Angela Tong, BscPharm, ACPR, met her patient, a woman in her 20s, when she’d just overdosed on acetaminophen. The overdose was not her first. Tong is a clinical pharmacist at Fraser Health Authority, a hospital system in Canada. She treated the woman as she stayed at the hospital for several months.
The woman had just started a new job as a medical assistant, but the stress quickly became overwhelming. She listed her symptoms to Tong.
“She felt really anxious. She feels sleepy during the day, but she had trouble sleeping at night. There are lots of voices in her head, which leads her to suicidal thoughts. She also complained of constipation, difficulty doing daily tasks, even opening a yogurt container,” says Tong. “She cannot write properly because her hands are too shaky. And she felt that her medication was not helping her.”
Tong noted that the woman had been prescribed 21 different drugs, half of which were psychotropic. She suspected that these drugs were likely causing many of the symptoms, such as shakiness which is often associated with antipsychotic medications. She also believed that the drugs were likely to be counteracting each other’s effects.
“Being on five antipsychotics, three mood stabilizers, and an antidepressant doesn’t make any sense,” says Tong.
The Therapeutics Initiative at the University of British Columbia (UBC) is hosting a series of webinars with healthcare professionals, sharing real-life stories about their own patients whose medications they were able to reduce, and what happened when they did. To bring deprescribing to life, healthcare professionals are sharing the stories of their patients.
The following story is the fourth in our deprescribing series.
How Bad Are the Side Effects? Very Bad.
Antipsychotics can be a lifesaving medication, critical for people who are experiencing psychosis, but they’re also known for causing seriously burdensome side effects. Since the woman was taking several of these drugs, Tong gave her a Glasgow Antipsychotic Side Effect Scale to assess the severity of her symptoms.
The scale showed the woman had sexual problems, increased heart rate, jerky muscles, and shaky hands.
“She also had had no period for a couple of months,” added Tong. Occasionally she had trouble urinating and had developed blurry vision. It was clear she was having serious side effects from the antipsychotics.
But antipsychotics are only a quarter of the drugs the woman had been prescribed. Next, Tong assessed her “anticholinergic burden.” Anticholinergic drugs are drugs that block a neurotransmitter called acetylcholine. Acetylcholine is involved in many processes and diseases, so blocking it can have wide ranging effects. Some drugs are designed specifically to block acetylcholine to exert their therapeutic effects, but many others only do so as a side effect.
Some of the conditions that anticholinergic drugs treat include:
- Respiratory disorders (asthma, chronic obstructive pulmonary disease (COPD))
- Cardiovascular disease
- Psychiatric disorders
The anticholinergic burden calculator gave the woman a score of 16; a score of 3 or above denotes a high risk of confusion, falls, and death.
Lastly, Tong gave her an assessment to test the severity of her drug-induced Parkinsonian symptoms such as tremors and difficulty initiating movements. Parkinson’s disease is characterized by a lack of a neurotransmitter called dopamine in a particular part of the brain, whereas psychosis is associated with large influxes of dopamine.
Antipsychotic drugs block this influx of dopamine, but sometimes can reduce it so much you end up with Parkinson’s-like symptoms. The test suggested that she had clinically significant movement symptoms.
Tong also notes that there are clear prescription cascades in her patient’s regimen. A prescription cascade is when you’re prescribed one drug to treat the side effects of another drug, and possibly even another after that. For example, Tong says, “we’re using benztropine for her Parkinsonian symptoms and then we are using multiple laxatives for constipation,” which is a well-known side effect of benztropine.
What Is Her Actual Diagnosis?
“What is the rationale for having five dopamine antagonists [drugs that block dopamine], which are the antipsychotics, and an agonist [drug that mimics dopamine] which is bromocriptine? Are we using medications that counteract the effects of each other?” ]wonders Tong. “What is the actual evidence for her diagnoses, what are we trying to treat?”
According to her medical history, she’d been diagnosed with schizoaffective disorder, bipolar disorder, anxiety disorder, borderline personality disorder, asthma, gastrointestinal reflux disease (GERD), hypothyroidism, obesity, constipation, and urinary retention due to a structural issue in the bladder. She’d also experienced sexual abuse as a child and was currently in debt due to an inability to keep jobs.
Tong and her team decided they needed to consult a psychologist. It was difficult to differentiate between bipolar disorder symptoms and borderline personality disorder symptoms, but the conditions are typically treated very differently. They turned to her emergency room (ER) records for clues. She’d had more than 10 ER visits within the last year for self-harm, urinary retention, and chest pain.
Interestingly, “whenever she was told by healthcare providers that her mental health had improved, she would overdose with acetaminophen and seek help for herself immediately.”
The psychologist determined that she had borderline personality disorder and major depression, but that she was not psychotic and showed very few symptoms of bipolar disorder.
Finally Starting to Deprescribe
After speaking with an endocrinologist who had treated the woman early in 2022, Tong found that some of the confusion was that one drug that can treat Parkinson’s symptoms can also help lower high levels of the hormone prolactin, caused by a pituitary tumor. The endocrinologist had prescribed the drug to her to treat such a tumor, but the plan was only to take it for three months and stop or see a different specialist for follow up. Tong and the woman’s primary care physician decided to stop that drug immediately.
Next, they decided to tackle the antipsychotics, which are typically used to treat symptoms of bipolar disorder and psychosis, which were no longer significant aspects of her diagnosis.
“There is really weak evidence to support pharmacotherapy for borderline personality disorder,” which the psychologist had recently determined was the diagnosis that fit her best, explains Tong.
About a month after she arrived in the hospital, Tong slightly increased the doses of one antipsychotic and one mood stabilizer, while completely stopping two other antipsychotics and lowering the doses of one more antipsychotic and one mood stabilizer.
One reason for continuing to deprescribe many of the drugs was to reduce side effects, but another was because the drugs did not seem to be working. In January, she had another suicide attempt.
After another few months, by March 2023, Tong had discontinued six psychotropic drugs and three drugs for non-psychiatric symptoms. She did add one new drug to help treat anxiety and raised the doses of two other psychotropic medications to treat mood symptoms. She’d agreed to start dialectical behavioral therapy (DBT) to help her process her trauma and emotions. By July, her mood was more stable, and Tong was able to discharge her to live in a group home with seven prescriptions.
After discharge, the woman saw a new doctor, who believed she was anxious and experiencing paranoia, and thus prescribed four new psychiatric drugs, while discontinuing two that she had been taking. She had another suicide attempt.
Tong says this was different, however. After having engaged in some DBT earlier in the treatment process, she was able to reflect on the real-world trigger that led to the attempt. Previously, she had always explained that she’d made the attempts because of the voices in her head.
When Tong saw her again in the hospital, she took her off the new medications and added back the older ones. Tong also encouraged the woman to restart the DBT that had been helping her previously.
The journey to find the appropriate treatment for the woman’s symptoms continues, but throughout the process, she’s gained confidence and introspection. She’s a bit afraid of change, but now believes she has the ability to adapt and wants to continue deprescribing.
Before, “I didn’t think I could stop any of the medication because none of them seem to work,” the patient told Tong, which may be a depressing, but apt, way to describe how so many people can end up on so many drugs and still be sick.
To read more patient stories about deprescribing, check out MedShadow’s: