DB is a 34-year-old female that presents to the emergency department. She is 5'2", weighs 120 lbs, and only known allergy is to Phenergan (severe hives). Her husband explains to the attending physician that DB woke up in the middle of the night and went to the kitchen to cook a meal but ended up stabbing herself several times on her left hand. DB is a chronic smoker and drinks about 3-4 glasses of wine a day. She is prescribed ibuprofen 600mg PO TID, Oxycodone 5mg PO TID PRN pain not relieved by ibuprofen, cephalexin 500 mg PO TID, naloxone 4mg intranasal PRN, and ondansetron 4mg PO PRN. The attending physician diagnoses DB with schizophrenia and would like to start the patient on Chlorpromazine 25 mg PO BID. DB has never received any previous antipsychotic medications. 

What is the most appropriate course of action to take?

A. Call the attending physician to discuss switching the patient from Chlorpromazine to Ciclopirox

B. Call the attending physician to discuss switching patient from Chlorpromazine to Invega Sustenna

C. Call the attending physician to discussing changing Chlorpromazine to Aripiprazole

D. Verify the order

Answers with rationale:

Schizophrenia is a chronic and disabling disorder requiring life-long treatment it is associated with psychotic symptoms such as hallucinations, delusion, and disordered thinking. It is commonly accompanied by cognitive impairment, impaired insight and judgement, and negative symptoms (avolition, restricted effects, and poverty of speech). The etiology is multi-factorial involving genetics, developmental, psychosocial factors, and neurophysiological factors (including serotonin, glutamate, and dopamine).

Brand/Generics: Ibuprofen (Motrin); Phenergan (promethazine); Aripiprazole (Abilify); Chlorpromazine (Thorazine); Invega Sustenna (paliperidone); Ciclopirox (Penlac); Oxycodone (Various); Cephalexin (Keflex); Naloxone (Narcan); Ondansetron (Zofran)

Answers with rationale:

Answer choice A is incorrect, as ciclopirox is a topical antifungal so would have no role here in treating schizophrenia. Be careful with many sound-alike, look-alike medications that start with "C" such as Celexa, Cerebryx, ciclopirox, etc. or the most notable one which is hydralazine/hydroxyzine which has even similar dosing. Many pharmacies even though they arrange drugs by alphabetical order will separate these two drugs to draw attention to common misfills that have occurred. 

Answer choice B is incorrect, because any trial of Invega Sustenna (paliperidone palmitate), a long-acting injectable antipsychotic, must be first given oral paliperidone or risperidone to assess tolerability. Once tolerability is established, then a trial of Invega Sustenna can be considered. 

Answer choice C is correct, because first generation antipsychotics are rarely indicated and are more prone to EPS symptoms whereas second generation antipsychotics do not display the typical side effects of EPS. Chlorpromazine is contraindicated in patients with significant concomitant use of CNS depressants and our patient is currently using significant ETOH and has a PRN order for opiates in pain not controlled by ibuprofen. In addition the patient has an allergy to Phenergan so chlorpromazine would be contraindicated (explained below).  

Answer choice D is incorrect, verifying the orders would not be the most appropriate action as it could potentially cause harm to our patient and increase the risk of readmission into the hospital. The patient has a known hypersensitivity to Phenergan which is a phenothiazine. Chlorpromazine is within the phenothiazine class and therefore would be contraindicated. Therefore a different agent must be chosen. 

NAPLEX Competencies Covered

• 2.1 – Pharmacology, mechanism of action, or therapeutic class
• 3.3 – Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions
• 3.6 – Drug contraindication, allergies, or precautions

You are almost to graduation! Keep up the studying!

A huge thanks to the students at the University of Howard College of Pharmacy who were outstanding during our 3-day review. Looking forward to our upcoming live reviews at other schools!

Dr. B