Successful rechallenge with paliperidone after clozapine treatment for a patient with dopamine supersensitivity psychosis

Abstract

We describe the case of a 49-year-old Japanese male patient successfully treated with a paliperidone rechallenge following 2-year treatment with clozapine for treatment-resistant schizophrenia. He had responded well to conventional antipsychotic treatment for the initial psychotic episode but gradually developed dopamine supersensitivity; even treatment with paliperidone and another antipsychotic medication (a total up to 1700 mg in chlorpromazine-equivalent dose) had not improved his psychotic symptoms. Clozapine treatment produced temporary symptomatic relief, but the clozapine dose could not be increased to > 150 mg due to the patient’s intolerance. Following low-dose clozapine treatment for 2 years, a rechallenge with paliperidone monotherapy ameliorated his psychotic symptoms. This suggests that clozapine may have the potential to release the dopamine supersensitivity state. Our patient’s case indicates that for patients with dopamine supersensitivity psychosis, a rechallenge with a previously ineffective antipsychotic after clozapine treatment may be successful.

Long-term effectiveness of antipsychotics

“…It is ironic that the recent American Psychiatric Association recommendations for long-term antipsychotic use in patients with schizophrenia recommend switching to clozapine when patients stop improving on their initial antipsychotic medication, in that clozapine has been found to mitigate the molecular sensitivity reaction in the dopamine system aiDSP caused by the long-term use of antipsychotic medications, and also to reduce the long term mortality risk associated with all other antipsychotic medications. (American Psychiatric Association, 2020;Fava, 2020;Fedak, Bernal, Capshaw, & Gross, 2015;Kobayashi et al, 2020;Kose & Cetin, 2018;Oishi et al, 2018;Vermeulen, van Rooijen, van de Kerkhof, Sutterland, Correll, & de Haan, 2019).…”

Efficacy of Asenapine in Drug-resistant Psychotic Patients with Dopamine Supersensitivity Psychosis: Two Cases

“…2016 [12] RLAIs were more effective for patients with DSP (n = 61) than those without DSP (n = 33) in a 2-year observational study Blonanserin Tachibana et al, 2016 [13] Case series Niitsu et al, 2020 [14] This randomized controlled study showed that add-on treatment with both blonanserin (n = 26) and olanzapine (n = 29) similarly provided significant efficacy for DSP patients Paliperidone Kobayashi et al, 2020 [15] Case report Aripiprazole Tadokoro et al, 2017 [16] Case report Kanahara et al, 2018 [17] Case series showing that the introduction of aripiprazole following ECT successfully stabilized two patients with severe DSP Kanahara et al, 2020 [18] Case series from a clinical trial: A very-slow switching strategy to aripiprazole from other agents provided DSP patients with potential clinical stability and haloperidol 3 mg, respectively, for their first episodes of psychosis. A slight delusional mood remained for Patient 1, and her medication was subsequently switched to aripiprazole with a final dose-up to 30 mg.…”

“…In this context, the use of an LAI other than aripiprazole oncemonthly is a common strategy. Similarly, some oral antipsychotics with long half-lives such as blonanserin and paliperidone might be beneficial for patients with DSP [4] (Table 1: showing agents with efficacy for DSP [6][7][8][9][10][11][12][13][14][15][16][17][18]). However, both of the present patients showed persistent positive symptoms that were not controlled even by antipsychotic agents with long half-lives.…”