Transcript Post-ictal psychosis successfully treated with quetiapine

Alberto Augsten
Student Pharmacist
Nova Southeastern University
College of Pharmacy
Fort Lauderdale, FL
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Incidence of psychosis among epileptic
population:3-7%1
PIP accounts for ~25% of the psychosis of
epilepsy (POE) population2
Onset of PIP usually occurs within seven days
of a seizure3
Patients with POE present with positive
symptoms as in schizophrenia3
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POE is generally classified as a group of psychotic
disorders based on temporal occurrence of
psychosis and seizures3
POE can be divided as follows:3
 Ictal psychosis (when psychosis is an expression of
seizure activity)
 Post-ictal psychosis (when psychosis occurs within 7
days of a seizure)
 Inter-ictal psychosis (when psychosis appears
independently of seizures)
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Main challenge for PIP patients is epileptogenic
activity of antipsychotics
Various antipsychotics used in the treatment
of PIP include:
 Haloperidol, molindone, fluphenazine, perphenazine
and risperidone (no predefined length of
treatment)2,3,4
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Evidence-based treatment with antipsychotics
for post-ictal psychosis is limited
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Differential Diagnosis
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Antiepileptic toxicity
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Drug induced
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Psychogenic seizures
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Schizophrenia
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HPI: 36 yo WM with no previous history of mental illness presented
to the psychiatric emergency room following several seizures with
no loss of consciousness over the past few days prior to admission
Patient reported his first seizure at the age of 12, making his onset
of PIP 24 years
Psychosis developed within one week of his seizure and lasted less
than three months
Symptoms: confusion, verbal aggression, auditory and visual
hallucinations
Previous episode: mental status changes during the post-ictal state;
however, symptoms lasted a few minutes
Current episode: post-ictal state lasted ~24 hours accompanied with
persistent confusion, auditory and visual hallucinations
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PMH
 Seizure disorder
since age 12
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 Combination Grand
Mal and Petite Mal
seizures (per father)
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HTN
Head CT negative for acute
changes/hemorrhage
Drug screen urinalysis
negative for illegal
substances
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No recent history of alcohol
use was documented
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All labs were within normal
limits
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No other seizure activity was
noted during hospital stay
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Oxcarbazepine (Trileptal®) 300 mg PO BID
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Zonisamide (Zonegran®) 100 mg PO Daily
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Citalopram (Celexa®) 40mg PO Daily
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Hydrochlorothiazide 25mg PO Daily
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Metoprolol (Lopressor®) 25mg PO BID
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Hospital Course
2nd Admission
1st Admission
Hospital Course
Medications
•Patient became
calm and denied
auditory or visual
hallucinations by
the end of his stay
•Discharged after
seven days with a
resolution of
psychosis
•Quetiapine 25 mg BID
initiated on day two of
admission
•Patient became
calm and denied
auditory or visual
hallucinations by
the end of his stay
•Discharged after
four days with a
resolution of
psychosis
•Patient was continued on
previous discharge
medications except:
•Titrated to 50 mg BID on
day four
•Clorazepate 3.75 mg ½
tablet QHS
•Quetiapine 150mg QHS
were added
Discharged Medications
1.Quetiapine 50mg BID
2.Oxcarbazepine 300mg BID
3.Zonisamide 100mg Daily
4.Citalopram 40mg Daily
5.HCTZ 25mg Daily
6.Metoprolol 25mg BID
1.Quetiapine 50mg qam,
150mg qHS
2.Clorazepate 3.75mg ½
tab qHS
3.Oxcarbazepine 300mg BID
4.Zonisamide 100mg Daily
5.Citalopram 40mg Daily
6.HCTZ 25mg Daily
7.Metoprolol 25mg BID
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Patient is currently being followed as an
outpatient by his psychiatrist
He denies any auditory or visual
hallucinations
Patient has not been readmitted for PIP (seven
months since last admission)
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MEDLINE search revealed no published case
reports for the treatment of PIP with
quetiapine
Other antipsychotic use in POE is limited to
cases and unpublished data
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Farooq and Sherin: performed a comprehensive literature review
which compared drugs and non-pharmacological interventions in
patients with epilepsy with psychotic symptoms 7
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One unpublished, randomized controlled trial met criteria
for inclusion
 Olanzapine (10 mg/day) vs. haloperidol (12 mg/day) in 16 adult
patients with “schizophrenia-like” psychosis of epilepsy
 Patients were evaluated with EEG recordings and brief psychiatric
rating scale (BPRS) at baseline, 3 and 6 months
 Thirteen patients completed the study
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Olanzapine treated patients had improvements in BPRS
scores at endpoint (p=0.02)
Limitations: small population size, lacked power to evaluate
the efficacy of antipsychotics in patients with POE
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“Postictal psychiatric events during prolonged
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Results:
 5/10 patients who experienced PIP after
video-electroencephalographic monitoring studies”
undergoing video EEG monitoring, treated
effectively with low dose haloperidol (2-5 mg/day)
 One patient required haloperidol 40 mg/day
 Remaining patients (3/10) resolved without
medication8
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Limitations: lack of reported duration of treatment
and efficacy was not measured by any specific scale
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SGA
N
# of Seizures
%
Clozapine
1742
61
3.5
Olanzapine
2500
23
0.9
Quetiapine
2387
18
0.8
Aripiprazole
4710
18
0.4
Ziprasidone
3834
15
0.4
Risperidone
2607
7
0.3
Alper K, et al Biol Psychiatry 2007;62:345-354.
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We report the first case of quetiapine used
successfully to treat a patient with post-ictal
psychosis
During both hospitalizations, patient remained
seizure free and had resolution of his psychotic
symptoms as his antiepileptic medications were
increased and quetiapine was titrated from 25 mg BID
to a total daily dose of 200 mg
Further randomized controlled trials with
antipsychotics in epileptic patients suffering from
psychosis are necessary to determine the most
appropriate treatment, dosages and duration of
therapy
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Anticonvulsant toxicity was not ruled out
 Oxcarbazepine 300 mg twice a day for one month
before psychosis developed
 Zonisamide (100 mg daily) duration of treatment
unknown
 Drug serum levels not obtained
 Toxicity unlikely since his medications were
continued and titrated throughout his admission
without further exacerbation of his psychosis
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Acknowledgements
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Jehan Marino, PharmD, BCPP
Assistant Professor of Pharmacy Practice
Nova Southeastern University
College of Pharmacy
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Joseph Henry, MD, FAPA
Assistant Professor of Psychiatry and Behavioral Sciences
University of Miami
Leonard M. Miller School of Medicine
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Devinsky O. Postictal psychosis: common, dangerous, and treatable. Epilepsy
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Alper K, Schwartz KA, Kolts RL, et al. Seizure incidence in psychopharmacological
clinical trials: an analysis of Food and Drug Administration (FDA) summary basis of
approval reports. Biological Psychiatry 2007; 62:345-354
Farooq S, Sherin A. Interventions for psychotic symptoms concomitant with
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