CPK

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sujalneuro

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I am seeing a patient with history of schizophrenia currently admitted for Subarachnoid hemorrhage, very high CPK in 2000s and Acute renal failure (sodium is normal now). He is on Trazodone 100mg, Trileptal 600mg, Geodon 80 mg. Do I need to adjust any of his medications. He is in his 50s? Please suggest?

Thanks in advance.
 
sujalneuro said:
I am seeing a patient with history of schizophrenia currently admitted for Subarachnoid hemorrhage, very high CPK in 2000s and Acute renal failure (sodium is normal now). He is on Trazodone 100mg, Trileptal 600mg, Geodon 80 mg. Do I need to adjust any of his medications. He is in his 50s? Please suggest?

Thanks in advance.
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Take a breath and think through the case.
What are you most concerned about in this patient? Is it the SAH, CPK or ARF? Is it symptoms of schizophrenia?
For each of the above, ask yourself in this particular patient, what is the most likely cause of this?
If any of the medications this patient is being prescribed feature in this answer, then you may have cause to alter this.
 
No offense but if you're an attending this presentation was very sub-par.

Could be NMS. If it is that is an absolute emergency. It likely is not. Further Geodon is an unlikely candidate for NMS (though still possible). It's usually higher D2 blockage meds at higher dosages. The elevated CPK could be due to other reasons. One of his meds could be causing rhabdomyolysis. E.g. statins could cause it.

But in any case without labs and more information there isn't enough to go on other than to say a CPK of this level needs serious investigation in the context of acute renal failure.
 
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sujalneuro said:
I am seeing a patient with history of schizophrenia currently admitted for Subarachnoid hemorrhage, very high CPK in 2000s and Acute renal failure (sodium is normal now). He is on Trazodone 100mg, Trileptal 600mg, Geodon 80 mg. Do I need to adjust any of his medications. He is in his 50s? Please suggest?

Thanks in advance.
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Not answerable. Not nearly enough information, and would warrant a power point presentation case review to really guide you here. Lot's of factors to consider if you're trying to be the best doctor you can be. Clinical presentation, clinical history, med history (psych and non-psych, we have to know everything he is taking), other lab values, hx of the CPK trend and suspected insults, red-herrings, substance abuse hx, expected consequences of med adjustments and how that will impact current clinical picture.
 
1. figure out why you're consulted (what's the objective?)

2. get as much information as possible (from patient, from chart review, from collateral)

3. get vitals, get labs (if not already done)

4. r/o psychiatric causes of elevated CPK (i.e. NMS), renal failure may be related to elevated CPK

5. if you're at a loss (no clue whatsoever), think about starting from scratch

Take away all medications, just leave on PRNs. Let medicine treat. Then introduce medications as the medical conditions get better. Trend labs as you introduce medications. Consider medications not affected by the kidney.

- not sure how much low-dose geodon helps with "schizophrenia"
- personally not fond of trileptal for "schizophrenia" (is it used as augmentation? why not increase antipsychotics before augmenting?)
- may need a more accurate diagnosis or cleaner regimen or both
 
Lol. Take him off his seizure/mood stabilizer after brain trauma? Just stopping meds seems like a bad idea. Another bad idea would be to add Wellbutrin.

Why does the guy have a SAH? If hit by a car, I can explain the CK elevation hah! There’s more story here.
 
DisorderedDoc417 said:
Lol. Take him off his seizure/mood stabilizer after brain trauma? Just stopping meds seems like a bad idea. Another bad idea would be to add Wellbutrin.

Why does the guy have a SAH? If hit by a car, I can explain the CK elevation hah! There’s more story here.
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If you're bleeding into your brain, wouldn't CPK be elevated regardless of the cause? Bleeding damages brain cells. Brain cells release CPK enzymes, right? Therefore, a stroke, regardless of external impacts, would raise CPK (I would think).

I remember some of this vaguely because I had an elevated CPK once and had to have it differentiated to figure out which type it was (ruling out heart mainly). And I remember that brain, lungs, heart, and skeletal muscles were the main groups that released it.
 
birchswing said:
If you're bleeding into your brain, wouldn't CPK be elevated regardless of the cause? Bleeding damages brain cells. Brain cells release CPK enzymes, right? Therefore, a stroke, regardless of external impacts, would raise CPK (I would think).

I remember some of this vaguely because I had an elevated CPK once and had to have it differentiated to figure out which type it was (ruling out heart mainly). And I remember that brain, lungs, heart, and skeletal muscles were the main groups that released it.
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Sure. Stroke, whatever cause. Just throwing out a random thought and example that illustrates we have no idea what’s going on.
 
DisorderedDoc417 said:
Lol. Take him off his seizure/mood stabilizer after brain trauma? Just stopping meds seems like a bad idea. Another bad idea would be to add Wellbutrin.

Why does the guy have a SAH? If hit by a car, I can explain the CK elevation hah! There’s more story here.
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There was no mention of seizure. Is it customary to give AED for SAH?

Anyways, I assume neurology is on board. I'll let neurology deal with that. I'm more concerned about the psychiatric part.
 
AD04 said:
There was no mention of seizure. Is it customary to give AED for SAH?

Anyways, I assume neurology is on board. I'll let neurology deal with that. I'm more concerned about the psychiatric part.
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Our neurosurgeons constantly start prophylactic AEDs for any kind of brain bleed, which is ironic because while there is not good evidence to support this it definitely does increase the rate of seizures among our neurologists.
 
AD04 said:
There was no mention of seizure. Is it customary to give AED for SAH?

Anyways, I assume neurology is on board. I'll let neurology deal with that. I'm more concerned about the psychiatric part.
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You don’t take away a medication that heightens the threshold for seizure in the context of brain damage when a potential epileptic focus is created be it through trauma, blood, whatever.
 
Which isoenzyme was elevated, CK-MM, CK-MB, or CK-BB?
 
DisorderedDoc417 said:
You don’t take away a medication that heightens the threshold for seizure in the context of brain damage when a potential epileptic focus is created be it through trauma, blood, whatever.
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It isn't so black and white.

If patient is a danger to self or others, you won't give antipsychotics because it can lower seizure threshold?

Evidence isn't there for AED in this case. Even if you want to use AED, trileptal may not be the best choice in the context of renal damage. The first objective in this case is to get the patient to a better medical state and taking out unnecessary / harmful medications helps facilitate that.

I don't think it is a good idea for a psychiatrist to play neurologist. If the neurologist wants to add something, at least he knows that trileptal isn't needed from a psychiatric POV which gives him more freedom to choose the best medication(s).
 
AD04 said:
It isn't so black and white.

If patient is a danger to self or others, you won't give antipsychotics because it can lower seizure threshold?

Evidence isn't there for AED in this case. Even if you want to use AED, trileptal may not be the best choice in the context of renal damage. The first objective in this case is to get the patient to a better medical state and taking out unnecessary / harmful medications helps facilitate that.

I don't think it is a good idea for a psychiatrist to play neurologist. If the neurologist wants to add something, at least he knows that trileptal isn't needed from a psychiatric POV which gives him more freedom to choose the best medication(s).
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Lol. No ones thinking black and white. We’re actually making the same argument — which is that there are significant considerations to be made contingent upon information we don’t currently have.
 
AD04 said:
It isn't so black and white.


I don't think it is a good idea for a psychiatrist to play neurologist. If the neurologist wants to add something, at least he knows that trileptal isn't needed from a psychiatric POV which gives him more freedom to choose the best medication(s).
Click to expand...


Also — if it’s a medication you prescribe you better know how to use it backwards and forwards. It’s not “playing neurologist” it’s being an M.D. and an expert with the medications you prescribe as well as considering the repercussions of a change in those medications in the context of your patients situation.
 
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