A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient has prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?
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A
ZiprasidoneCorrect. Ziprasidone has the most weight-neutral metabolic profile among the listed antipsychotics, making it ideal for a patient concerned about weight gain.
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B
ClozapineIncorrect. Clozapine causes severe weight gain, metabolic syndrome, and agranulocytosis - reserved for treatment-resistant schizophrenia and not appropriate first-line for a weight-conscious patient with new psychosis.
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C
ClonazepamIncorrect. Clonazepam is a benzodiazepine - it would not treat the psychotic visual hallucinations described and is not an antipsychotic.
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D
ChlorpromazineIncorrect. Chlorpromazine is a low-potency typical antipsychotic with high anticholinergic effects, sedation, weight gain, orthostasis, and corneal/lens deposits - not the best choice for metabolic neutrality.
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E
OlanzapineIncorrect. Olanzapine is highly effective for psychosis but causes substantial weight gain, dyslipidemia, and insulin resistance, making it a poor choice for a patient already obese and concerned about weight.
↑ Tap an answer to reveal the reasoning
Answer: A. This woman has new-onset psychosis (visual hallucinations) alongside panic attacks and attentional problems, and the question stem signals her concern about weight gain. The best antipsychotic in a patient prioritizing metabolic neutrality is ziprasidone, which has the most favorable metabolic profile among the atypical antipsychotics - it is essentially weight-neutral and has minimal effects on lipid and glucose metabolism. Aripiprazole and lurasidone are also options with low metabolic burden, but among the listed choices ziprasidone is the clear answer.
Ziprasidone's main caveats are QT prolongation (requires baseline ECG, avoid in patients with long QT or on QT-prolonging drugs) and the requirement for food (>=500 kcal meal) for adequate oral absorption. It has moderate efficacy for both positive and negative symptoms.
The alternatives have major drawbacks for a weight-conscious patient: clozapine and olanzapine cause the most weight gain and metabolic syndrome among atypicals; chlorpromazine (low-potency typical) is highly sedating and anticholinergic; clonazepam is a benzodiazepine and not an antipsychotic at all.
**Why each option:**
**A.** Correct. Ziprasidone has the most weight-neutral metabolic profile among the listed antipsychotics, making it ideal for a patient concerned about weight gain.
**B.** Clozapine causes severe weight gain, metabolic syndrome, and agranulocytosis - reserved for treatment-resistant schizophrenia and not appropriate first-line for a weight-conscious patient with new psychosis.
**C.** Clonazepam is a benzodiazepine - it would not treat the psychotic visual hallucinations described and is not an antipsychotic.
**D.** Chlorpromazine is a low-potency typical antipsychotic with high anticholinergic effects, sedation, weight gain, orthostasis, and corneal/lens deposits - not the best choice for metabolic neutrality.