Reserpine, would you ever use it & under what conditions?

[whopper]

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I'm working on a unit that gets the worst of the worst. Long term forensic facility with also involuntary committed patients, several who have failed on other units and about 2-5 other psychiatrists worked on these patients with little success.

I've had some cases where I'm considering ECT on them because they are on several antipsychotics, at maximal dosages (over the manufacturer's guidelines) and with still no benefit. I'm talking Zyprexa at 40mg/day among 4 others, and yes with lithium & depakote augmentation.

On some of them Clozaril is not an option because their ANCs are too low.

So I'm considering ECT, but Nasrallah at UC (who I don't see often, but do from time to time) is known to recommend Reserpine in cases like this. I don't see him much, so I don't know when the next time I'll cross paths with him.

Got me wondering, when would others here use it? I have never used this medication in residency, & have seen no others use it in clinical practice.

 

[MoodDoc]

I am the psychopharmacologist of last resort at a large teaching hospital. I have never used reserpine. If someone is not responding to anything and is on four different antipsychotics, the first thing I would look at is getting them on less medication. Toxic delirium is common. ECT can be an option. There is no compelling evidence for multiple antipsychotics other than adding a typical to an atypical.
Reserpine has an impressive side effect profile and a high incidence of worsening psychosis when stopped.

 

[OldPsychDoc]

I am the psychopharmacologist of last resort at a large teaching hospital. ....

Now that is a title to strive for!


[Wasn't that a song by the Eagles?]

 

[MoodDoc]

Perhaps this silver bullet will help to identify me.

 

[Faebinder]

I'm working on a unit that gets the worst of the worst. Long term forensic facility with also involuntary committed patients, several who have failed on other units and about 2-5 other psychiatrists worked on these patients with little success.

I've had some cases where I'm considering ECT on them because they are on several antipsychotics, at maximal dosages (over the manufacturer's guidelines) and with still no benefit. I'm talking Zyprexa at 40mg/day among 4 others, and yes with lithium & depakote augmentation.

On some of them Clozaril is not an option because their ANCs are too low.

So I'm considering ECT, but Nasrallah at UC (who I don't see often, but do from time to time) is known to recommend Reserpine in cases like this. I don't see him much, so I don't know when the next time I'll cross paths with him.

Got me wondering, when would others here use it? I have never used this medication in residency, & have seen no others use it in clinical practice.

Agree with MoodDoc... horse before the cart... diagnosis before treatment.. back to basics.. what are you treating?

 

[whopper]

Perhaps this silver bullet will help to identify me.

Hmm---I'm curious.

The patient is a young female with schizoaffective disorder-Bipolar type. She is not antisocial, and she has frequent audio hallucinations telling her to attack other people, which she sometimes does, and was doing on the order of every 3-5 days on the previous unit she was on.

On Zyprexa 40mg, Risperdal 16 mg, Lithium--to the point where her blood concentration is 1.2 mmol/L, Loxapine 250 mg, and Depakote where the concentration is about 100 ug/ml, Haldol 10mg/day I started the Loxapine because Zyprexa & Clozaril were some of the only meds where she said she felt a benefit. Clozaril is not an option now because her ANC is about 1.6.

The attacks only went down in frequency when I added lithium--and she was stable for 3 months in terms of violence (though she was still having audio hallucinations). I was actually considering her for discharge, but had to keep her in the unit because she was there for legal reasons which just expired. Right when the legal incarceration expired, she started getting violent again (and I don't think that's intentional on her part. She didn't know her NGRI expired, and wants to be discharged). but now she's violent again-now about every 2-3 weeks.

The other stumper case I have is a female with treatment resistant schizophrenia who tries to strangle people as a result of her audio hallucinations, and she too is not antisocial. The thing majorly complicating this case is that she also apparently has Bulemia, which only became apparent after she cleared up to some degree on Clozaril (now at 700mg/day). Forgot what the serum clozaril level of the top of my head (I'm at home today), but its well over 1500. She's frequently vomiting out the medications we're giving her.

 

[maybepsych]

Forgive my noobness, but when I think about adverse reactions of Reserpine I think about depression.

Epocrates has this list...
Serious Reactions

• arrhythmias
• syncope
• bradycardia
• dyspnea
• depression, severe
• parkinsonian syndrome
• extrapyramidal symptoms
• anxiety, paradoxical
• deafness
• optic atrophy
• glaucoma

Common Reactions

• dizziness
• loss of appetite
• diarrhea
• nausea/vomiting
• dry mouth
• nasal congestion
• sexual dysfxn
• headache
• depression
• chest pain
• edema
• vivid dreams
• anxiety
• hyperprolactinemia
• black stools
• rash
• pruritus
• muscle aches
• weight gain
• drowsiness

To me this list doesn't seem that different from other antipsychotics. What exactly gives Reserpine such a bad name?

 

[whopper]

Reserpine's side effects are on a more extreme level than most other antipsychotics--to the point where it was discontinued in the UK.

I wasn't even considering its use until I heard Nasrallah mentions it from time to time in extreme cases like this. Our institution has an option where for hard cases that are way beyond the norm--he is consulted, and when he does, it usually draws an audience of psychiatrists & psychologists who want to hear his thoughts on it.

Last time he was over was about 3 weeks ago. It was a case of someone with severe OCD & schizophrenia whose core Body T went to dangerous levels, probably as a result of his antispychotic or depakote medication.

I've heard when my fellowship starts, I'll see him on a more frequent basis. I'll ask him more about it when I get the chance.

An option I was considering was Sulpiride for the Clozaril/Bulemia patient mentioned above, but its not available in the US.

Something we do for cases like this is we have a case presentation where all the doctors are asked to attend--from pharmacy, psychiatry, IM & psychology-which puts about 20 or more people's minds on it. This might have to be one of those cases.

 

[maybepsych]

So there isn't like 1 or 2 of the serious side effects that are generally cited as the reason for its bad rep?

Just the entire package? interactions?

 

[Regnvejr]

LOL. I have 2 kids like that. 🙁 Have you considered a neuro consult? It might be that Keppra for some neurostimulatory effect can do the trick?

 

[whopper]

Have you considered a neuro consult?

I would except that I do not find any nonpsychiatric basis for their presentations, and believe me, I've fished for it. I've pretty much put every non-psychiatric cause for psychotic symptoms on the list and I've seen no labs pointing in that direction, nor any behaviors or physical examination findings indicative of such conditions such as Wilson's, Lupus, MS etc.


Add to mix that I don't really think too much of the institution's neurologist......

One of my patients had Trigeminal Neuralgia, and he pretty much blew her off when I asked for a neuroconsult, with a comment to the effect of "I'm not going to see her she's psychotic" (hey its a psychiatric hospital, what do you expect? How could it not me Trigeminal Neuralgia--same exact symptoms, when has schizophrenia ever presented with sx of TN?) I had to treat it myself. Him and his $500/hr consulting.......I could do a better job.

 

[Regnvejr]

There are some parietal-lobe seizure type stuff that can mimic this, making people rather paranoid. I forget the name, but it might be worth an outside consult.

 

[whopper]

Thanks for the suggestion. I'll look into it.