Commentary
When making changes to medications, providers should consider detailed documentation, including medication reconciliation, communication with specialists, review of medical history evidence, discussions with family, and documentation of education provided to the patient or guardian.
Case Details
A 7 YOM (5'5”, 50 lb) presented with his mother to the defendant family medicine physician (FMP) for a medication renewal appointment. The patient’s past medical history included Asperger’s, ADHD, bipolar disorder, and major uncontrolled aggressive behavioral problems.
The defendant FMP had treated the minor patient on six previous occasions for common ailments and checkups. The only medications the defendant FMP had prescribed were Vyvanse for his ADHD and clonidine for sleeping problems. The patient had been seeing a psychiatrist since April who had been treating him for ADHD, Asperger’s, and mood disorder. The psychiatrist had prescribed Abilify for the patient’s mood disorder. The last time the psychiatrist saw the patient was in July, where his Abilify was continued at 2 mg twice daily.
During the visit with the defendant FMP, the patient's mother asked for an increase in dosage of Abilify for her son, who was having mood disorder issues. The defendant FMP was not aware of the Abilify dosage that the patient was currently prescribed, and asked the patient’s mother how much the child was taking. She informed him that he was taking 20 or 25 mg. The defendant FMP checked the Monthly Prescribing Reference (MPR), determined that the maximum daily dosage for Abilify in children was 30 mg per day, and wrote a prescription for same. However, chart documentation for the patient included six references to Abilify 2 mg on the last entry recorded earlier that year by the medical assistant. Abilify 2 mg was also recorded on the patient’s medication list.
In September, the patient received his first dose of 30 mg Abilify. Per the patient’s mother, he began complaining of pain in his tongue, started drooling, and could not speak 20 minutes later. The patient’s mother presumed he had been stung by a bee and gave him Benadryl. Shortly after administering the Benadryl, the patient's jaw locked open; he began crying and twitching with seizure-like symptoms, and was taken to the hospital via ambulance. The patient was admitted for overnight observation. During this time, he was given IV Benadryl and his symptoms improved. The patient was discharged with instructions to discontinue the Abilify for a few days, follow up with the defendant FMP, continue Benadryl, and restart Abilify the following Monday.
Over the following two weeks, the patient was seen in the ED twice with symptoms ranging from headache, slurred speech, eye twitching/staring off to the right, rapid heartbeat, and painful breathing. He was discharged in stable condition after both episodes, and was diagnosed as having dystonic reaction secondary to Abilify, which was controlled by Benadryl. In the follow-up visit, the defendant FMP found that no residual sequelae of the overdose was noted.
The patient continued treatment for his two-year history of Asperger's, severe ADHD, emotional issues, focusing and concentration difficulties, obsessive compulsive behavior, and suicidal and homicidal threats.
A lawsuit was filed against the defendant FMP alleging that he improperly increased the Abilify prescription to 30 mg, resulting in seizures and brain damage.
Expert Testimony
Defense experts differed on whether the behavioral problems were exasperated by the excessive Abilify dose since the patient had exhibited many of the same behaviors prior to taking the medication. The patient also had a history of choroidal cyst with complaints of headache, which were not attributed to the child ingesting 30 mg of Abilify.
The defense had difficulty obtaining experts for a number of reasons. First, the MPR recommends that the drug not be prescribed in any dosage to a child under 13 years of age. There was also no documentation of the mother informing the doctor that the child was previously taking 20 mg of Abilify. The chart was also missing documentation from the August visit that showed there was a script written for Abilify 30 mg and no reference to the current dosage. Further, the defendant FMP did not have documentation of any communication with the psychiatrist who was treating the child’s mood disorder. The child’s medical record did support multiple references, dating back to February of the same year, that indicated the patient was taking Abilify 2 mg.
Resolution
Due to a lack of expert support, the case was settled.
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