Abstract

Introduction: Long-acting injectable antipsychotics (LAI-APs) are used in patients with chronic psychiatric disorders as a strategy to manage oral medication nonadherence. Inpatient LAI-AP administration may assist with transition to the outpatient setting. The study objective was to characterize receipt of the next LAI-AP injection as planned in the outpatient setting following administration during inpatient psychiatric hospitalization.

Methods: Patients 18 years and older were eligible for inclusion if they received an LAI-AP while inpatient and provided consent to monitor their 90-day follow-up. The primary outcome determined the percentage of patients who received the same LAI-AP administered during their inpatient psychiatric admission at their initial visit post discharge. The secondary outcomes compared appropriate documentation of the LAI-AP follow-up plan, oral overlap, and early psychiatric rehospitalization rates.

Results: Fifty-one patients were included. Twenty-nine patients (56.9%) followed up within the outpatient setting after discharge and received their next scheduled LAI-AP as planned. Twenty-two patients (43.1%) did not receive an LAI-AP injection following discharge, 15 of whom did not attend their initial follow-up appointment. Thirty-nine patients (76.5%) were newly initiated on LAI-AP therapy, 19 of whom received their next follow-up injection.

Discussion: More than 40% of patients who received an LAI-AP inpatient did not follow up in the outpatient setting despite appropriate discharge planning. Patients more likely to receive follow-up LAI-AP were older, received a maintenance injection while inpatient, and had a scheduled follow-up appointment. Prior to inpatient administration of LAI-AP, multiple factors should be considered, including outpatient adherence, access, feasibility of outpatient continuation, and transition of care plan.

Abstract

Introduction: Using long-acting injectable (LAI) medications increases treatment adherence and promotes positive outcomes for patients with substance use disorders (SUD). Despite documented benefits that LAI medications can have over their oral counterparts, they continue to be underused. With the expansion of pharmacists’ scope of practice for medication administration services, there is a need to document and evaluate the benefits of pharmacist engagement in LAI administration services for SUD and identify growth opportunities.

Methods: A PubMed database search for articles related to a pharmacist’s role in LAI administration services for buprenorphine and naltrexone was conducted. Articles published before December 15, 2023, and in English describing or reporting outcomes of pharmacists administering LAI buprenorphine or LAI naltrexone in the United States were included.

Results: A total of 56 articles were identified in the search process. After removing duplicate citations and exploring references and similar article recommendations, a total of 5 articles were included in the final analysis. All 5 articles discussed pharmacist administration of LAI naltrexone, and no articles discussed pharmacist administration of LAI buprenorphine. Outcomes for each article varied and included cost analyses, implementation procedures, and identified barriers.

Discussion: Current literature on pharmacist-administered LAI services is limited. With many states allowing pharmacist administration of LAI medications, there is a significant opportunity to expand patient access to LAI medications for SUD in the pharmacy setting. Standardized training on LAI administration, development of standard operating procedures, and clarity on reimbursement policies are needed to help accelerate the implementation of pharmacist-administered LAI services.

Abstract

Weight loss surgery has become more common in the United States because of the increasing rates of obesity. The physiological changes caused by weight loss surgery have the potential for clinically significant changes in the pharmacokinetic parameters of mood stabilizers, including valproic acid (VPA). A patient with a history of Roux-en-Y gastric bypass and bipolar disorder was hospitalized because of mania. The dosing regimen of the VPA was changed multiple times due to unexpectedly low and inconsistent trough levels. Despite a significant increase in the total daily dose, the final trough level obtained was not significantly different than the initial level. The VPA was changed from the delayed-release to the immediate-release formulation to achieve better absorption. However, no trough level was obtained after this change. Weight loss surgeries, such as Roux-en-Y gastric bypass, may continue to impact the pharmacokinetic parameters of VPA for several years after the procedure. This patient was titrated to a dose of 39 mg/kg/day (typical range 20-30 mg/kg/day) with minimal change in level. Pharmacokinetic changes are a concern in the use of mood stabilizers, including VPA, after weight loss surgery. Close monitoring is essential for safe and effective treatment. If strict drug level monitoring is not an option, it may be preferable to consider an alternative mood-stabilizing treatment. Switching to the immediate-release formulation of VPA may also be an option; however, further investigation is required to determine if this makes a clinical difference in the management of bipolar disorder.