Clozapine is established as the gold standard for antipsychotic treatment of patients suffering from treatment-resistant schizophrenia. Over virtually 3 decades, the level of inadequate response to clozapine was found to range from 40% to 60%. A heightened interest developed in the augmentation of clozapine to try to achieve response or maximize partial response. A large variety of drug groups have been investigated. This article focuses on the meta-analyses of these trials to discover reasonable evidence-based approaches to the management of patients not responding to clozapine.Abstract
Multiple sclerosis is a chronic, unpredictable, and disabling disease. Significant advances have been made in recent years supporting an earlier, more accurate, diagnosis and have led to more than 15 disease-modifying therapies approved by the Food and Drug Administration for relapsing forms of multiple sclerosis. Disease-modifying therapies are now being classified into categories based on level of efficacy. Strategies to use disease-modifying therapies earlier and in a more customizable manner are also emerging. A clinical case study will be used throughout this pearl to review the disease-modifying therapies and use patient-specific factors to develop and provide recommendations on therapeutic strategies for individuals with relapsing forms of multiple sclerosis.Abstract
The number of pregnant people affected by the opioid epidemic in the United States continues to rise. The following key aspects of opioid use disorder in pregnancy are explored through the progression of a pregnancy via a patient case: treatment options, treatment decisions, substance use screening, dosing modifications, and other aspects of peripartum care. Many factors affect opioid use disorder treatment choices during pregnancy; however, when a pregnant person is medically eligible for a therapy and multiple options are available locally, the ultimate decision regarding treatment selection should be left up to the patient and strong support services provided. This approach to treatment results in optimal maternal and neonatal outcomes and long-term maternal engagement and retention in care.Abstract
Current clinical practice guidelines for the treatment of posttraumatic stress disorder offer varying recommendations regarding the use of pharmacotherapy. Many direct head-to-head comparisons of pharmacotherapy are lacking, and recommendations are based on meta-analyses and small trials. While selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are considered first-line pharmacotherapy, clear distinctions do not exist when considering other classes of psychotropic medications. Ultimately, when selecting an appropriate medication for a patient diagnosed with posttraumatic stress disorder, the clinician needs to consider the current symptomatology being experienced, comorbid conditions, and evidence for efficacy of specific treatments prior to initiating medications.Abstract
Harm reduction is a term for strategies that minimize the negative outcomes of drug use. Given the progressing opioid epidemic, identifying barriers to harm reduction dispensing in community pharmacies is essential. This online, survey-based study assessed community pharmacist attitudes toward harm reduction and perceived dispense rates of both naloxone and needles/syringes to patients without verifiable injectable prescriptions. The online survey was distributed to members of the Bexar County Pharmacist Association and university alumni. The survey collected demographics, perceived dispense rates of naloxone, needles and syringes, availability of pharmacy protocols for dispensing these products, and Likert-scaled attitudinal questions. Responses were collected for 6 weeks. Thirty-two survey responses were analyzed. Participants were generally white (n = 14) or Hispanic/Latino (n = 14), had a median age of 37 years (interquartile range, 32-49 years), and had a median graduation year of 2011 (interquartile range, 1988-2016). Most pharmacists agreed or strongly agreed they should be involved in harm reduction (n = 26) and that pharmacies are an appropriate place to access these resources (n = 26). However, most reported never or rarely dispensing both naloxone (n = 19) and needles and syringes (n = 22). Naloxone or needle and syringe protocol use was reported by 66% (n = 21) and 47% (n = 15) of pharmacists, respectively. Pharmacy protocols significantly enhanced the likelihood of naloxone dispensing (P = .007) but not needle and syringe dispensing (P = .24). Community pharmacists exhibited positive attitudes toward harm reduction but reported low rates of dispensing both naloxone and needles and syringes. Pharmacy protocols could be enhanced to better support community pharmacists in this area.Abstract
Introduction
Methods
Results
Conclusion
In veterans, the prevalence of 12-month and lifetime alcohol use disorder (AUD) is 14.8% and 42.2%, respectively. Alcohol use disorder treatment is often plagued by medication discontinuation with relapse rates being as high as 39% in patients who sought treatment. One proposed benefit of long-acting injectable (LAI) medications is improved adherence. The purpose of this trial was to compare the difference in time to relapse between patients on oral and LAI naltrexone. This study was a retrospective electronic chart review of patients with AUD who were treated with oral or LAI naltrexone at a Veteran's Affairs Medical Center from August 1, 2016, to July 31, 2018. The primary outcome assessed was time to relapse. Secondary outcomes for this study included medication possession ratio (MPR), comorbid mental health diagnosis, substance use, past pharmacological treatment, liver and kidney function, and enrollment in addiction-focused psychosocial therapy. Thirty-two patients met inclusion criteria. The median time to relapse was longer for those treated with LAI naltrexone versus oral naltrexone (150.5 days vs 50.5 days, P < .01). The MPR was similar among both groups (P = .47). No significant differences were found between the groups regarding safety outcomes. Results suggest that LAI naltrexone is associated with increased time to relapse and should be considered as a first-line option for patients. Given the retrospective nature and small sample size of this study, larger, randomized, controlled trials comparing LAI and oral naltrexone head to head would help determine most appropriate treatment for these patients.Abstract
Introduction
Methods
Results
Discussion
The association of psychosis with albendazole monotherapy has not been established in current literature. We present the first reported case of acute psychosis associated with albendazole. Upon cessation of the agent and the introduction of aripiprazole, the patient's psychosis remitted, and the patient did not present for acute treatment in the months to follow. The temporal relationship and laboratory data support albendazole's role in leading to the aforementioned toxicity. Such reactions, although rare, can drastically impact patient care and may warrant increased provider consideration when choosing to prescribe albendazole.Abstract
Introduction
Case Report
Discussion/Conclusion
It is well known that antidepressants have the potential to cause withdrawal symptoms upon abrupt discontinuation. At the time of this case report, no literature has identified intense, body-wide pruritus as a result of abrupt mirtazapine discontinuation. However, there is literature to suggest that mirtazapine may be used as a treatment for pruritus at doses as low as 15 mg/d due to its high affinity for central and peripheral histamine H1 receptors. Considering this information, it is suspected that the abrupt discontinuation of mirtazapine in the following patient case resulted in pruritus due to the reversal of antagonism at histamine receptors.Abstract
Limited evidence exists for the use of psychiatric medications in patients with end-stage renal disease on hemodialysis. Many psychotropic medications are not well-studied in this population, and optimal dosing of these medications is not well-established. Therapeutic drug monitoring is a useful tool in assessing the safety and efficacy of psychotropic medications; however, the use is unclear with long-acting injectable antipsychotics. We present a case of a 73-year-old male initiated on hemodialysis while on risperidone microspheres long-acting injection (RMLAI). Risperidone and 9-hydroxyrisperidone plasma concentrations obtained from this patient were relatively similar before and after initiation of hemodialysis, therefore it appears hemodialysis does not significantly influence clearance of RMLAI. Plasma concentrations in this patient were higher than those reported in the literature for equivalent doses, which may indicate accumulation of the medication secondary to renal impairment.Abstract