Track III: New & Late Breaking Clinical Pearls

The following pearls were selected by the CPNP Program Committee after evaluating a number of member and non-member submissions.

3:15-3:17 PM: Session and Speaker Introduction
Bri Englett, PharmD, BCPP

3:17-3:31 PM: Lamotrigine Rash in Refractory Bipolar Depression: Determining When Continuation, Discontinuation, or Rechallenge is Warranted
Suzanne Harris, PharmD, BCPP

Patients with bipolar disorder spend almost 40% of their lives in a depressive phase. Lamotrigine is an effective treatment option for bipolar depression, however it is limited due to the risk of potentially serious dermatologic reactions. Though the rate of severe dermatologic reactions with lamotrigine has been decreasing from 1% to 0.1---0.01%, the rate of benign skin reactions has not changed, remaining between 8% and 11%. The appearance of a benign rash is a problem for clinicians, who often discontinue lamotrigine at the appearance of any rash, but then have few therapeutic alternatives effective for bipolar depression.

The purpose of this clinical pearl is to present a case of a difficult-to-treat patient with bipolar depression who developed a rash while on lamotrigine. The case will outline the decision-making process of the team based on evidence reported in the literature and patient-specific factors that informed our overall treatment approach. This case will serve to inform other pharmacists in considering possible predictive factors for a successful or unsuccessful lamotrigine rechallenge and treatment strategies based on initial rash severity.

3:31-3:45 PM: Management of Psychosis in Anti-NMDA Receptor Encephalitis
Petricia Pepa, MS, PharmD, and Danielle Boggie, PharmD, BCPP

Anti-NMDA Receptor Encephalitis, recently discovered in 2007 by Dr. Josep Dalmau, is a neurologic disorder characterized by severe psychiatric and neurologic symptoms. Psychiatric symptoms such as anxiety, agitation, bizarre behavior, hallucinations, delusions, and disorganized thinking, typically present early and can be mistaken for new-onset psychosis. If patients are treated with antipsychotics and develop rigidity and autonomic instability, it can be mistaken for extrapyramidal symptoms or neuroleptic malignant syndrome (NMS). However, this can be the next phase of anti-NMDA receptor encephalitis, which is characterized by orofacial dyskinesias, dystonic reactions, seizures and autonomic instability.

It is important to understand the disease pathophysiology and clinical presentation because patients may present first to a psychiatric provider for care and/or psychiatric providers may be consulted on how to manage the psychiatric symptoms. This presentation will describe the pathophysiology and presenting symptoms of anti-NMDA receptor encephalitis and will include a review of the literature for the management of psychiatric symptoms of the illness. It will focus on the dilemma that arises from the similar presentation of antipsychotic side effects and the disease itself.

3:45-3:59 PM: Beta Blockers for Behavioral and Psychological Symptoms of Dementia
Emily Wright, PharmD

Pharmacological treatment of Behavioral and Psychological Symptoms of Dementia (BPSD) is problematic due to increased risks of adverse effects and falls in the older adult population. While nonpharmacological treatment is preferred in the elderly, patients presenting with severe agitation or aggression may require high doses of psychotropic medications, including antipsychotics, antidepressants, mood stabilizers, and benzodiazepines. This issue was seen in the case of a 56 year-old male with frontotemporal dementia who was tried on various medication regimens as well as a course of Electroconvulsive Therapy (ECT) for his behavioral symptoms. This pearl will describe the need for alternatives to psychotropic medications to improve safety in patients with dementia and the utility of beta blockers for these patients based on available literature.

3:59-4:13 PM: Morgellons Disease - Delusional Parasitosis or Unexplained Dermopathy?
Beth DeJongh, PharmD, BCPS, BCPP

Morgellons disease is a rare, unexplained, and controversial skin disorder characterized by skin lesions that contain multicolored, fiber-like filaments. The source of the filaments has not yet been elucidated. Some clinicians believe the signs and symptoms of Morgellons disease are caused by mental illness and refer to this condition as delusional parasitosis or delusional infestation. Other clinicians believe this is a true illness that results from an infectious process associated with Lyme disease spirochetes. This pearl will provide an overview on the signs and symptoms of Morgellons disease, the controversy surrounding the diagnosis, and its connection to mental illness and Lyme disease. A brief summary of the literature and review of possible treatment options will also be provided.

4:13-4:15 PM: Session Conclusion
Bri Englett, PharmD, BCPP