, mirtazapine, citalopram, alprazolam and clonazepam are available with orally disintegrating tablets. These quickly dissolving formulations may be useful for the treatment of our psychiatric patients with non-compliance behaviors and who have an underlying medical condition which impedes taking oral medications. References
3. Discussion Many factors influence compliance, including those that affect patients' beliefs about their illness and the benefits of treatment (e.g., insight into illness, belief that medication can ameliorate symptoms), perceived costs of treatment (e.g., medication side effects), and barriers to treatment (e.g., ease of access to treatment, degree of family or social support) (Perkins, 2002). To our knowledge, this is the first description of medication noncompliance as a result of esophageal stricture plus chronic pharyngitis in a manic patient. It appears that the ODT olanzapine may be helpful for the treatment of this kind of patient. Taken together, our case and previous reports of ODT olanzapine for the treatment of acutely ill non-compliant patients with schizophrenia or schizoaffective disorder (Kinon et al., 2003), and psychotic and behavioral disturbances associated with dementia (Reeves and Torres, 2003), suggest that this formulation could facilitate antipsychotic medication compliance. To follow the example described here, a patient with frequent solid food or liquid dysphagia should be evaluated for the presence of an esophageal stricture (Castell and Donner, 1987). A combination of a barium esophagram and endoscopy can differentiate whether the strictures is benign or malignant (Castell
Castell DO, Donner MW. Evaluation of dysphagia: a careful history is crucial. Dysphagia 1987;2:65–71. Citrome L. Re: treatment noncompliance with orally disintegrating olanzapine tablets. Can J Psychiatry 2004;49:413. Freudenreich O. Treatment noncompliance with orally disintegrating olanzapine tablets. Can J Psychiatry 2003;48:353–4. Kinon BJ, Hill AL, Liu H, Kollack-Walker S. Olanzapine orally disintegrating tablets in the treatment of acutely ill non-compliant patients with schizophrenia. Int J Neuropsychopharmacol 2003;6:97-102. Levine MS, Rubesin SE. Diseases of the esophagus: diagnosis with esophagography. Radiology 2005;237:414–27. Marks RD, Richter JE. Peptic strictures of the esophagus. Am J Gastroenterol 1993;88:1160–73. Patterson DJ, Graham DY, Smith JL, Schwartz JT, Alpert E, Lanza FL, et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 1983;85:346–50. Perkins DO. Predictors of noncompliance in patients with schizophrenia. J Clin Psychiatry 2002;63:1121–8. Reeves RR, Torres RA. Orally disintegrating olanzapine for the treatment of psychotic and behavioral disturbances associated with dementia. South Med J 2003;96:699–701. Yatham LN, Kennedy SH, O'Donovan C, Parikh S, MacQueen G, McIntyre R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005;7(Suppl 3):5-69.