2019 Research Forum

Tyler Torrico MS III 1 , Nakisa Kia’i MS III 1 , Carlos Meza MD R2 2 , Sara Abdijadid DO MS 2 1.Ross University School of Medicine, Barbados 2. Kern Medical, Bakersfield, California Aripiprazole Induced Neutropenia in a Geriatric Patient: A Case Report

UCLA-Kern Psychiatry Residency Program

Conclusions The use of aripiprazole in the geriatric population is common, not only as an augmentation agent for depression but also in other psychiatric disorders. Psychiatrists must be mindful of this potential side effect which may be life threatening, specially in the elderly population who may suffer from numerous comorbidities. Obtaining a baseline CBC and monitoring for blood dyscrasias is crucial when adding agents that may cause blood dyscrasias, no matter the frequency of the side effect profile. References 1. Lenze EJ, Mulsant BH, Blumberger DM, Karp JF, Newcomer JW, Anderson SJ, Dew MA, Butters MA, Stack JA, Begley AE, Reynolds CF 3rd. Efficacy, safety, and tolerability of augmentation pharmacotherapy with aripiprazole for treatment of resistant depression in late life: a randomised, double-blind, placebo-controlled trial. Lancet. 2015. 386 (10011):2404-12 2. Berman RM, Marcus RN, Swanink R, McQuade RD, Carson WH, Corey- Lisle PK, Khan A. The efficacy and safety of aripiprazole as adjunctive therapy in major depressive disorder: a multicenter, randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2007. 68(6)843-53 3. Nelson JC, Thase ME, Trivedi MH, Fava M, Han J, Van Tran Q, Pikalov A, Qi Y, Carlson BX, Marcus RN, Berman RM. Safety and Tolerability of Adjunctive Aripiprazole in Major Depressive Disorder: A Pooled post Hoc Analysis (studies CN138-139 and CN 138-163). Prim Care Companion J Clin Psychiatry. 2009. 4. Felin Tricia, Naveed Saiq, Chaudhary Amna. Aripiprazole-Induced Neutropenia Case Report and Literature Review. Journal of Psychosocial Nursing. 2018. Volume 56, No. 5. 5. Majeed M, Ali A. Aripiprazole-Induced Neutropenia in a Seven Year- Old Male: A Case Report. Cureus. 2017. 9(8): e1561. 6. Sala Uddin Qureshi, Eleonora Rubin. Risperidone- and Aripiprazole- Induced Leukopenia: A Case Report. Prim Care Companion J Clin Psychiatry. 2008; 10(6): 482-483. 7. Dattatreya Mendhekar, et al. Leukopenia and thrombocytopenia on adding aripiprazole to phenytoin. The World Journal of Biological Psychiatry, 2009. 10(4): 1043-1044. 8. Flanagan R, Dunk L. Haematological toxicity of drugs used in psychiatry. Hum Psychopharmacol. 2008 Jan;23 Suppl 1:27-41. 9. Matthew Lander, Tarun Basiampillai. Neutropenia associated with quetiapine, olanzapine, and aripiprazole. Australian and New Zealand Journal of Psychiatry. 2011; Volume 45, page 89

Case Presentation

Introduction

Treatment refractory depression can be challenging to manage. Augmentation of SSRI’s with antipsychotics is effective. However, each pharmacologic agent comes with it’s own set of unique side effects. Aripiprazole has been shown to be effective in managing late-life treatment resistant depression [1,2]. Common side effects include akathisia, insomnia and blurred vision [3]. Neutropenia is a rare side effect mentioned in only a few case reports [4,5,6,7]. This is the first case of aripiprazole induced neutropenia in an geriatric patient.

• A 68-year-old man with major depressive disorder was admitted to the hospital for suicidal ideations with plan and intent. He was started on citalopram due to a previous positive response. However, this time he showed no symptomatic improvement. Therefore, his SSRI was augmented with levothyroxine and subsequently aripiprazole. After the addition of aripiprazole his suicidal ideation decreased dramatically. However, he developed neutropenia, eventually reaching an absolute neutrophil count (ANC) of 0.7X10^3. We suspected aripiprazole as the culprit but discontinued all pharmacology just in case. The patients ANC returned to normal. All medications except aripiprazole were restarted and the patient did not develop neutropenia again. The patient showed continued symptomatic improvement throughout and was discharged. Table 1. Medication regimen and blood cell count by day of hospitalization. Discussion • Aripiprazole has a half life of 75 hours, it is predicted that this is why the ANC continued to drop for three days after its administration was held. • Clozapine and olanzapine are atypical antipsychotics that are molecularly similar, and their mechanism of action for blood dyscrasias has been partially explained [8]. Aripiprazole’s molecular structure is unrelated to either clozapine or olanzapine, therefore it’s mechanism of action for neutropenia is likely different [9].

Aripiprazole

Olanzapine

Clozapine

Figure 1 . Contrast between the molecular structures of clozapine, olanzapine and aripiprazole.

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