(040) Rational Polypharmacy in Manic Patients with Covid-19: Case Series

Abstract: Background

Psychiatric emergencies in patients with COVID-19 place a unique burden on the healthcare system. Many of these patients are treated on medical floors with psychiatry consultation, posing infection risks to staff and patients. There is sparse literature on management of COVID-19 patients with acute mania on medical floors. We will discuss the role of rational polypharmacy along with pearls and pitfalls of various strategies to manage agitation in these cases.

Cases

We present two patients with Bipolar I Disorder who presented with symptoms of mania in the context of medication non-adherence, necessitating inpatient level of care. Both patients were diagnosed with asymptomatic COVID-19 and were transferred to general medicine units per hospital guidelines. Due to high levels of agitation, homicidal ideation, and ambulation that potentially exposed others to COVID-19, these patients were managed with aggressive polypharmacy. To address their mania and associated aggression and agitation, Patient 1 was treated with a regimen of ziprasidone, divalproex sodium, quetiapine, and lorazepam, and Patient 2 was treated with divalproex sodium, risperidone, and lorazepam.

Discussion

These cases outline the practical and ethical challenges of managing acute mania in patients with COVID-19. Literature regarding management of agitation in patients with COVID-19 encourages judicious use of psychotropic medications and avoidance of mechanical restraints, however, in manic COVID-19 patients a conservative approach may risk spread of infection. Polypharmacy rather than monotherapy was preferred in these patients given their level of agitation, homicidal ideation, and risk to others due to COVID-19. Polypharmacy provided the additional benefit of allowing mechanical restraints to be discontinued early in their admissions and their manic episodes resolved prior to discharge. Psychotropic medications and oversedation carry risks, however, in manic patients with COVID-19 these risks must be weighed against the risk of spreading infection to others. In these unique situations where providers must balance non-maleficence and general welfare, polypharmacy with close surveillance for signs of instability or side effects should be the preferred option.

Conclusion

CL psychiatrists frequently manage patients with acute mania on medical floors which is difficult under normal circumstances, and if that patient has COVID-19, the balance of appropriately treating the patient for their psychiatric condition while mitigating risk of infection of others becomes even more precarious. We propose utilizing rational aggressive polypharmacy when managing acute manic patients with COVID 19 on medical floors.

References

Mahgoubl, N., et al. (2021). Inpatient psychiatry unit devoted to COVID-19 patients, Comprehensive Psychiatry, Volume 107,152237.
Ostuzzi, G., et al. (2020). Safety of psychotropic medications in people with COVID-19. BMC Med 18, 215.
Wong, A. H. et al. (2020). Management of Agitation During the COVID-19 Pandemic. The western journal of emergency medicine, 21(4), 795–800.