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Clinician's Guide to Preparing and Administering L ...
Presentation and Q&A
Presentation and Q&A
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Hello and welcome. I'm Benjamin Dress, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and a member of the SMI Clinical Expert Team. I'm pleased that you are joining us for today's SMI webinar, Clinician's Guide to Preparing and Administering Long-Acting Injectable Antipsychotics. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Donna Rollin and Ms. Sarah McGoran, PMHNP. Dr. Rollin is a Clinical Associate Professor and the Director of the Psychiatric Mental Health Nurse Practitioner Program at the University of Texas with 23 years of experience in psychiatric nursing. She is co-leading interdisciplinary graduate training initiatives with schools of nursing, medicine, educational psychology, social work, and pharmacy with funding from the Health Resources and Services Administration and the Texas Higher Education Coordinating Board, aiming to expand a culturally diverse workforce for underserved populations. She serves as the co-director of the Institute for Domestic Violence and Sexual Assault, working alongside schools of social work, law, and Bureau of Business Research. Sarah McGoran is a Psychiatric Mental Health Nurse Practitioner at the Freedom Trail Clinic in Boston. She is Director of Community Health Integration for North Suffolk Mental Health Association and the Massachusetts General Hospitals SCRP. In this role, she has developed a coordinated health and medical prevention service through which the clinic provides guideline-concordant care and moves towards population management of disease. Sarah works closely with the Department of Mental Health, specifically engaging the residents of two DMH homeless shelters. In this role, she advocates for systematic change and supports the education of psychiatry residents and DMH staff. Dr. Rowland and Ms. McGoran, thank you both for leading today's webinar. My disclosure is that I participate in a Nurse Practitioner Advisory Board for Alkermes. First off, we will be speaking about the preparation and negotiation that needs to occur between patients and their prescribing clinicians. So first of all, the reason to start talking about long-acting injectables early in treatment include a lower risk of relapse because compliance is assured, more consistent medication levels, and regular face-to-face clinical encounters during which the patient can be carefully assessed and treatment adjusted as necessary. Repeated psychiatric episodes can worsen both psychiatric, cognitive, and social function, so prevention is absolutely key to lessen what we call social toxicity, which can be the loss of relationships, employment, and educational achievement. Similar to clozapine, long-acting injectables reduce overall mortality because, as former director of the World Health Organization, Dr. Brock Chisholm said in 1953, without mental health, there can be no true physical health. Before we can talk with our patients about long-acting injectables, we first need to consider how we view them ourselves, what biases we as clinicians may hold. For example, you may think patients just don't like injections, that talking about, recommending, or giving a long-acting will damage the alliance, that patients may see injections as punitive, or we may even see them as punitive ourselves. And so some research has looked at this, the Wieden paper, that psychiatrists tend to present long-acting injectables in a negative light, and that the majority of patients who initially seemed to decline the recommendation said they would actually be willing to accept it. And I think it's important to consider who do we talk about LAIs with, which patients, and in which patients do we not. It's important to remember that it's not just an option for people who have a history of non-compliance. It can be a positive option to present early on to anyone before non-compliance actually becomes an issue. In these current days and current climate, it's particularly necessary, important to be mindful of the history of anti-psychotic use in black men who received first-generation decanoates in a higher ratio than white men. This was studied in 2003, reviewing some previous work developed with support guidelines. Factors identified in impacting the use of LAIs include patient eligibility, their use in inpatient settings, support around medication decisions, and interclinician infrastructure, and payee factors as well. Thinking about common barriers that influence clinician use of LAI, there are the injection-specific barriers, which tend to be practical in nature. Where and how does one get the LAI? Does the patient pick it up at the pharmacy on his or herself? Is it delivered to the clinic? Is there another way? Sometimes long-acting injectables can take longer for the pharmacy to order. They may not have them on hand. Sometimes special working with a specialty pharmacy can be helpful. Another practical factor is who administers the injection. I think one of the things that's really important to think about is, as most places are moving towards team-based care, and a lot of our patients have not only a prescribing clinician, but also a social worker or a therapist, maybe group home staff or other community workers, to have conversations and making sure all members of the team understand the risks and benefits and rationale of using an LAI so that there's a consistent message being given to the patient. As I mentioned earlier, LAIs decrease the risk of relapse. Many studies have shown that clozapine and LAIs are the most effective treatment in preventing psychiatric and all-cause hospitalization, both in chronic and first-episode patients with schizophrenia. Again, the reason that reducing the risk of relapse is so important is to minimize social toxicity, help people maintain relationships, not burn those bridges, and continue on in the meaningful activities of their life, whether that be education, friendship, employment, those sorts of things. In Park's meta-analysis, the group treated with long-acting injectable second-generation antipsychotics was characterized by a significantly lower relapse rate, a longer time to relapse, and fewer hospitalization, hospital days than the group treated with oral second-generations. And when the studies that followed subjects longer than a year found a significantly lower relapse rate and higher remission rate than the orals. LAIs were not necessarily superior to orals regarding hospitalization risk and hospitalization days, but keep in mind that these results occurred in LAI patients who were more severely and or chronically ill. And one other thing to keep in mind when thinking about the use of LAIs and risk of relapse is to make use of therapeutic drug monitoring. There are some tips on the SMI advisor website about therapeutic drug monitoring, but for LAIs, it's important to make sure that you have the correct dose. We're assuring compliance, and so learning who might be a fast or slow metabolizer, and also kind of considering patients' reports and complaints if they level may be high and they may be struggling with side effects. So again, we can look to another Scandinavian population study. There was the Danish study several years ago that showed a nearly two-fold higher mortality rate among individuals with treatment-resistant schizophrenia who were not treated with clozapine compared with those treated with clozapine. Now we have this study from Sweden showing that patients with schizophrenia who take an antipsychotic medication have a reduced mortality risk 40% lower, and the mortality is reduced 30% when LAIs are used compared to oral antipsychotics. And this one should also be noted that the study lung-acting injectable aripiprazole was not yet available, was not included in the study. So as we think through all of this, and kind of weigh the advantages and disadvantages of LAIs with ourselves, and also in thinking how we'll present these to family members. Some advantages include you don't have to fight with your parents or the group home staff about whether or not to take the pills every day. And for people who may be higher functioning and living independently, it can be an internal fight. Do I really need this medication? I don't want to take this medication. Whereas a monthly or even longer visit at the clinic, you can kind of have that discussion. The patient can have that discussion with the provider. Similarly, these regular clinic visits can provide an opportunity for ongoing building of rapport and working towards recovery goals. And so there can be less of that kind of back and forth discussion. The drug levels within the body are much more even than taking a pill where the half-lives may cause fluctuations over the course of the day. And once again, decreased relapse and mortality rate. For disadvantages, I think it is important for us to be aware of those and in order to have those honest, transparent conversations with patients and families. There can be pain associated with the injection and the injection site. And not to minimize that. Most patients do not complain about this, say that they may have a little bit of pain for a day or so. But it is a possibility. Some people have a fear of needles. The practicalities can be a disadvantage depending on your clinic setting and even the differences between rural and urban settings and what the options are. One other possible risk is just if the dosage is wrong and someone does experience side effects. Those can be somewhat prolonged if they do occur. The last bullet on the slide for disadvantages is the perception of stigma. And I think that can go either way actually. Say it is a young person who has roommates and social life. Nobody has to see them taking pills. In some ways, that can reduce stigma. But for other people having to go to a clinic every month, that can feel like an increase in stigma. Now that we have talked about how we as clinicians think about long-acting and the key points to know, the next step is to dialogue with the patient and ideally family members or other supports. Again, presenting it as an option early on in treatment, even for people in their first episode. It is an option to consider that people should have on their radar and present some of those advantages we talked on the previous slide. Not having to argue about medications, to have those even drug levels over the course of time, reduce the risk of relapse, and also reduce the risk of unintentional or intentional overdose during early periods of time when there can be more impulsivity or demoralization. And also be sure to educate the families as to what the process would look like. Specifically, would they need to continue oral supplementation for a few weeks or would a loading dose strategy be used? You can refer families to NAMI, National Alliance for Mental Illness, and see an article where they talk about LAIs, which can provide some more of a peer perspective for families and patients. For further guidance on these sorts of discussions, is the use of shared decision-making. Shared decision-making is a collaborative process between patient and clinician. And one of the reasons that it has such an impact is that it can lead to a sense of ownership in one's course of recovery, and ownership over treatment through greater engagement with the providers. And so it's a more, the patient and clinician can feel as though they're on the same team, and again, less arguing. And this goes back to some of the barriers we talked about before and the importance of the whole team, the therapist, case managers, understanding the rationale and recommendations for using LAIs. On the SMI advisor website, there are a couple tips, one on shared decision-making more generally, and one specifically for long-acting injectables. In review, these are some of the pros and cons of using LAIs. Increased adherence, steady plasma levels, decreased risk of relapse and mortality, regular visits, and decreased family conflict. Sometimes there can be a slower titration period, the issue of pain and side effects, as I mentioned. And although those clinic visits can be a good thing, but can also be logistically challenging for some. And then there's a historical perception of stigma associated with long-acting injectables. And I think sometimes people think about injections, they think of the more acute chemical restraints and clarifying how these are very different type of injection with a very different intent and purpose. And now I'll turn it back over to Donna. Thanks, Sarah. Now we'll shift to discussing best practices and how we monitor patient outcomes. We'll touch on the monitoring of efficacy, side effects, timing, charting, what to report, as well as how to handle missed doses. In studies comparing long-acting injectables to placebo, LAIs show significant efficacy in symptom reduction. Compared to oral antipsychotics, long-acting injectable studies are limited and difficult in design. This comparison of apples to oranges, if you will. But when examining well-designed studies, results show significantly improved outcomes when measuring things such as inpatient hospitalization, as Sarah had touched on a bit ago. When comparing apples to apples or the LAIs side by side, there's little evidence that one LAI outperforms another. We'll discuss the comparison of different long-acting injectable agents later on, but selection is most often based on many factors, such as patient choice, history of success, or having had issues with oral antipsychotics, and timing logistics. This slide outlines the most common side effects of long-acting injectables collectively as a class. They all carry some risk of increasing metabolic markers, impacting cardiac function or QTC prolongation, having sedation, anticholinergic effects, as well as extrapyramidal symptoms and tardive dyskinesia. The next few slides will highlight the most common side effects per LAI agent. Toward the end of this presentation, we will detail recommended monitoring parameters that cover all of these potential side effects. Notably though, up to 10% of patients receiving LAIs will report a localized site reaction, as Sarah had described. And she'll also address the post-injection management in more detail later. Next let's look at the first-generation agents. These have been around for many years, and we're all probably quite familiar with them. Gluthenazine, or prolixin decanoate, and haloperidol, or haldol decanoate. They both have similar side effect profiles. EPS and TD top the list. Prolactin elevation, however, is more common with gluthenazine, and QTC prolongation is more common with haloperidol. Side effect profiles of the second-generation agents are a bit more varied. What I've included here are the top or most frequently reported side effects of each. Keep in mind that they're similar to their oral agents. Notably, LAIs are generally well-tolerated with their steadier blood levels and delivery systems. Let's look first at aripiprazole. This includes both Abilify-Mentenna and Aristata LAIs. Here they have the most common side effects involving abnormal movements and weight gain. Haloperidol includes Invegasistina and Invegatrenza. The most common side effects here involve metabolic concerns, abnormal movements, orthostatic hypotension, and elevated prolactin. Respiradol includes Respiradol-Consta and the newest LAI agent, Perseris. These have the most common side effects involving metabolic concerns, abnormal movements, orthostatic hypotension, and QTC prolongation. And lastly, Olanzapine's LAI, Cyprexorelprev, has a similar side effect profile, but most notably this agent is associated with a severe and potentially fatal reaction known as post-delirium sedation syndrome. Injection for this agent involves strict post-injection monitoring and enrollment in a REMS program, which stands for Risk Evaluation and Mitigation Strategy. It's a program run by the FDA similar to that for Clozapine. Sarah will discuss this post-injection process in more detail later. Charting and timing. These are tasks that are often taken for granted, but they are essential in streamlining the care for our patients who are on LAIs. Nurses are skilled in tracking and documenting medication administration, yet some practices that are best practices for LAIs are worth mentioning to promote optimal care. Nurses should establish a plan for tracking, including the planned injection dates, logistics for getting patients into clinic or seen off-site sometimes, and contingency plans for any issues that may be commonly encountered. These include things such as lateness of medication availability, refusals, delays, or any kind of misdoses, really. Once a long-acting injectable is given, it should be immediately charted, including the injection site and the next due date as well. In this Medication Administration Record, or MAR, image that I marked up on the bottom of this slide, I marked the due dates for an example of a long-acting injectable given every 14 days. As a prescriber, one should always ask during appointments things like, when was the last date or dose given, and when is the next dose due? At each visit, questions should be asked like, were there any issues with med fillability, missed appointments, lateness, refusals, etc. You'd be quite surprised about how common these disruptions in treatment and workflow occur. Missed Doses of Long-Acting Injectables. This can be quite complex. The APA SMI Advisor Workgroup on LAIs has put together many clinical tips and resources for clinicians to use for best practices. Here we pulled, as a clinical tip online, all of the available information for all of the long-acting injectables that have published guidance for how to proceed when a patient misses a dose for any reason. I'll give you an example using Endaga Sistena. The FDA label for Endaga Sistena advises very specifically, depending on frequency intervals, how to proceed. This SMI Advisor tip points clinicians to the specific directions for each agent. And I'll read that, which we have for Sistena. If less than 6 weeks have elapsed since the last Endaga Sistena injection, then the previously stabilized dose should be administered as soon as possible, followed by injections at monthly intervals. And if more than 6 weeks have elapsed since the last injection, resume the same dose the patient was previously stabilized, unless the patient was stabilized on a dose of 234 mg. Then the first injection should be each 156. Then resume the stabilized dose at monthly intervals. As you can see through this long-winded example, this challenge is complex of missed doses. So clinical tips such as this can help clinicians keep patients' treatment on track by using this quick reference. Those LAIs on the bottom of the slide do not have any published guidance for how to proceed following treatment disruption. This clinical tip can be found on the SMI Advisor Lung Acting Injectables Center of Excellence page, which I'll show you later in the presentation. Sarah will now talk to you about the different lung acting injectable agents and delve into the preparation for their administration. Thank you very much, Donna. In the last 15 years, the number of LAI options have increased from the two decanoates, flucenazine and haloperidol, to a total of 10, with the second-generation LAIs having multiple dosing options that are often very separate. It's not with the decanoates. You have the one vial and can adjust the dose kind of in the spur of the moment based on clinical presentation. For the second generation, it is quite a different process. In considering which LAI is appropriate to use, as Donna mentioned, it's important to have assessed tolerability and efficacy before proceeding to use of an LAI, but also factors to consider are timing, the frequency of injections that's appropriate for the patient, the route of injection, route and location, and whether or not it is appropriate to, whether oral overlap is needed and for whom that may be challenging. So examples of those, most of the LAIs, all but one, are given via intramuscular injection. Percerus, the new risperidone LAI, is given subcutaneously. And for LAIs, the decanoates recommend overlap with oral medications. The range of LAI dosing is from two weeks to 12 weeks, so quite a range. Going back to the first one for a moment, in terms of the, the majority of them are by intramuscular injection and some have specifics. For example, the Aristata can only, the Aristata 441 can be given in the deltoid muscle, but all the other Aristata doses need to be given gluteally. We'll discuss that a little bit more further down the line. All right, so this is a slide showing a table of all the different long-acting injectables that are currently available in the United States. This can be found on the SMI Advisor LAI work group. The tip is called What Long-Acting Injectable Antipsychotics Are Available in the U.S. And you can see at the top, there are the two first-generation antipsychotics, flucenazine decanoate and haloperidol decanoate. Both of these require oral overlap and can be given every two, depending, as frequently as every two weeks, but extended out up to four weeks for the haloperidol and up to six weeks for the, for the flucenazine. Second generation LAIs include two aripiprazole options, as Donna mentioned. There is the Mantana monohydrate, and that requires oral overlap for two weeks. With that one, it's, we'll talk about it a little bit further on as well, but there are two different packaging and preparation options that allow for dose adjustment when seeing the patient. It is brought into solution and then the clinician can actually make the decision of which dose is administered to the patient based on the volume after the solution is mixed together. And that is the only one of the second generations that is similar to the flucenazine and haldol, where you can adjust, adjust the dose based on patient need in the moment. Aristata is a aripiprazole laroxal, and this has a loading dose strategy. Aristata initio is a 675 milligram injection that is given with the target dose of the Aristata and one 30 milligram pill of aripiprazole can be given all, all of those can be done on the same day or the initio can be given and then the Aristata within, within 10 days from that first injection. If oral supplementation is more appropriate for your patient, there is a three week overlap of the comparable oral aripiprazole, excuse me. For paliperidone, there are the two LAI options. Cystena is the every four week version that also has a loading dose strategy, 234 milligrams is injected on day one. And then on day eight, 156 milligrams is injected. And there is no oral supplementation needed. Paliperidone palmitate, the 12 week version is Invegatrinza. And that is given every 12 weeks. It is important to note that there is no loading dose strategy because the patient must be stabilized on Invega Cystena for, for four months prior. And it's really important that, that full time has elapsed because when the loading, when somebody is started on Invega Cystena, there may need to be some adjustment month to month as you're dialing in on the most appropriate dose. And you want to make sure that is correct, optimal efficacy and minimal side effects before you inject someone with a medication that will be in their system for at least 12 weeks. Risperidone microspheres, LAI is Risperdal Consta. This was the first of the second generation long-acting injectables. This requires PO overlap for the first three weeks, which is, which is important to note the person will actually receive two Risperdal Consta injections and, and even after that continue the oral Risperidone for, for three weeks. It's also important to note that this is the only LAI that has FDA approval in adolescents. All of the others only have approval for adults. It is also important to note, and more information can be found about this on the specific tip on the SMI advisor website, but Risperdal Consta, the highest dose is 50 milligrams and that corresponds with four milligrams oral. So keep that in mind as you're considering your options. Perceris is the newest of the second generation LAIs and is given every four weeks by subcutaneous dosing and Donna will explain and has some really good diagrams to help understand where that is given. Lastly, we have Olanzapine LAIs, Iprexa, Relprev, which is given every two to four weeks. And it does, it does have a loading dose strategy during, it's an eight week loading dose strategy where a higher dose and higher frequency is given for those first eight weeks. And then there is a maintenance dose or a maintenance strategy, which is every four weeks. As with oral Olanzapine, keeping in mind smoking status and how cigarette smoking significantly reduces Olanzapine levels because of the P450 metabolism. All right, and next we'll go on even more into the specifics of things. Okay, we will be talking here about the practical details necessary for your patients to receive their medication once you've convinced yourself and them how great an option LAIs are. All right, so injections must be administered by a healthcare professional, most often a nurse and it's important to know, I'm not sure of the details of our audience, but many nurse practitioners or clinical nurse specialists are the prescribers for patients with serious mental illness and people have different opinions and different clinics have their own workflows regarding administration. Personally, I give my own injections and I think it can be an efficient and kind of meaningful encounter to be doing my assessments while I'm doing the preparation as well. Keeping in mind community mental health centers may not be the most medical settings. For example, there may be no running water, maybe just Purell in the offices or not even have an exam table, but be creative. Don't think outside the box and it is possible. You need a cabinet to keep your supplies and can make things do. If you are going to be using Risperidone or Perseris, you will need a small refrigerator. All right, so for those injection supplies that you will need, the basics that you would think of, gloves, alcohol swabs, band-aids, syringes. The syringes are primarily really only for the Decanoate injections. We use three milliliter syringes are sufficient. That's kind of the maximum volume injection and those that come with an attached needle. Simplify preparation, you prepare it, change the needle to the right size for the injection, shorter for the deltoids, longer for the gluteal, of course. One thing to keep in mind, Haldol Decanoate comes in two strengths. It comes in a 50 milligram per milliliter vial and a 100 milligram per milliliter strength. So pay attention as you're preparing your injection, especially if you keep all of your patient's supplies in one place. Make sure you're getting the right dose. For all of the second generation LAIs, they come in kits with the needles supplied. You can see here, most kits give a few different options so that you have everything you need regardless of the body habitus of the person that you'll be injecting. A couple of specific notes, Trinza requires a thin walled needle that has to do with the volume and the microsphere size based on the longer acting formulation. So just don't use, it's not an option to trade out another needle if somehow these get lost. And for the Aristata, remember that only the Initio and the 441 can be given in the deltoid. The others must go into the gluteal muscle. All right, for reconstitution, Percerus is the newest one. As I said, that's the risperidone that goes in subcutaneously. That requires 60 cycles of mixing between the delivery system and the powder syringes. The package inserts have clear instructions and including diagrams and pictures, which are helpful. But just keep that in mind. And it's always a good idea to review the process before you're giving it for the first time with the patient. Abilify Maintena, Risperdal Consta, and Zyprexa Ralprev all require reconstitution of the powdered microspheres. And there are a couple different ways. The Abilify Maintena has a dual chamber syringe, but in one packaging, and the other has a single dose vial, as I mentioned before, which allows for dose adjustment. The others just require shaking. Aristata is of particular note as it is a non-Newtonian formulation that has a property of sheer thinning. These kind of concepts can sound complex. Think of it like ketchup. You need to shake it really hard and get it started with a very firm squeeze. And then it flows smoothly. Aristata, you need to really be vigorous in your tapping and shaking so that the crystalline particles do not clog the needle tip. All right, and now I'm going to turn it back over to Donna. Thanks, Sarah. So next we'll look at actual lung actin injectable implementation and how to best give the injections. We'll look at details of anatomical sites or landmarks, differences in IM and sub-Q procedures, as well as site rotation. Okay, so for we should always determine our site injection site first. Our first consideration is the patient's preference. They may prefer one site over another. For example, those with any kind of trauma history might have discomfort with any gluteal injection site since they must partially disrobe. They may strongly prefer a deltoid injection and or less frequent injections in general. Body habitus, as Sarah mentioned, is the patient's build or physique. Some patients may be quite thin, others much larger. Their habitus must be considered for several reasons. For example, thinner patients with much less muscle mass will often experience less gluteal discomfort. For obese patients, longer needles must be utilized in order for the intramuscular injections to reach their intended tissue layer. Each injection site has a designated maximum volume which can be injected. More on this shortly. And additional considerations by injection site might be stipulated by the injection manufacturer and their corresponding FDA prescribing guidelines. Now let's look at some anatomy. We'll look at the anatomical sites and landmarks useful in precisely locating injection sites. We'll start with the deltoid site. For deltoid injections, clinicians should do the following. Find the knobby top of the acromion process. The top border of an imaginary inverted triangle is two finger widths down from the acromion process. This is illustrated on the diagram on the right side by the red dots. The top border, sorry, stretch the skin and then bunch up the muscle. Hold the syringe like a pencil or a dart for any IM injections. Insert the needle at a 90 degree right angle to the skin in the center of this imaginary inverted triangle. Caution though, this is a small site and we should only give one to two milliliters or less of fluid in this site. The actual recommendation is for one milliliter or less, but sometimes we can use it for up to two. Consider again the patient's body habitus, how large their particular deltoid muscle is and whether they might be able to accommodate more than one milliliter. Next we'll look at the ventrogluteal site. This site has a greater thickness of gluteal muscle than the dorsogluteal site, which we'll look at next. And the thinner layer of subcutaneous fat there makes inadvertent subcutaneous injection less likely. The bony landmarks there are considered easy to palpate, making the site simple to locate. For ventrogluteal injections, clinicians should do the following. Find the greater trochanter. It's the knobby top portion of the long bone in the upper leg or the femur. It's about the size of a golf ball. Find next the anterior iliac crest. Place the palm of your hand over the trochanter. Point the first or index finger toward the anterior iliac crest or toward the abdominal direction. Spread the middle finger toward the back, making a V-shape as you can see on the right side diagram. The thumb should always be pointed toward the front of the leg or abdominal side and always use the index finger and middle finger to make this V. Give the injection between the knuckles on your index and middle fingers. Stretch the skin taut, pull the syringe like a pencil or dart again, and insert the needle at a right angle. Up to 2.5 or 3 milliliters maximum of fluid may be given in this site. Lastly, we'll look at the ventrogluteal site. I'm sorry. Lastly, we'll look at the dorsogluteal site. This site is not recommended as a first choice anyhow. Some patients may prefer it though or be accustomed to receiving injections in this site. There are several risks associated with an IM injection into the dorsogluteal site, including contact with the sciatic nerve or the superior gluteal artery. Additionally, having too much fatty tissue here can lead to a poor and unpredictable absorption rate for IM injections. For dorsogluteal injections, clinicians should do the following. Find the greater trochanter, again the knobby top portion of the femur. Again, it's about the size of a golf ball. Patients should assume a prone or sidelined position with the femur internally rotated. This minimizes pain at the injection site by relaxing the muscle. However, in practice, this may not be achievable. Next, find the posterior superior iliac crest. Many people have dimples over this bone. The crest stretches between the posterior and anterior iliac spines. So here you would draw an imaginary line between the posterior superior iliac crest and the greater trochanter. This is illustrated in the right side diagram by the red dots. After locating the center of this imaginary line, find a point one inch toward the head, lateral and superior to this line. This is where you should insert the needle, where the arrow on the diagram on the right denotes the gluteus maximus muscle, right at the tip of that arrow. Stretch the skin tight, hold the syringe like a pencil or dart, inserting in a 90 degree angle. Up to three milliliters of fluid can be given at this site. I'd like to mention an important consideration for invegatrenza, as this injection has a high volume. Whether administering in deltoid or gluteal muscle, you should alternate injections between each muscle. For instance, if you inject the deltoid, alternate subsequent injections between the left and the right deltoid. 2.625 milliliters is the highest recommended calculated volume for any trenza injection. And their prescribing information recommends either deltoid or gluteal, but it doesn't specify which gluteal site. Z-tracking technique can be used for intramuscular injections to prevent leakage from the injection site. In order to do this, a clinician should pull the skin away from the injection site sideways, holding it taut. Keep holding the skin while injecting, and then release the skin once the needle is retracted. There's some debate about the necessity of this long-standing practice. Prescribing information for flutinazine and haloperidol decanoates includes directions to specifically use the Z-track technique. Other LAIs do not specify. Aspiration is another technique that is taught but inconsistently implemented for several reasons. The process of aspiration before injection is as follows. First, inject the needle into the skin and then aspirate or pull back on the syringe plunger, observing for blood return. If no blood appears, proceed with injecting the medication, and then repeat the process. If no blood appears, proceed with injecting the medication. However, if blood does appear during aspiration, the clinician should discard the syringe and needle and prepare the medication again. You should follow this practice if your agency requires aspiration. According to the CDC, aspiration is not indicated for IM injections of vaccines and immunizations, nor is it required for sub-Q injections of immunizations, heparin, or insulin. However, it may be indicated for IM injections of medications such as penicillin. FDA prescribing information for Vivitrol specifically instructs clinicians that they should aspirate prior to injecting, and further notes that this medication must not be given intravenously or subcutaneously. A widely used nursing textbook, Perry and Potter, describes aspirating when using the Z-TRAC method for injections. Yet for routine injections in the deltoid or vastus lateralis muscles, aspiration is not necessary as the sites do not contain large blood vessels. Also, some safety-engineered syringes don't allow for aspiration. The prepackaged supplies may not allow this because they may lead to breaking a seal. So, always follow the specific drug's prescribing information, and if you have any questions, contact the manufacturer. And lastly, whether aspirating or not, do not massage the injection site. Okay, so anatomical landmarks for abdominal injections, subcutaneous injections, may be much less frequent. And this is familiar to us all, unless you happen to be a radiologist. The transpyloric and transtubercular planes are parallel imaginary lines used in radiology, centering the abdominal area appropriate for subcutaneous injections. The transpyloric line is generally anterior to the L1 or first lumbar vertebra. The transtubercular line is generally anterior to the L5 vertebra. Practically, however, a clinician may choose an injection site several inches lateral, superior, or inferior, all the way around the umbilicus, as long as it has adequate subcutaneous tissue. Be sure the area is free of any skin conditions or deformities. Subcutaneous injections differ greatly from the intramuscular injections that we're used to with LAIs. The patient should lie supine on their back, and the injection should be introduced at a 45-degree angle, not at 90 degrees like the intramuscular injections. The clinician should pinch the skin before injecting and continue to hold the skin pinched while injecting. This assures that the medication is received in the subcutaneous tissue and not deeper into the muscle beneath. It's recommended to always check each lung acting injectable package insert or prescribing information for preparation and administration instructions. The information in this webinar is an overview and does not represent a comprehensive instruction on each LAI. Based on the LAI's composition, they should be administered with a certain pace. And Sarah had touched on this earlier. Decanoates must be administered with a strong and steady pressure. Deltoid or gluteal sites may be used. Aristotle should be injected rapidly. In order for the particles to engage properly, as Sarah mentioned, the shear process, the gluteal site is required if Aristotle is 441 milligrams or higher. The first or loading dose of Invagasistina should be given in the deltoid site for faster distribution. Cyprexoralprev must be given in a gluteal site. Perseris is currently the only LAI which is administered subcutaneously. Patients may find this injection site and this process to be less painful as the injection site is located in the deltoid site. Injections should be administered with a slow and steady pressure. Patients may find this injection site and this process to be less painful as the injection isn't introduced deeply into muscle tissue, but others may fear using an abdominal injection site or not prefer it. No matter which type of LAI you're administering or at which site, it's important to always rotate injection sites. Specifically, the next injection should be at least one whole finger width away from the previously used injection site. Reusing injection sites frequently or more than once a month may lead to tissue damage. Rotation of sites will avoid tissue damage, including muscle hypertrophy or formation of abscesses. And we'll shift back to Sarah who will now discuss management of patients following injections. Sorry, in the interest of time, we'll go through these last couple quickly so that we can get to any questions that you may have. So, after receiving, you can go after receiving injections, patients are encouraged to resume their normal activity, be active, walk. When people receive deltoid injections, I encourage them to kind of move their arm around, do a few push-ups to act to kind of use the muscle and work things around. Injection site reactions tend to be minor events, such as a little bit of pain, swelling or redness, but they can range up to nodules or cyst formation or sterile abscesses. These tend to be rare, although within vagus systemic can be a relatively common report, not necessarily painful, but a nodule that you can steal. And you should ask patients about this at their subsequent visits and encourage them to contact you or the clinic if there is pain persisting past 72 hours. Lastly, olanzapine pamotate, the zyprexoralpev requires a three-hour window of observation following because of the risk of post-injection delirium sedation syndrome. There's a less than 1% incidence, which is about one in 14,000 injections or 1.7% of patients. However, the monitoring requires having many more kind of medical equipment on site than many community mental health centers do. And so this can be a barrier to this medication being used frequently. The symptoms of PDSS is similar to an olanzapine overdose from too high olanzapine concentrations. And it appears mild progressing rapidly and is similar to the presentation of alcohol intoxication. 15 cases of those that do have it had temporary unconsciousness. And there is much more about this on the manufacturer's website and also a risk and evaluation mitigation strategy is required similar to clozapine REMS. Okay. And the use of LAIs require much monitoring, of course, as with initiation, as well as in between injections. First clinician should monitor efficacy of the medication. Are their target symptoms improved? Closer monitoring for several weeks would be warranted when the medication is initiated or a change is made. Next, look for any side effects. Even if a particular patient has tolerated numerous similar drugs, they should specifically be assessed for any side effects. Closer monitoring would be warranted for several weeks with a new medication. And ongoing monitoring should occur for potential cardiometabolic effects of LAIs. These final few slides detail guidelines for patient monitoring who are prescribed antipsychotics. These tables are compiled from the most recent APA practice guideline. APA recommends that at the initial psychiatric evaluation that the patient is assessed for whether or not they have an ongoing relationship with the primary care health professional. Please note that although this practice guideline recommends that patients treated with antipsychotic medications be monitored for physical conditions and side effects on a regular basis, that there are no absolute criteria for frequency of monitoring. The recommendations are presented here for monitoring of vital signs, BMI, diabetes risk factors and symptom screening, lipids, and metabolic syndrome. I've included the detailed parameters for each here for your use as an easy reference. And this slide continues this table of the remaining parameters for ongoing monitoring as recommended by APA's practice guideline. EKGs are recommended with certain antipsychotic agents, but none of these are utilized in LAI formulations. During each visit, patients should be screened for symptoms of elevated prolactin, and levels could be drawn based on clinical history of symptoms and use of specific agents. Assessment for antipsychotic induced abnormal movement should occur at every visit. And structured assessments for those instruments should be used annually or twice yearly for patients at higher risk. And those recommended examples include the AIMS, Abnormal Involuntary Movement Scale, and the DISCUS. We hope the information that we presented here today is helpful for you in managing your patients treated with LAIs. Finally, I'd like to point you to an excellent resource offered by SMI Advisor that I've referenced a few times. Follow the URL on this slide to our long-acting injectable center of excellence, led by Rob Kotez and myself. This site provides free access to curated evidence-based resources and educational offerings, such as webinars like this and clinical tips. Various tools are provided for navigating the complexities of starting, switching, and managing LAIs and other considerations for working optimally with our patients. Additionally, free and confidential consultations with our clinical expert team are just a click away. Send us inquiries about anything related to LAIs, and you'll receive a response in 24 business hours. Thank you so much for joining us today and for your attention. Thanks for such an interesting presentation, Donna and Sarah. We're a little short on time. I'd like to at least have one question. I want to thank everyone for being here today. The question is, do you have any recommendations for reducing the amount of waste associated with giving these injections? Sorry, Ben. Did you say weight? Waste, like W-A-S-T-E. Waste. Yeah, disposed waste. Sarah, would you like to take that one? Sure. I was going to say, we actually have identified a volunteer organization that will take our old needles. I believe it's Samaritans, but we save all the extra needles that come in the kits. Every once in a while, we will ship a box out because you're right, there is a good bit of waste. It would be an advocacy project for sure to work with them on that, but at least the needles we feel like can be going to good use. Wonderful. Thank you. And again, noting time, I guess we'll move on.
Video Summary
In this video, Benjamin Dress, a professor at Emory University, introduces a webinar on preparing and administering long-acting injectable antipsychotics. He introduces the faculty for the webinar, Dr. Donna Rollin and Ms. Sarah McGoran, who have extensive experience in psychiatric nursing and mental health care. The webinar discusses the benefits of using long-acting injectables, such as lower risk of relapse and more consistent medication levels. It also addresses potential biases and stigma associated with injections, and highlights the importance of discussing LAIs with patients early on in treatment. The webinar covers various topics, including the different types of LAIs available, preparation and administration techniques, monitoring patient outcomes, injection site rotation, and managing side effects and missed doses. It also provides information on the monitoring and assessment required for patients on LAIs, including vital signs, metabolic markers, and symptoms of side effects. The webinar concludes with a discussion on reducing waste associated with LAIs. Overall, the webinar offers valuable information for clinicians on the use of long-acting injectable antipsychotics and emphasizes the importance of personalized care and shared decision-making with patients.
Keywords
Benjamin Dress
Emory University
webinar
long-acting injectable antipsychotics
Dr. Donna Rollin
Ms. Sarah McGoran
psychiatric nursing
mental health care
LAIs
patient outcomes
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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