Clinical Case Query (2)

 

I need suggestions from my forum colleagues regarding this case:

Patient in her mid 20s with diagnosis of schizoaffective disorder admitted to inpatient psychiatry unit.

C/C: Command auditory hallucinations (religious based involving devil and God), visual hallucinations (devils), paranoid ideations, worsening depression (secondary to hallucinations), suicidal ideations (passive death wishes), pressured speech, labile affect and racing thoughts.

Multiple medications trials with poor response including haloperidol, risperidone, olanzapine, quetiapine, lithium, depakote and carbamazepine.

Patient agreed for clozapine trial- titrated gradually to dose of 100 mg AM and 300 mg HS. Minimal improvement in paranoid ideations, visual hallucinations and symptoms of depression and mania. Persistence of auditory hallucinations, which are intrusive and distressing for patient.
Clozapine level: 580 ;
norclozapine: 223 ;
clozapine/norclozapine: 803

Lithium was also added for management of mood symptoms (during gradual titration of clozapine). Lithium 300 mg BID with Lithium level of 0.6.

After 2 weeks on this above combination (Clozapine 100 mg AM + 300 mg HS with Lithium 300 mg BID): Paliperidone was added (with plan of converting it to Invega Sustenna: for patient has history of poor compliance on discharge). Paliperidone is gradually increased to 9 mg HS.

Patient clinical status on this combination (~1 month of inpatient stay so far):
Positives: Not seclusive, attending groups, denies visual hallucinations, no manic symptoms, improved sleep, improved appetite
Negatives: Persistence of auditory hallucinations (religious based- devil), episodes of internal preoccupations & fighting with devils (mostly when patient is alone), which is distressing to patient.

What should be the next best step?
- Increasing clozapine dose?
- Increasing Paliperidone dose?
- Switching Paliperidone?
- ?

Thanks in advance for all the suggestions.