Aripiprazole for the Treatment of a Manic Patient With Clozapine-Related Colonic Obstruction Receiving Total Colectomy
Publication: The Journal of Neuropsychiatry and Clinical Neurosciences
To the Editor: For treating bipolar disorder, clozapine has demonstrated efficacy in treatment-resistant mania.1 However, problems may arise with its potential fatal side effect such as agranulocytosis, myocarditis, aspiration pneumonia, and ileus.2 Olanzapine and aripiprazole have also shown significant efficacy in the treatment of mania.3 We described a treatment-resistant manic patient who suffered from severe clozapine related ileus, and subsequently, colonic obstruction receiving total colectomy. After the operation, a new manic episode developed. He was first treated with olanzapine for his manic symptoms. Unfortunately, postoperative ileus developed. After switching to aripiprazole, his manic symptoms were successfully treated without worsening ileus.
Case Report
“Mr. L,” a 33-year-old man with a 15-year history of bipolar I disorder, has been suffering from a half-year uncontrolled manic episode for about 14 years ago. At that time, lithium carbonate, valproate, risperidone, and olanzapine were given in various combinations but without improvement. Finally, this treatment-resistant manic episode was controlled under medication of clozapine 500 mg/day combined with carbamazepine 800 mg/day.
Recently, he was brought to the emergency room and was admitted to the surgical ward because of colonic obstruction at the level of the hepatic flexure. Because of severe and persistent signs that colon motility is completely disrupted even nil per os (NPO) and nasogastric (NG) decompression for days, he received total colectomy with ileorectal anastomosis.
The operation went well; he had flatus passage on the next day. However, a new manic episode developed after operation. Mr. L was treated with oral olanzapine 20 mg/day. After a 4-day treatment, the manic symptoms improved and the patient's score on the Young Mania Rating Scale (YMRS) decreased from 48 to 40. Unfortunately, he developed postoperative ileus at this time. He started to receive NPO and NG decompression treatment. Then, the parenteral olanzapine 20 mg/day was prescribed for the following 1 week. Although the patient's score on the YMRS decreased from 40 to 34, the ileus did not improve.
Taking into account that the anticholinergic property of olanzapine might worsen postoperative ileus, we switched olanzapine to aripiprazole 15 mg/day. Treatment with aripiprazole resulted in gradual improvement of his manic symptoms over a period of 2 weeks and a further decrease in the YMRS from 34 to 20. His ileus was treated successfully with conservative medical care.
Discussion
Clozapine has extensive anticholinergic properties, constituting a serious risk factor for constipation, and subsequently, ileus.2 Patients who receive this medication should undergo proper monitoring and interventions to minimize the burden of ileus.2 Olanzapine has around one-fifth of anticholinergic affinity compared with clozapine.4 Given the temporal association between the use of medication and onset of symptoms in our patient, olanzapine might be predisposed to postoperative ileus.
Aripiprazole, an agent without significant anticholinergic properties, was associated with lower risk for constipation compared with other atypical antipsychotics.5 There were no ileus cases found associated with aripiprazole treatment. The case presented here supports that aripiprazole, which has minimal anticholinergic properties, might be a preferred agent for manic patients with ileus concern.
References
1.
Poon SH, Sim K, Sum MY, et al.: Evidence-based options for treatment-resistant adult bipolar disorder patients. Bipolar Disord 2012; 14:573–584
2.
Nielsen J, Correll CU, Manu P, et al.: Termination of clozapine treatment due to medical reasons: when is it warranted and how can it be avoided? J Clin Psychiatry 2013; 74:603–613, quiz 613
3.
Geddes JR, Miklowitz DJ: Treatment of bipolar disorder. Lancet 2013; 381:1672–1682
4.
Chengappa KN, Pollock BG, Parepally H, et al.: Anticholinergic differences among patients receiving standard clinical doses of olanzapine or clozapine. J Clin Psychopharmacol 2000; 20:311–316
5.
De Hert M, Hudyana H, Dockx L, et al.: Second-generation antipsychotics and constipation: a review of the literature. Eur Psychiatry 2011; 26:34–44
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History
Published online: 1 July 2014
Published in print: Summer 2014
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
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