psychiatric medication update...psychiatric medication update kelly a. gabel, pharm.d. director of...
TRANSCRIPT
Psychiatric Medication Update
Kelly A. Gabel, Pharm.D.Director Of PharmacySoutheast Missouri Mental Health CenterFarmington, MO 63640(573) 218-7022
q Become familiar with VMATII
Inhibitors
q Discuss new advancements with
antipsychotics available in Long
Acting Injection formulations
q Gain an understanding related to
changes in pain management
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Objectives
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Tardive Dyskinesia
Pathophysiology of TD
Tardive Dyskenesia
q Incidence:q 8.5% Typical antipsychoticsq 3% Atypical Antipsychotics
q Most often involving the mouth, lips, and tongue (e.g., lip smacking, facial grimaces, etc).
q Repetitive unintentional movements.q Twitchyq Shakyq Jitteryq Jerky
q Likely caused by a hypersensitivity of dopamine (D2/D3) receptors following the chronic blockade by antipsychotics
What is it?
Example1 Example2
Tardive Dyskinesia
q Drug Selectionq Lowest effective doseq Shortest possible durationq Minimize polypharmacyq Regularly review ongoing need to ensure continued efficacy.q Early Identification of symptoms
Prevention
Tardive Dyskenesia
.q The causative medication should be tapered in patients who are able to tolerate it.
q Begin the taper promptly at the first sign of tardive dyskinesia.
q Abrupt discontinuation of the antipsychotic can actually cause or worsen tardive dyskinesia.
q Consider alternative antipsychotics with different neurotransmitter profile.
What now???
Treatment
Tardive Dyskenesia
q Clonazepam
q Botulinum Toxin
q Amantadine
q VMATII Inhibitors
q Austedo® (Deutetrabenazine)
q Ingrezza® (Valbenazine)
q Xenazine® (Tetrabenazine)*
Treatment
*Not FDA Approved for Tardive Dyskinesia
Tardive Dyskinesea
Ingrezza ® (Valbenazine)
q Once daily administration
q Initial dose is 40mg daily titrated up to 80mg
once daily
q ADRS: Somnolence (>5% and twice the rate
of placebo)
q INBRACE ® Program
Austedo ® (Deutetrabenazine)
q Twice daily administration
q Initial dose is 6mg twice daily titrated up to a max
of 24mg twice daily
q ADRS: Nasopharyngitis and Insomnia
q Also approved for chorea associated with
Huntington’s disease
q Shared Solutions® Program
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Selective VMAT2 Inhibitors
Let’s talk Long Acting Injectable Antipsychotics (LAIs)
“Around 8% of patients with psychosis are prescribed long-
acting, injectable antipsychotics in the United States,
compared with 40% in Europe!
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Long Acting Injections
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1960s 1972
1960s
1986 20092003
First Generation
Fluphenazine enanthate
Fluphenazine decanoate
Paliperidone palmitateInvega Trinza®Haloperidol
deaconate
Risperidone microspheres
Risperdal Consta®
Paliperidone palmitate LAIInvega Sustenna®
2013 2015
2015
2018
AirpiprazoleLauroxilAristata®
AripiprazoleAbilify Maintena®
Second Generation
Olanzapine pamoate
Zyprexa Relprevv®
AirpiprazoleLauroxil
Aristata Initio®
Long Acting Injections
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q Early identification of non-adherenceq Provides adherence reassuranceq No daily pill burdenq Regular patient interactionq Reduced relapse frequency and rehospitalization ratesq Reduce the risk overdoseq More stable plasma concentrations than oralq Lower and less frequent peak plasma level – reduced side
effects
Potential Advantages
Long Acting Injections
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Long Acting Injections
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q OUCH!q Slow dose titrationq Longer time to achieve steady state
levelsq Less flexibility of dose adjustmentq Delayed disappearance of side effectsq Accessq Perception of stigmaq Cost
Potential Disadvantages
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Brand Name Chemical Name Manufacturer Available Formulations Injection interval CommentsRisperdal Consta® Risperidone
microspheres Janssen 12.5, 25, 37.5, or 50mg 25-‐5-‐mg Q2 weeksOral overlap of 3 weeks required.
Zyprexa Relprevv® Olanzapine Pamoate Lilly 210, 300, 405 mg vials150–300 mg q2 weeks300–405 mg once/month
No oral overlap needed. Requires monitoring post injection (3 hours) for Post Injection Syndrome.
Invega Sustenna® Paliperidone palmitate Janssen 39,78,117,156 or 234 mg
prefilled syringes 117 mg once/month
No oral overlap needed. Requires two separate loading dose injections during the first week.
Abilify Maintena® Aripiprazole monohydrate Otsuka 300,400 mg vials, prefilled
syringes. 400 mg once/monthRequires a period of 2 weeks of overlap with oral aripiprazole.
Invega Trinza® Paliperidone palmitate Janssen 273, 410, 546, 819 mg
prefilled syringes 410 mg q3 monthsUse in patients already treated with Invega Sustenna for 4 months.
Aristada®
Aristada Initio®
Aripiprazole lauroxil Alkermes
Initio: 675mg prefilled syringe
Aristada: 441, 662, 882 mg prefilled syringes
One oral tablet and Aristada administered on day one. 441–882 mg once/month882 mg q 6 weeks1064 mg Q 2 months
Oral supplementation needed for one day.
Long Acting Injections
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q OUCH!q Slow dose titrationq Longer time to achieve steady state
levelsq Less flexibility of dose adjustmentq Delayed disappearance of side effectsq Accessq Perception of stigmaq Cost
Potential Disadvantages
100 MillionOf US Population reports chronic pain
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215 Milli0nOpiate Perscriptions in 2016
Ranked #2Pain Medication are the second most prescribed drugs in the United States.
62 MillionPatients received at least one Opiate Prescriptions
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“Whatever the Patient says it is”
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NSAIDS APAP SNRIsAnticonvulsantsTCAS
Improvement in Pain and Function
Opioids
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Opioid Risks q Dependence: Development of a physiologic withdrawal syndrome upon reduction or cessation of the drug.
q Tolerance: The development of a need to take increasing doses of a medication to obtain the same affect
Euphoria/anti-anxiety/sedation- Occurs within weeksAnalgesia- occurs within months
q Respiratory Depression---silent killerq Hyperalgesia: A paradoxical response in patients who become more sensitive to pain in response to long term opioid therapy.
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CDC Guidelines for Opiate Management Summary• Opioids are not first-line or routine therapy for chronic pain • Establish and measure goals for pain and function • Discuss benefits and risks and availability of nonopioid therapies with patient• Use immediate-release opioids when starting • Start low and go slow • When opioids are needed for acute pain, prescribe no more than needed • Do not prescribe ER/LA opioids for acute pain • Follow-up and re-evaluate risk of harm;; reduce dose or taper and discontinue if needed• Evaluate risk factors for opioid-related harms • Check PDMP for high dosages and prescriptions from other providers • Use urine drug testing to identify prescribed substances and undisclosed use • Avoid concurrent benzodiazepine and opioid prescribing • Arrange treatment for opioid use disorder if needed
www.cdc.gov/drugoverdose/prescribing/guideline.html
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Changes in Missouri LegislationSection 195.010 has been amended to limit “initial prescriptions” of an opiate for acute pain to a seven (7) day supply. The statutory restriction applies to all healthcare practitioners except veterinarians.
An “initial prescription” is defined as
Issued to a patient who has never been issued a prescription for the drug or its
pharmacy equivalentor
Issued to a patient who has not used or been prescribed or administered the medication
within the five (5) months prior to the current prescription being issued
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The 7-day supply limit does not apply if the prescriber determines more than a 7-day supply is required to treat the patient’s acute pain based on his/her medicaljudgment. The 7-day supply limit also doesn’t apply to opioid prescription for:
Changes in Missouri Legislation
• Patients currently undergoing cancer treatment• Patients receiving palliative care• Patients receiving hospice care from hospice
certified • Residents of a long-term care facility • Patients receiving treatment for substance abuse
or opioid dependence.
