CENTRE FOR ADDICTION AND MENTAL HEALTH



CENTRE FOR ADDICTION AND MENTAL HEALTH *PLEASE AFFIX TO CHART*

Pharmacy Care Plan

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|Patient: RM MRN: xxx542 |Current Medication |

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|DOB: 15/4/75 Sex: F Working Dx: I. SCZ |Regular |PRN |

| |Risperidone 4mg bid |Lorazepam 2mg po/im q1hx3,anxiety,agitation |

|Allergies: haloperidol ?( possible EPS) |Paroxetine 20mg qam |Loxapine 25mg po/im x3,agitation |

| |Benztropine 2mg qam |Clopixol acetate 50mg q48h,severe agitation, as chemical restraint |

|Med Condition(s); mild leukopenia |Lorazepam 2mg bid | |

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|Current Drug-related Problem |Treatment Goals |Special Considerations |Assessment of Options |Therapeutic Recommendations |Monitoring Plan |Date |Follow Up |

|(1) pat. is still psychotic & |1.treat psychotic |1.mild leukopenia |1.Is she compliant? |1.Wait and see, the dose is |1.Check the pat. | | |

|delusional (experiencing |sx without | | |high enough |after each dose | | |

|auditory hallucination, |significant |2.Non-compliance with |2. increase dose of |2.monitor EPS/ |2.observe | | |

|religiously preoccupied), |adverse effects |medication, treatment |risperidone (up to |akathisia closely |psychotic | | |

|c/o many somatic sx | | |12mg/day) | |symptoms daily | | |

|likely caused by meds | | |3. add high potency |3. switch benztropine |3. evaluate the | | |

| | | |typical antipsychotics |to biperidine (up to |efficacy and | | |

| | | |such as haloperidol |16mg/day) to |adverse effects | | |

| | | |(up to 10mg/day), |minimize peripheral |of antipsychotics, | | |

| | | |perphenazine (up to |anticholinergic |adjust the dose, | | |

| | | |32mg/day) or |adverse effects |add, or switch | | |

| | | |loxapine ( up to | |medications if | | |

| | | |50mg/day) as |4. increase |neccessary | | |

| | | |augmentation |lorazepam |4. monitor adverse | | |

| | | |4. switch to other |(up to 8mg/day) for |effects (esp.EPS, | | |

| | | |atypical antipsychotics |akathisia |akathisia) daily | | |

| | | |such as | | | | |

| | | |Olanzapine (start with |5. add propranolol |5. monitor | | |

| | | |5mg qhs up to |(up to 40mg tid - |hypotension | | |

| | | |20mg/day), zydis |monitor bp ) or, | | | |

| | | |Quetiapine | | | | |

| | | |(start with 100mg bid |6. add diphen- |4. 6. monitor excess | | |

| | | |up to 1000mg/day) |hydramine (up to |dizziness, | | |

| | | |* clozapine-not an |150mg/d) |drowsiness and 6. toxic | | |

| | | |option because of | |delirium | | |

| | | |leukopenia | | | | |

| | | |5. switch to depot |Need oral supplement which |Start with low dose, | | |

| | | |clopixol decanoate |may be tapered off in 10-20 |increase slowly while | | |

| | | |(200mg im q2w, up to |weeks |monitor EPS and other | | |

| | | |400mg im q2w, |(Takes 5 T1/2 to reach steady |side effects. | | |

| | | |clopixol acetate |state) |Loading dose for quick | | |

| | | |400mg, 5 doses in total |risperidone depot coming in |onset | | |

| | | |as chemical restraint |Jan 2003 | | | |

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|Current Drug-related Problem |Treatment Goals |Special Considerations |Assessment of Options |Therapeutic Recommendations |Monitoring Plan |Date |Follow Up |

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| | | |Also, requires consent |Clopixol 200mg im q2w =20mg | | | |

| | | |for tx. |po /day | | | |

| | | | |= risperidone 4mg/day | | | |

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| | | | | | | | |

| | | |Flupenthixol decanoate |Flupenthixol 50mg im q2w = | | | |

| | | |(start with25mg im q4w, up to |risperidone 4mg/day | | | |

| | | |80mg q2w) | | | | |

| | | | |Pipotiazine 25mg im q2w = | | | |

| | | |Pipotiazine palmitate |risperidone 4mg/day | | | |

| | | |(start with25mg im q2w, up to | | | | |

| | | |250mg q4w), or |Fluphenazine 25mg im q4w = | | | |

| | | | |risperidon 4mg/day | | | |

| | | |Fluphenazine decanoate | | | | |

| | | |(start with 12.5mg im | | | | |

| | | |q2w, up to 200mg im q2w) | | | | |

| | | | |Tapering off to minimize the | | | |

| | | |discontinue paroxetine |possible withdrawal symptoms | | | |

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|(2) Does this pat. require |Minimize drug induced | | | |Monitor dizziness, | | |

|paroxetine? – not |adverse effects such as| | | |lethargy, malaise | | |

|depressed, rather |insomnia, anxiety | | | |insomnia,nausea,headache| | |

|manicky? |nausea, akathsia, | | | |, fever, electric | | |

|Is this for panic or |constipation, headache,| | | |-shock-like sensation | | |

|anxiety attack? |and drug induced mania | | | |x48hrs | | |

| | | | | |after d/c of paroxetine | | |

| |resolve the problem | | |1.avoid nap/ caffeine, | | | |

| |without | | |take hot bath and | | | |

| |worsening of psychosis | |1.Educate and counsel |drink hot milk before | | | |

| |or | |the pat. for sleep |go to bed |Monitor day time | | |

|(3) pat. c/o insomnia, |adverse effects | |hygiene | |drowsiness, | | |

|day time drowsiness, | | | |2. warn the pat. reg. |dizziness closely | | |

|dizziness | | | |Postural hypotension | | | |

| | | |2. Cut morning dose of |(advise to get up | | | |

| | | |Lorazepam, |slowly) | | | |

| | | |Risperidone, and | | | | |

| | | |increase | | | | |

| | | |Evening dose |3. might worsen the | | | |

| | | | |day time drowsiness, | | | |

| | | |3. Add other Bz, |dizziness | | | |

| | | |zopiclone or chloral | |Monitor sleep pattern | | |

| | | |hydrate for insomnnia | |daily after each | | |

| | | | | |adjustment | | |

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|Current Drug-related Problem |Treatment Goals |Special Considerations |Assessment of Options |Therapeutic Recommendations |Monitoring Plan |Date |Follow Up |

|(4) pat.c/o nausea, |resolve the problem | |1.Possible adverse | |Monitor sx daily | | |

|indigestion |without | |effect from med | | | | |

| |worsening of psychosis | |or somatic delusion | | | | |

| |or | | | | | | |

| |adverse effects | |2.Pat. education |Advise to take with | | | |

| | | | |food | | | |

| | | | | | | | |

| | | |3.Maalox prn |15-30ml prn, separate | | | |

| | | | |from other meds at | | | |

| | | | |least 1 hr apart to | | | |

|(5) pat. c/o anxiousness, |resolve the problem | |1.Possible adverse |avoid interaction | | | |

|occassional anxiety |without | |effect from risperidone | | | | |

|attack |worsening of psychosis | |and paroxetine | | | | |

| |or | |(akathisia, EPS) | | | | |

| |adverse effects | |-> increase dose of | | | | |

| | | |Lorazepam up to | | | | |

| | | |12mg/day, | | | | |

| | | |if not working well | | | | |

| | | |Add diphenhydramine | | | | |

| | | |Or propranolol | | | | |

| | | | | | | | |

| | | |2. part of the illness |2. increase the dose of |2.Monitor EPS & | | |

| | | | |antipsychotic |other adverse | | |

| | | |3. switch lorazepam to |3. Lorazepam 2mg =clonazepam |effects closely | | |

| | | |other long acting Bz. |0.5mg =diazepam 5mg |3. monitor efficacy | | |

| | | |(clonazepam, diazepam) | |after each change | | |

| | | | |4. start with 10mg bid |is made | | |

| | | |4. Buspirone |up to 40mg/day | | | |

| | | |takes long time, | | | | |

| | | |ineffective as prn, | | | | |

| | | |can’t cover withdrawal | | | | |

| | | |sx. of Bz. | | | | |

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| | | |Anticholinergic effects | | | | |

| | | |1.Pat.education and | | | | |

| | | |counseling | | | | |

| | | | |1. advise to drink more | | | |

| | | | |water, sour juice, |Monitor sx daily | | |

|(6) pat.c/o dry mouth |resolve the problem | | |chew sugarless gum, | | | |

| |without | |2. Oracare D spray |brush teeth more | | | |

| |worsening of psychosis | | |often | | | |

| |or | | | | | | |

| |adverse effects | | |2. coconut flavor, | | | |

| | | | |use freely | | | |

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|Current Drug-related Problem |Treatment Goals |Special Considerations |Assessment of Options |Therapeutic Recommendations |Monitoring Plan |Date |Follow Up |

|(7) pat. c/o mild |resolve the problem | |Anticholinergic effects | | | | |

|constipation |without | |1.Pat.education and |1.advise to take more |Monitor sx daily | | |

| |worsening of psychosis | |counseling |fiber, fruit, vegetable |Use mild med first | | |

| |or | | |prune juice | | | |

| |adverse effects | |2. lactulose |2. 15-60ml regularly | | | |

| | | |3. prodiem, |3. 5-10g regularly | | | |

| | | |metamucil |15-30g regularly | | | |

| | | |4. docusate cal/ sod. |4. prn basis | | | |

| | | |5. Bisacodyl tab/supp. |5. prn basis | | | |

| | | |6. fleet enema |6. reserve for the worst | | | |

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|(8) pat. c/o headache, | | |1.could be part of |1.Acetaminophen | | | |

|back pain | | |somatic delusion or |500mg prn up to | | | |

| | | |simple headache |4g/day | | | |

| | | | |2.NSAIDS | | | |

| | | | | | | | |

| | | |2. adverse effect from |decrease the dose or d/c | | | |

| | | |paroxetine or other |unnecessary med | | | |

| | | |meds? | | | | |

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|(9) pat. c/o back pain, | | |possible EPS | | | | |

|stiffness in legs | | |1.increrase dose of |1.up to 8mg/day |monitor sx daily | | |

| | | |benztropine for stiffness | |(AIMS), | | |

| | | | | |cogwheeling | | |

| | | | | |and other sx. | | |

| | | |2. switch to other |2. amantadine | | | |

| | | |antiparkinsonian agents |biperidine | | | |

| | | |if benztropine is not |ethopropazine | | | |

| | | |working well |procyclidine | | | |

| | | | |trihexyphenidyl | | | |

| | | | |diphenhydramine | | | |

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|(10) pat. c/o missing | | |pat. counseling |probably due to increased |Observe sx closely | | |

|periods | | | |prolactin caused by | | | |

| | | | |risperidone, | | | |

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| | | |1.decrease the dose |1.may worsen | | | |

| | | | |psychosis | | | |

| | | |2.switch to clozapine? |2. not an option | | | |

| | | | |because of leukopenia | | | |

| | | |3.switch to olanzapine or |3. less to similar risk | | | |

| | | |quetiapine | | | | |

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|Current Drug-related Problem |Treatment Goals |Special Considerations |Assessment of Options |Therapeutic Recommendations |Monitoring Plan |Date |Follow Up |

| (11) pat. worries about |resolve the problem | |1.pat education and | |Measure body weight | | |

|possible weight gain |without | |counseling reg. diet, | |weekly | | |

| |worsening of psychosis | |exercise and weight | |Ask pat. to make a list | | |

| |or | |watch | |of what she eats | | |

| |adverse effects | | | | | | |

| | | |2. switch to quetiapine? |risk of inducing weight gain | | | |

| | | | |is similar to that of | | | |

| | | | |risperidone, | | | |

| | | | |clozapine or olanzapine also | | | |

| | | | |has high risk | | | |

| | | | | | | | |

| | | | |ziprasidone is an | | | |

| | | |3. switch to loxapine, |Investigational drug | | | |

| | | |ziprasidone |Molindone is not available in | | | |

| | | |or molindone |Canada | | | |

| | | | | | | | |

| | | | |may increase |Advise to consult with a| | |

|(12) pat. wants some |Recommend | |1.old H1 receptor |sedation, drowsiness |pharmacist or an MD | | |

|OTC allergy pills |appropriate | |antagonists such as |and risk of collapse. |before taking any of | | |

| |product that | |Diphenhydramine, |Advise not to drive, |these meds to avoid | | |

| |dosen’t have | |Pseudoephedrine |get up slowly. |harmful effects/ drug | | |

| |drug interaction | |Or chlorpheniramine |Also, increase the |interaction | | |

| |or affect the efficacy | | |risk of anticholinergic | | | |

| |of other meds that she | | |toxic delirium. | | | |

| |takes | | |Monitor closely | | | |

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| | | |2.non-drowsy H1receptor | | | | |

| | | |antagonists such as | | | | |

| | | |Cetirizine, or | | | | |

| | | |Fexofenadine | | | | |

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| |Educate and counsel the| |3. steroid nasal spray | | | | |

|(13) pat. wants high dose |pat. | | |1.intake of excessive | | | |

|mega vitamins and |Reg. appropriate use of| |1.high dose mega |amount of high dose | | | |

|herbal medications |these meds | |vitamins |mega vitamin may | | | |

| | | | |induce toxic adverse | | | |

| | | | |effects | | | |

| | | | |The efficacy for | | | |

| | | | |schizophrenia | | | |

| | | | |is not established | | | |

| | | | | | | | |

| | | | |2. safety, efficacy and | | | |

| | | |2. herbal medications |quality of these | | | |

| | | | |products are not well | | | |

| | | | |established | | | |

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