Abstract

Vesicular monoamine transporter 2 inhibitors (VMAT2i) are currently Food and Drug Administration–approved for the treatment of Huntington disease chorea and tardive dyskinesia. Additionally, they are often used for other hyperkinetic movement disorders in clinical practice. Due to a lack of head-to-head clinical trials, management of VMAT2i in the clinical setting may be unclear and rely on the clinical experience of the practitioner. Due to the limited distribution model, which typically requires VMAT2i to be dispensed by specialty pharmacies, access and initiation of treatment may present as barriers. Patient cases allow for the exploration of switching between VMAT2i, alternative routes of administration, utilization in pediatric and off-label conditions, and how to successfully initiate and monitor a patient on VMAT2i therapy.

Abstract

The effective use of duloxetine can be complicated by acute kidney injury, acute and/or chronic hepatic dysfunction, dysphagia, enteral nutrition, and common pharmacokinetic interactions. This article aimed to review the pharmacological properties of duloxetine pertinent to its use and to discuss the management of duloxetine in patients with common acute and chronic medical comorbidities. Management strategies based on clinical data and expert opinion are reviewed in 3 patient cases.

Abstract

Two Supreme Court cases in the United States describe the use of involuntary medication in individuals with mental illnesses. In addition to these legal requirements, clinicians must also incorporate ethics into treating these individuals, including the principles of autonomy and beneficence. Current guidelines do not provide specific recommendations for choosing an antipsychotic for a patient with schizophrenia who is being treated involuntarily. However, it is recommended that clinicians use general guidelines for the treatment of schizophrenia as a basis for narrowing down appropriate therapy, which may involve the use of long-acting injectable antipsychotics. Clinical considerations that should be accounted for include past medication trials, potential adverse effects, whether tolerability has been demonstrated, route of administration, dosing interval, requirement for oral overlap, comorbid conditions, patient preference, and access to the medication.

Abstract

Managing suicidality in persons with chronic pain is a challenging clinical scenario with no treatment guidelines to inform clinical decision-making related to suicide risk mitigation. Applying appropriate risk mitigation strategies, such as opioid education and naloxone distribution, lethal means safety education, increased frequency of appointments, individualized opioid tapers, consideration of nonopioid pharmacotherapy, nonpharmacological treatment options, and addressing modifiable risk factors, can decrease suicide risk. Recommending a treatment plan for patients with chronic pain experiencing suicidality is explored through 3 patient cases.

Abstract

Introduction: Single-dose injectable aripiprazole lauroxil (SDIAL) is used with long-acting injectable (LAI) aripiprazole lauroxil in the treatment of schizophrenia. SDIAL can be used to either initiate treatment or supplement during maintenance when follow-up doses are not given within labeling recommendations. The primary objective was to determine the usage and appropriateness of SDIAL between the initiation and the maintenance supplementation use in a Medicaid database. The secondary objective was to determine the overall associated costs with the potentially inappropriate use of LAI aripiprazole lauroxil.

Methods: International Classification of Diseases, 10th edition codes were used to identify adult patients with schizophrenia and related disorders (18-64 years) who received SDIAL and/or LAI aripiprazole lauroxil between 2018 and 2020 using MarketScan Medicaid databases. The appropriateness of SDIAL was determined by package insert labeling timelines for treatment initiation and maintenance supplementation. Two authors independently reviewed each SDIAL claim for appropriateness. Descriptive statistics were used to analyze the data.

Results: After excluding possible billing errors, a total of 582 claims were identified for SDIAL. Of these, 21% were potentially inappropriate, with a higher proportion occurring during the maintenance phase. Overall, potential inappropriate use resulted in costs over $307 000.

Discussion: It appears that prescribers should be better educated on the appropriate use of SDIAL during maintenance supplementation.

Abstract

Oseltamivir (Tamiflu) package labeling has a warning for neuropsychiatric adverse events (NPAE), most commonly in children and adolescents, especially males. There are several case reports of NPAE in adults treated with oseltamivir, but few document patients with preexisting neuropsychiatric conditions without additional contributing factors. This case report describes a 22-year-old male with a history of bipolar disorder, depression, and attention-deficit/hyperactivity disorder who had been stable on his medication regimen before experiencing sudden worsening of symptoms after the initiation of oseltamivir. The case adds to previous literature by strengthening the correlation between oseltamivir and a sudden increase in neuropsychiatric symptoms. Providers should be aware that oseltamivir may exacerbate symptoms of previously stable patients. Depending on the severity of neuropsychiatric effects, discontinuation of oseltamivir and symptom treatment with pharmacotherapy may be warranted.