LAUSR

CASE REPORT Ms Q (who provided her approval for this report) was a 25-year-old white woman with a history of bipolar illness type I. She developed depressive symptoms, and lurasidone (20 mg/d) was added to her lamotrigine (200 mg/d). After 20 months of treatment, lurasidone was stopped owing to weight gain (146–154 lbs or 5.5% increase). Because she was only receiving 20 mg, it was stopped and not tapered. At the same time, she was advised to restrict her consumption to artificially sweetened beverages to aid in weight loss (which resulted in an average consumption of 450 to 600 mg of aspartame per day). Within 6 weeks, she noted abnormal movements that manifested as chewing movements and pursing of her lips. There were no previous abnormal movements. Contemporaneously, she developed manic symptoms, and lurasidone was restarted and increased to 20 mg. Over the subsequent 2 months, the movements worsened, but the mood stabilized. Lurasidone was tapered and stopped over an additional 4 months. Vitamin E (400 IU) twice daily was started for the TD, but 6 weeks later, the movements were worse. Use of artificially sweetened products was stopped, and within 2 weeks, the movements were significantly better and nearly gone after an additional 2 months. Concern that shemay have had premorbid elevations of plasma phenylalanine led to testing for the carrier state of the phenylalanine hydroxylase gene, but it was negative. Similarly, laboratory evaluations including complete metabolic profile, complete blood count, and thyroid function were normal throughout this period.