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ORIGINAL RESEARCH

Assessment of oral overlap with antipsychotic long-acting injectables initiated in an inpatient setting

PharmD,

PharmD, BCPP, and

PharmD, BCPS, BCPP

DOI: 10.9740/mhc.2023.06.147

Abstract

Introduction

Long-acting injectable (LAI) antipsychotics are a promising solution to combating issues related to nonadherence to oral antipsychotics. Oral overlap is utilized when an LAI is initiated to achieve therapeutic concentrations. The place in therapy in which additional overlap is warranted is often mistaken, and providers may prescribe additional overlap based on the presentation of the patient or misunderstanding of appropriate overlap.

Methods

This retrospective chart review assesses patients who were initiated on an LAI while admitted to the acute inpatient psychiatric unit from January 1, 2016, to December 31, 2019. The primary outcome assesses the appropriateness of oral overlap with LAIs. Secondary outcomes include adherence to oral overlap, discontinuation of an LAI within 4 months, and reason for discontinuation of LAI.

Results

A total of 62 patients were included: 40 (65%) had appropriate overlap, and 22 (35%) had inappropriate overlap. The most common LAI was paliperidone (n = 50, 81%). Patients were adherent to oral overlap in 67% (n = 6) of the appropriate overlap group and 85% (n = 17) of the inappropriate overlap group. Discontinuation of an LAI in 4 months occurred in 62.5% (n = 25) of the appropriate group and 40.9% (n = 9) of the inappropriate group. There were no significant differences in secondary outcomes when comparing adherence to oral overlap (p = .26), discontinuation of LAI within 4 months (p = .62), and reason for discontinuation (p = .69).

Discussion

This study identified that a majority of patients had appropriate prescribing of oral antipsychotic overlap.

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CASE REPORTS

Differences in serum concentration with valproate oral solution versus delayed-release divalproex in an adherent patient

PharmD, BCPS, BCPP

DOI: 10.9740/mhc.2023.06.152

Abstract

Background

Several different formulations of valproic acid derivatives are available in the United States. Although these formulations have different absorption characteristics, they are believed to be interchangeable, with the exception of the extended-release product.

Case Report

A 31-year-old African American man with schizoaffective disorder was started on fluphenazine concentrate and valproate oral solution on admission to an inpatient unit. A 12-hour steady-state concentration, drawn on 1000 mg/day, resulted in 40.8 mg/L, and the dose continued to be titrated. Despite increasing doses, confirmed medication adherence, and accurate lab sampling, his concentrations remained low: 60.3 and 60.1 mg/L on 1500 mg/day, and 65.6 mg/L on 1750 mg/day. He was switched to divalproex delayed-release tablets, and his dose was increased to 2000 mg/day. Follow-up 12-hour steady-state concentrations were significantly higher, at 126.6 and 113.8 mg/L. It is theorized that the formulation of divalproex/valproic acid is what contributed to these differences in concentrations.

Discussion

Valproic acid formulations are considered to be interchangeable, and several studies have demonstrated that chronic psychiatric inpatients stabilized on delayed-release divalproex may be safely switched to valproate oral solution without changes in psychiatric stability. This case demonstrates a significant difference in serum drug concentrations when switching from valproate oral solution to divalproex delayed-release tablets.

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Precipitated withdrawal with kratom use following naltrexone administration

PharmD, BCPS, BCPP and

PharmD, BCCCP

DOI: 10.9740/mhc.2023.06.155

Abstract

Kratom is an herbal supplement with reports of use for natural pain relief or treatment of opioid withdrawal symptoms. Kratom has metabolites that bind to and agonize mu-opioid receptors similar to opiate medications. There have been reports of serious adverse reactions, with a potential for dependence with long-term use and withdrawal that may occur upon discontinuation. Naltrexone can result in abrupt withdrawal symptoms when used with opioids or opioid-like supplements such as kratom. This case report describes withdrawal precipitated by naltrexone administration in a patient with undisclosed chronic kratom use. This case highlights the importance of thorough assessment of all self-administered herbal and over-the-counter supplements as they may have serious interactions with other prescribed medications and affect therapeutic outcomes.

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LETTER TO THE EDITOR

Medications for opioid use disorder in professional recovery programs in the United States: Policies and recommendation patterns

PharmD, MS,

PharmD, and

PharmD

DOI: 10.9740/mhc.2023.06.163

Dear Editor:

The use of medications for opioid use disorder (MOUD) by health professionals engaged in professional recovery programs (PRPs) is a topic of persistent controversy.¹ However, discussions of this topic are limited by a reliance on outdated publications and anecdotal reports.²

The purpose of this study was to describe current policies and clinician recommendation patterns for MOUD in PRPs. A survey was developed and pretested during 2 live interviews with PRP directors in Texas. The final survey focused on collecting data for each form of MOUD approved by the FDA: methadone (MTD), buprenorphine (BUP), and naltrexone

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Comment on “An update on recently approved long-acting injectable second-generation antipsychotics: Knowns and unknowns regarding their use”

PharmD, BCPP,

PharmD,

PharmD, BCPP,

PharmD, BCPP, and

PhD

DOI: 10.9740/mhc.2023.06.165

Dear Editor:

We read with interest Dr. VandenBerg’s Psychopharmacology Pearl article¹ in the October 2022 issue of Mental Health Clinician discussing recently approved long-acting injectable second-generation antipsychotics. We appreciate that Psychopharmacology Pearl articles reflect the views and practices of authors, substantiated with evidence-based data as well as professional opinion and experience. However, we noticed inaccuracies regarding aripiprazole lauroxil (AL; Aristada, Alkermes Inc, Waltham, MA) in the VandenBerg article and would like to offer corrections and clarifications.

The article states, “The difference in molecular weight drives much of the difference in dose between” aripiprazole monohydrate (AM) and

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Response to comment on the recently published article “An update on recently approved long-acting injectable second-generation antipsychotics: Knowns and unknowns regarding their use”

PharmD, BCPP

DOI: 10.9740/mhc.2023.06.167

Dear Editor:

Thank you for the opportunity to respond to the letter submitted by Dr. Still and colleagues¹ regarding the December 2022 article entitled “An update on recently approved long-acting injectable second-generation antipsychotics: Knowns and unknowns regarding their use.”² The purpose of that article was to review key clinical pearls of newer long-acting injectable (LAI) second-generation antipsychotics informed by clinical evidence, pharmacokinetic properties, and clinical experience using these products in practice since the first risperidone LAI came to market. An additional aim was to provide a succinct case-based framework for clinicians to apply to multiple medications

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