Hello and welcome. I'm Dr. Megan Aret, professor at the University of Maryland School of Pharmacy and pharmacy expert for SMI Advisor. I am pleased that you are joining us today for today's SMI Advisor webinar, Expanding Your Long-Acting Injectable Antipsychotic Medication Toolbox. Next slide, please. 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 for the care of your patients. Next slide, please. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Nursing Continuing Professional Development Contact Hour, and one Continuing Pharmacy Education credit. Credit for participating in today's webinar will be available until November 13, 2023. Next slide, please. How to download the slides. Slides from the presentation today are available to download in the webinar chat. Select the link to view and you will be able to download a copy. Next slide, please. How to turn on captions. There is captioning for today's presentation available. Click on the captions at the bottom of your screen to enable. Click the arrow and select view full transcript to open captions in a side window. Next slide, please. Please feel free to submit your questions throughout the presentations by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for questions and answers. Next slide. Now I'd like to introduce the co-presenters for today's webinar, Dr. Donna Rowland and Ms. Catherine Hanley. Dr. Rowland is the Director of the Psychiatric Mental Health Nurse Practitioner Program at the University of Texas Austin School of Nursing and Nursing Expert for SMI Advisor. Ms. Hanley is the Clinical Instructor at the University of Texas at Austin School of Nursing. She is also a Psychiatric Nurse Practitioner at Ascension Seton Shoal Creek Hospital. Thank you both for leading today's webinar and I look forward to our presentation. We'll move on to the presentation now. Thank you. Oh, disclosures. I apologize. The only disclosure is I'm also a paid consultant to Saladex Biomedical, but we will not be discussing that today. Next slide. Learning objectives. Upon completion of the activity today, we will be able to identify landmarks for all injection sites utilized for the administration of LAIs. We'll understand clinical consideration for individual patients when injecting at each of these anatomical sites. We'll also demonstrate decision-making using knowledge of LAI antipsychotic medication options, patient variables, injection site locations, and including recently approved agents. Thanks, Dr. Arendt. I will walk everyone through how to locate the landmarks of each of the injection sites that LAIs can be utilized and or administered. We now have five injection sites instead of just the three IM sites that we had in the past. Next. So we'll start with the deltoid site, the one that most people are probably most familiar with, but we'll walk you through the proper way to find the landmarks. First of all, the injection angle will be a 90 degree angle and the maximum recommended volume is one milliliter. You can go up to two milliliters depending on body habitus if it's a larger person. So to find the injection site, you find the knobby top of the acromion process in the shoulder. Imagine the base of an inverted triangle starting two finger widths below the acromion process. You can see this pictured on the right. Give the injection in the center of the inverted triangle into the deltoid muscle. And some long-acting injectables require aspiration before you inject the actual formulation. So to do this, you pull back the plunger to check for blood before injecting. This is advised by FDA for certain injectable meds, including the two decanoate agents and the olanzapine LAI Zyprexa relprev. Next. And these are the steps that I've just gone through, but I want to point you to the bottom of the slide for the Z-track method in case you're not familiar. Doing this, you displace a skin layer about one centimeter before injecting the medication below subcutaneous layer and into the intended muscle. The requirements for the Z-track are the two decanoate agents because they're so thick and based in sesame oil. Next. Next we'll look at the ventral gluteal muscle. Again, a 90 degree IM injection. Maximum recommended volume is three milliliters, but some specific agents may have been FDA approved for up to five mLs. Note, this site is not really recommended because of the risk of contact with the sciatic nerve and or the superior gluteal artery. And additionally, poor and unpredictable absorption in this site compared to other IM sites. But if a patient prefers this site, you can certainly do that. So steps to find the landmarks, have a patient lie in a prone or sideline position with the femur internally rotated to minimize pain. Sometimes though, you may have to administer while standing. Find a greater trochanter, the size of a golf ball at the top of the femur. Find the posterior superior iliac crest. Many people have dimples over this bone on the top. Draw an imaginary line between the greater trochanter and posterior superior iliac crest. Locate the center of that line and find a point about one inch superior to it and give the injection into the gluteus maximus muscle. Next. There is an alternate method to locate the dorsal gluteal site. Would you go back one? Okay. It's not on the slide. I'll describe it. However, it's on the accompanying handouts that I'll point you to at the end of our presentation. Another method is called the double cross method. And you imagine the buttock divided into four quadrants. And then you imagine that upper outer quadrant divided into four quadrants again. And you give the injection into the gluteus maximus muscle. And you give the injection in that top outer quadrant. Next. The ventral gluteal muscle, another 90 degree intermuscular injection, the maximum recommended volume for this as well as three milliliters. But some specific agents may have been approved for up to five mLs. So to start this one, you find the greater trochanter again at the top and find the anterior iliac crest. Place the palm of your hand over the greater trochanter with your thumb pointing toward the front of the person's body. Can you go back one? Thanks. Point the index finger up to the anterior iliac crest and the middle finger straight up making a V shape with the index finger. Use your thumb to stabilize. Again, your thumb should be pointing forward. Give the injection in the V into the gluteus medius muscle. Next. Now go forward, please. There's the picture I was looking for on the bottom that describes the double cross method. Okay, next. Now we'll move into the newer subcutaneous injection sites where we can give certain LAIs. So currently there are two LAIs using sub-Q administration. They're both Risperidone, Agents, Perseris, and Uzeti. And you'll hear more about them shortly from us. So the injection volume for a subcutaneous injection is a 45 degree angle. And for the abdomen, the max recommended volume is 1.5 milliliters. Next. So to find, you find the costal margin, which is at the bottom of your ribs and that's your upper border. And then your bottom border is the top of the iliac crest and draw an imaginary line connecting them. That's your lower border. Visualize a two by two grid across the area with these two borders on the patient's abdomen. The umbilicus should be in the center of this grid and avoid that area when injecting. Choose an injection site in one of the four quadrants, which is a minimum of two inches from the umbilicus. Pinch a two inch fold of skin to pull up the adipose tissue from the muscle before and during the injection. This helps to keep the medication in the subcutaneous tissue and not in the deeper muscle. Next. And our last site and newest site is the lateral aspect of the upper arm subcutaneous. So again, it's a 45 degree subcutaneous angle. A maximum recommended volume is 1.5 mL. And to find the injection site, you should stand slightly behind the patient, choosing a spot in the area, halfway between the shoulder and elbow, at least three inches below the shoulder and three inches above the elbow on the side or back of the arm with enough adipose tissue for an injection. You will give the injection at a 45 degree angle. Again, pinching the skin like the abdominal, the abdominal route, pinching two inches of skin before and during the injection. Again, keeping the medication in the subcutaneous tissue and not into the deeper muscle. And one thing to note on this administration route is this injection should not be confused with the deltoid intramuscular injection that we're also used to. Next. I will turn it over to Kate. Next, to talk about newly released agents. Thank you, Dr. Rowland. My name is Kate Hanley, and I'm going to be just introducing some newly released LAI agents. First, we have the Abilify Asymptify. It's indicated for schizophrenia and bipolar one maintenance. It's in an aqueous suspension. Its half-life has not been calculated yet, but it maxes at one to 49 days. The same drug interactions as oral Abilify, CYP2D6 poor metabolizers, CYP3A4 inducers and inhibitors, and CYP2D6 inhibitors. The Asymptify is administered every 56 days. The oral overlap medication is required is 14 consecutive days, comparable to the Mentenna. The dose conversion is here for your review. 15 milligrams oral equals 720 milligrams of Asymptify. 20 milligrams oral equals 960 milligrams of Asymptify. For missed doses, if the timeframe is more than eight weeks or below, 14 weeks late, the administration dose is as soon as possible. If the patient has gone over 14 weeks, then restart concomitant oral or epiprazole for 14 days with the next administrated injection. Perseris is a new Risperdal agent. It was created to be administered subcutaneously, either in the abdomen or the back of the upper arm. The Rikindo delivery vehicle is microspheres that are suspended in an aqueous solution. Its half-life is three to six days. Its Tmax is 14 to 17, has similar drug interactions, CYP3A4 inducers and CYP2D6 inhibitors. It's dosed every 14 days and its oral overlap is seven days of oral risperidone as compared with 21 days for the risperidone consta. There are no current guidelines on dosing conversions. If there is a missed dose, the patient should receive the next dose as soon as possible and supplement with the seven days of oral risperidone as needed. Preparation and administration of the Rikindo for constitution and refrigeration is required and it is solely a gluteal IM injection. For the Uzeti, the delivery vehicle is an aqueous suspension. Its half-life is 14 to 22 days and its Tmax is 8 to 14. Drug interactions include the CYP3A4 inducer and it's a CYP2D6 inhibitor. This shot is meant to be administered every 28 or 56 days and oral overlap is not required. If Uzeti is missed, the patient should receive the next dose as soon as possible. For Uzeti, this particular medication requires refrigeration. It may be stored for up to 90 days and it's unopened original packaging at room temperature. This medication is given subcutaneously in the abdomen or the upper arm via injection. To prepare this product, you flicked the syringe forcefully three times to move the bubble to the cap. The package insert does say flick, but it is more like a whip, like you're actually really forcefully moving your wrist to move that bubble to the cap. If the bubble is not moved to the cap, it could result in incomplete dosage. Standing while flicking or whipping the syringe may help achieve the required force bubble to move. It will also help you to determine if the bubble has moved and will appear opaque after it has moved. Holding the syringe up to light or against a dark backdrop can help improve visibility to make sure that that bubble has moved to the cap. To administer the medication, you pinch the subcutaneous area, inject the needle, then unpinch the skin, push the medication, leaving the needle in the skin for at least three seconds post pushing of the medication to allow for all medication to be injected into the skin, and then remove the needle for disposal. Here are some comparisons of the LAI agents by drug. Here we have a comparison of the first generations versus the second generation antipsychotics to give you an idea of what the volume of injections are and where the injections can be placed. Here are the remainder of the generation two LAI injectables. I will hand it over to Dr. Irette. Thank you so much. So we're going to move the presentation a little bit into some clinical pearls about the various products, and some of them we might all be familiar with, and then hopefully with the newer agents, we're able to share some clinical insight. So with our first generation LAIs, these are an oil-based product, so we do need to verify the patient doesn't have an allergy to sesame seeds because they are made out of a sesame oil. And as suggested during the earlier presentation with administration, it's important that we are aspirating with these particular products. Additionally, because the suspension is an oil, you do need to potentially use a new needle, and so you may use a larger gauge needle when you're pulling the oil out of the vial and then using a smaller gauge needle when you actually inject the medication. And those needles are not provided. Those are things that the clinic would need to provide on their own. Again, it is a Z-Track administration with haloperidol. It's important to verify the strength that is being ordered to avoid medication error. So there are two strengths available, the 50 and the 100, and we have seen errors occur there, or patients end up receiving a larger volume because the 50 is ordered and they end up receiving 3 to 4 milliliters versus if we would have ordered 100, it might have been less. So just keep in mind that you're watching those orders. Next slide. So the first-generation antipsychotics, here is sort of the nuts and bolts of what those look like, the needle gauge that's recommended. Interestingly, the flufenazine can be given subcutaneously as well in the package insert. Most of the time, that is given gluteal or deltoid because of the oil formulation. And then the oral supplementation, they do both require it for both products, and they're very different in how they do that. But no refrigeration or reconstitution, and no observation of patients post-injection with these. Next slide, please. So, for the Abilify Asymptify, these come as pre-filled syringes. You'll recall your Abilify Maintainer comes as a syringe and a vial. So, these ones are syringe only. The syringe needs to be tapped at least 10 times on your hand, and then shaken vigorously. And you want to make sure that you're doing that very vigorously for at least 10 seconds prior to administration. And if your patient isn't readily available, I would also make sure that I give that an additional shake right before administration to the patient to make sure that it's thoroughly mixed. Next slide. The Abilify Maintainer, as I just stated, is vials and pre-filled syringes. And this is based on which dose you might need. So, you may need to select your product based on that dosing. The vials must be mixed and shaken vigorously for 20 seconds prior to withdrawing the suspension. And you should only be using the sterile water for injection that's provided. So, that is a full encompassing kit when utilizing this product. Next slide. For Aristata and Aristata Inicio, it is important that you are storing these correctly. They need to be stored flat to help avoid clogging, as well as proper mixing to help avoid that clogging. You want to tap the syringe at least 10 times to dislodge any material that may have settled in the syringe. And then very vigorously shake that syringe for 30 seconds to ensure that you have a uniform suspension. Here again, if you don't use it within 15 minutes, shake that syringe again for 30 seconds, just to make sure that all of it is uniformly suspended in there. This is, these are the two injections that require a rapid injection. This is not one that you want to hesitate on. If you hesitate, you run the risk of clogging the syringe. So, you want to make sure that, one, you've stored it correctly, you've mixed it correctly, and that you do rapidly inject that. So, just keep your finger on the plunger and go. It's not something you want to do slowly. Next slide, please. For those that may be unaware, so you have the Abilify Maintainer and the Aristata. Both ultimately are aripiprazole products. The Aristata is the prodrug of the 9-hydroxymethyl aripiprazole, which is a prodrug of aripiprazole, uses the LINQ-Rx technology. It potentially can help increase the dissolution-enhancing bioavailability, so we get to a faster time to therapeutic concentration. So, with Abilify Maintainer, you do need 14 days of oral overlap. If you're using Aristata, you only need 21 days of oral, or you need 21 days of oral overlap, unless you use the Inissio. The Inissio eliminates all need for oral overlap, so we've included the dosing here as well. One 30-milligram oral aripiprazole, then you would receive the Aristata 675 on day one, and then on the same day, or up to 10 days later, you would give your Aristata dose. So, really quickly gets the patient the therapeutic concentration without having to do any oral overlap. So, different dosing recommendations here to keep in mind if you're using the Aristata product. Next slide, please. So, here are the various aripiprazole products, and they're laid out for you. Please keep in mind that the Aristata Inissio is not a long-acting injectable. We might consider it like a short-acting, mid-range sort of product that really is only there to bridge the patient from their oral tolerability to the Aristata. So, it's not a long-acting. You use it only to get the patient onto Aristata, or if they are missing an Aristata, you may use it to reestablish care, but you would do that based on the package insert dosing. Next slide, please. Looking at our Invega products, we do have three Invega products, the Sistena, Trinza, and Hafira, so one-month, three-month, and six-months. These all need to be shaken. Their pre-filled syringes need to be shaken at different time intervals. Sistena, 10 seconds, the Trinza, it's 15, and then once you get to Hafira, it's 15, but you do that twice, and you want to do it with a very loose wrist. It does require quite a bit of shaking to make sure that that is thoroughly suspended as well. You'll refer to the package insert or any of our tips for information on whether they're deltoid or gluteal injections. Some of them, depending if you're using the loading, might be deltoid, and then more of the maintenance is gluteal. As you get to the Hafira, this is where you're going to see upwards of three-and-a-half to five milliliters of injection, so you're going to need to do those as a gluteal injection. Next slide. So, here are the different paliperidone products. These products don't require oral supplementation. With the Sistena, there is a loading dose, and then to get to Trinza, you need to step through Sistena, and to get to Hafira, you do need to step either through Sistena or Trinza. So, I'd refer you to the package insert to sort of look at those or any of our tips or dosing app. They don't require refrigeration or reconstitution, and you don't have to have any observation period at the end of any paliperidone product. Next slide. Prosterous, as stated, this is an additional risperidone product. It is subcutaneous. It was the first subcutaneous LAI that was available on the market. Originally, it was only in the abdomen, but now we have the upper lateral arm as well. It may be stored for up to 30 days in its unopened packaging at room temperature. Otherwise, it does need to be in the refrigeration. If given in the abdomen, there is a risk of a lump due to the atrogel formulation that it does come in when you do give that in the abdomen. There is a risk of the patient having a bit of a lump, and so educating the patient that this is the medication, don't rub it, don't do anything like that. You don't want to disrupt that. Don't wear fitting pants where that lump is as well. The preparation for prosterous is a little bit more cumbersome than some of our other products. It does require a mixing, and it requires you to cycle between syringes, so 60 cycles. So it's 120 different pushes in order to make the suspension completely uniform. Prosterous is available as a 90 and a 120 milligram injection, so it equates to 3 or 4 milligrams of risperidone. So patients need to be established on either 3 or 4 before you would consider prosterous. Next slide, please. Ritonsta, this was our first second generation antipsychotic available on the market. This does require refrigeration and reconstitution. Some of the important clinical pearls is the pharmacokinetics of risperidone constant. There is a delay in the release from the microspheres of 3 weeks. So patients do need a 3-week oral overlap, and keeping in mind then when you're switching doses that it may take 3 weeks for you to see the effect of the dose that you gave. And so the patient will have received their second dose before their first dose has even started working. So there is a little bit of thought process in thinking about how you may dose this and when you want to increase dosing. It may be used for up to 6 hours after mixing, but it does need to be resuspended by shaking before administering. Next slide, please. Uzeti is the new subcutaneous risperidone product. This can be given in the abdomen or upper lateral arm. This is an every month or 2-month injection. And as you saw earlier, we provided the doses. So there are quite a few different doses available of Uzeti, and it depends on what oral dose of risperidone you're on and then whether you want the patient to get it monthly or every 2 months, and then you would select your dose. This does come as a solid refrigerated temperature. So it's very important that you put this at room temperature for 30 minutes prior to administration. So you need to get it out 30 minutes before the patient's going to arrive so that it sits at room temperature so that it does become a liquid. You're not going to be able to inject that solid that's in there. It's very important, too, when you're mixing this product, the package insert is going to say flick the syringe. And many of us would think about, you know, just like using 2 fingers and flicking the syringe. And that's not all, that's not what's needed. So really, it's a very forceful whip, 3 times with your whole wrist, really forcefully whipping it, not flicking it with your fingers. And this is ultimately to move the bubble up to the cap prior to administration. And if you don't move that bubble up to the cap prior to administration, you risk losing part of the dose. And because this is a subcutaneous injection, the volume of administration is very small. So this is a medication that you do not want to prime, and that you need to make sure that you have moved that bubble up to the cap. You might want to hold a dark piece of paper behind the syringe so that you can see that that bubble has moved up, because you don't want to lose any of the dose. You want to make sure the patient gets the full dose of the medication. Next slide, please. Rikindo, this particular risperidone product is FDA approved in the United States. I have not seen it on the marketplace yet. It is given every 2 weeks. It is a microsphere technology, similar to risperdal-consta, but does have a faster release. The elimination is faster. So we're, will overlap for 7 days for 21 days. This could be beneficial in that there could be dosage changes that could be made earlier, because you're not waiting 21 days for the release. The assumption looks as if there is going to be parallel dosing to consta, the 25, 37.5, and 50, and there may be equal dosing oral overlap with risperidone that we've seen. But we're still waiting for more information on how some of that dosing will look. But it does need to be refrigerated and reconstituted as well. Next slide, please. So here are various risperidone products with perseris, consta, rikindo, and uzeti. Some of the things to keep in mind, the consta and rikindo, again, are those microspheres. So they do take a little bit longer to release. There is some delay there, and do require oral overlap. Perseris and uzeti do not require that oral overlap. Uzeti is a wider dosage range, goes from 2 to 5 milligrams of risperidone. The perseris is 3 or 4 milligrams of risperidone. None of them require observation post-injection. Next slide. Okay, and rounding out the products with zyprexorrelprev. Zyprexorrelprev does have a REMS program associated with it, which does require registration by the healthcare facility and the pharmacy. And this is due to the post-injection delirium syndrome. So if the medication were to be administered, and it would nick any sort of blood vein in the gluteal muscle, it could result in what looks like an olanzapine overdose. So the patient does need to be monitored for three hours. You do need to aspirate before administration to verify that you're not injecting this into any sort of blood source, and it's going directly in the muscle. So keep in mind that that can occur on any injection. It's not just the first couple of times. So it's any time the patient receives zyprexorrelprev, they do need to be observed for three hours. And you do need to have access to emergency services, should that be needed. Next slide, please. So here's the product. This is a gluteal injection. The medication can be given every two or four weeks. It does require reconstitution, and there's detailed instructions. But no oral overlap is required. But it does have that three-hour observation, and you do need to be a REMS-certified center in order to administer or dispense this particular product. Next slide. And now I'm going to turn it back over for decision-making considerations when selecting LAIs for individuals. Thank you, Dr. Arett. So I'm going to talk a little bit about considerations when you're choosing LAIs for your individual patients. Considerations include administration interval, ejection site, needle length, injection volume, preparation technique, and ease of initiation. Administration interval can include patient preference, level of comfort with injections, and access to the clinic, office, or in-home care. You also might want to consider monitoring mental health status of your patient. Ejection appointments can be a good time to check in on your patients and affirm efficacy. Injection site, needle length, and injection volume. You want to consider the patient body habitus. This can guide some of our options. Body habitus also dictates needle length for IM injections. Patient pain tolerance and history of issues with injections. So choosing the right site and route, subcutaneous versus IM, gluteal versus deltoid, are all considerations you may want to make. The ease of initiation, does it require a loading dose? Some LAIs require a loading dose to increase blood concentration. Also, oral overlap. Is the patient able to manage an overlap of oral medication while awaiting LAI to reach efficacy? And also, of course, patient choice. There's a lot of research that indicates that patients having a role in medication choice can increase adherence. So by educating our patients on the different LAIs and the considerations discussed, we can aid them in making the best decision for themselves. And I will hand this back over to Dr. Rowland. Thank you. So I would like to introduce our audience to some of the many SMI advisor tools around long-acting injectables. We've tried really hard to kind of curate resources and develop tips and webinars that are very digestible and very practical for busy clinicians. Next. So first, if you're not familiar with our Long-Acting Injectable Center of Excellence, this is sort of a repository where we put all of the clinical tips that we have written and updated and the tables of long-acting injectables that are available in the United States. And you can click into those and there's a clinical tip for each and every agent. We've also got tips on things like how to switch from risperidone LAI to an aripiprazole LAI and how to do that tapering and timing and all of those things. And again, we've made them as short as we could. We also, any webinars that we've done live like this that are related to long-acting injectables will be archived there. And so you can look, there's quite a bit of material and they are on demand and still have continuing education credits associated with them. So take a look at that page if you haven't already. Next. Okay. This is another resource that we talked about earlier and it's a handout on a one page that shows all of the LAIs, what sites that you can give them in and the injection volume on a one page PDF that is pretty handy to have around your office or hospital. Next. Also on our LAI Center of Excellence page, you'll find these wonderful videos. So there's a video for each of the five injection sites that I discussed earlier, as well as a one page PDF kind of reminder handout that does have the illustrations of the sites on them. So this is a wonderful educational tool for new nurses or prescribers or administrators of the injections or refresher for them and would be great to have around the office so that everyone's using the correct techniques. And then the DOS conversion tool on the top, I'm going to talk a little more detail in a couple of slides on that. Next. All right, on the next slide, there it is. So our SMI advisor app has lots and lots of content in it. You can practically access any of the SMI website content through the app. But most recently we developed this LAI conversion tool. So you can see on the right side, you input the oral dose of whichever agent that you're interested in starting an LAI on and it will give you all of the options and what dose is equivalent to the oral dose that the patient was already on. Next. And that's where you find it on the app. Next. Okay. Thank you all for your attention and for coming to this webinar today. We've got plenty of time for questions and answers. If we could go to the next slide before we get to questions and answers. I want to remind everyone that here's the app, just as Donna was talking about, that it is accessible from your mobile device. It has resources, education, upcoming events. It also has the complete mental health rating scales. And you can actually submit questions directly to our team of SMI experts right from the app. So here it is, just in case you hadn't had an opportunity to review the app yet. And this time we'd like to switch over to questions and answers. So please go ahead and get those jotted down into the Q&A section of the Zoom chat and we will be happy to engage our experts in some of these questions. I'd like to ask Kate or Donna if you guys have had the opportunity to use any of the new products yet or have any insight clinically. Yeah. So I'll talk about the rating scales for a moment. Some of which we've had in there for a while and some are newer. They're more than just the three that are listed on the far right of the screen. And to just let everyone know that we don't store any data. So if you do the PHQ-9 with a patient, it will interpret the score for you and then you can send it to yourself either by text or email if you'd like to incorporate it in the EHR or print it for a patient. That's an added feature that we put in later, which I think is very handy. And what else is up here? The education catalog is in the middle picture on the top right. So that's where you'll find all of the webinars on various topics and you can filter by subject. And then I'm going backwards. On the far left is the main screen that you'll see. It looks very similar to the main screen of smiadvisor.org website. So you'll see on the left there is a side for clinicians and on the right there's a side with resources for individuals and families. And I've used the dose conversion tool a couple of times recently. I think it's really a great ad that we built. Have either of you used it yet? Yes, that is my new favorite app addition to the app. Being able to quickly, instead of having to go search various package inserts, to be able to find all of those different dose adjustments have been extremely valuable. And also it provides the options. And so if you put in, you know, risperidone 3 milligrams, it's going to give you all of the options that are available. And I think this feeds very well into what Kate was discussing regarding discussing all of the options with the patients, right? Making sure that the patient has some say in maybe where do they want the injection? You know, what kind of needle can you anticipate? That two-inch needle, if you pull it out, it's quite a long needle. So having those discussions and what the patient preference might be, that tool is very helpful in sort of seeing the various products and thinking through all of those options. Can we go back to the injection volume slide? Sure. Let me see. Sorry. That's okay. It's going to take me the long way. This one. Yeah. So there's a really big gap in how these ranges are so different. And if you'll notice like there's from 0.5, 0.8 mls, 0.25 mls, and then the tiniest injection volume is the Uzeti. So I think Megan, it might be worth you repeating the instructions for Uzeti and what you have to do, especially for that, to make sure that that tiny injection volume actually gets into the patient's subcutaneous tissue. Yes. I think many of us are probably familiar with giving things that are about a CC. I think that's what, you know, or half CC is about, you know, where a flu shot or COVID vaccine might be. And so I think many of us are familiar with that size. But when you think about Uzeti, it's a much smaller volume. And because it comes as a solid, I don't think many of us are as familiar with that as well. We're used to the pre-filled syringes, which are all liquid or if they're a powder and we have to mix it. So the Uzeti is really a solid dosage form. And so I think this might be a good opportunity. So when you see the package insert and it says flick, I think many of us think this. And they were working to change with the FDA and the package insert to think about whip. So more like an actual whipping of a syringe so that you get all of the liquid down and that the air bubble floats to the top. And so really making sure that air bubble floats to the top at that point and not priming it. So I know we think about priming all kinds of things, inhalers and different kinds of injections to make sure all different kinds of injections to make sure all of the air is moved out. But if you prime it, you could lose some of the dose and then it may not work as long or it might not work as effectively. So one of the things that I would suggest for any of the products, probably not the first generation because the manufacturers aren't going to have anyone, but definitely reach out to any of your educators, industry educators in the area. They have demonstration kits for all of the various products and allow you some hands-on utilization to come and practice one, how to prepare and how to mix and then how to inject the various products. And they all have videos online as well. So I think those are great tools to think about too, to make sure that we're mixing all of these products correctly. Because that does end up being a lot of the questions we get is when things aren't working well, we start at the beginning and think, did we mix it right? And did we store it right? So make sure you're looking at all of that information with the products. And to tack on another question about priming, well, it's a two-part question. So one for clinicians who might not be familiar with priming of syringes, if you could explain that process. And then the second part is which of the agents should you be priming? Not use Addi, but. Not use Addi. So priming really means kind of moving the liquid up to the top of the syringe. And you might even wait till like one tiny drop comes out the other end. It is not recommended like or required for the products. Sometimes we do it as best practice to sort of just make sure that there's no error within that syringe. But it's not something that has to be done, but definitely should not be done with use Addi. Okay, so we have our first question, which is a great question about monitoring serum or plasma levels of the LAI after initiation of them. If so, how often? Anyone want to take a stab? Yeah, well, I can take a stab. You want to, if it's feasible to wait until you get steady state and you'll have to calculate that based on the half-life of that particular LAI, then that's when you should check it. And that should be at the end of the dosing interval. So just before their next injection is due is when you should check that level for it to be meaningful and comparable to any repeated levels that you check. And anything to add on that is going to tackle the how often next. No, I think that's perfect, right? Trough level right before your next injection, once you've reached steady state. So. Right. Half-lifes. I'm sorry, repeat. Oh, half-lifes are important, right? That's about five half-lifes to get to steady state. Right. And then so how often should you be checking levels? I guess this is going to depend on whether your patient is having side effects that you wouldn't expect at the dose they're on, or they're not responding to a higher dose. So it's going to be case by case and how often to get it, or if you're planning to make a change, either increasing or decreasing the dose of whichever LAI. Donna, I agree. I sometimes consider therapeutic monitoring if maybe the dose is wearing off sooner than we expect. Sometimes that helps me to think about is it the medication itself that is wearing off? Are they having a really low level at that point? What is the clinical picture that we might be seeing? And so sometimes if I have a product that's every 28 days and it's wearing off at 21, if it's possible, I'd like to get a level at 21 days to see where it is in comparison to 28 days and sort of map out where the patient is just to determine if we increase the dose, or do we need to shorten the interval? Is there something going on? So I think LAI's therapeutic drug monitoring has a good place in practice. And there are some excellent guidelines available that are published too by the guideline group. I have them, but you can definitely get those. Are injectables the future? Oh, go ahead, Donna. I was just going to say back on what we were talking about, the guidance around therapeutic drug monitoring, we do have a clinical tip in the LAI center of excellence around that. And with some really good references, such as the book by Meyer and Stahl, that's the plasma level handbook. It's got a lot of really good descriptions about why the timing and how frequent we would want to check these things. That can also safeguard in case you want to, you know, oral overlap a little bit, which is recommended with some LAIs when they start to wear off early. Yeah. And you might not have the luxury of timing the plasma level exactly right, depending on what setting you're working in or what information you're able to get from the patient or collateral person. They may not know when they got their last injection. And so some information is typically better than not perfect information. So it's not a hard and fast rule that it has to be at the very end. It's optimal though. There's a question asking if LAIs or injectables are the future. And I would, I think that they're moving, we're seeing a lot more of them. I will say the pipeline is strong in this area. There are a lot of additional LAIs being trialed. And so I think that it's going to be a growing area. I don't think it's going to be something that's stopping anytime soon. Right. And I think patients are moving toward wanting to build an easier medication regimen. I mean, there are a couple that are indicated for bipolar disorder. And I even had a patient ask me when they were going to be able to get a long-acting injectable for their treatment of depression. So I'm not sure what the pipeline looks like for that, but that has been a request. Yeah, it's mostly antipsychotics, but not mood stabilizers or antidepressants or things of that sort, but not only in the area of psychiatry, but osteoporosis. I believe there's one cardiology drug. We've now seen that HIV treatments are available as long-acting injectables. So they are becoming increasing across the medical scene. Right. RA, migraines, they all have injectables. All right. There are more questions coming in. Someone's asked, how much discomfort do patients mention after LAIs? My knee-jerk reaction is it always depends on the site and the injection volume. And depending on probably how often the nurse is the one giving them, if they have developed a comfortability around that. I was definitely going to say that. There's definitely some people that are better at injecting LAIs than others. And I have seen that difference in some patients. And I think that's a good thing. Others that I have seen that difference in some patients that I work with inpatient, for sure. Yeah, I guess the highest injection volumes are like 3.9 and 5 mls. And it's going to depend on the patient's body size and can their muscle actually take in that much at one time. I have a recent patient who's been on Risperdal-Constantin for years and is finally saying, I don't want so many shots. So we're going to switch to a longer acting version of Risperda and LAI because they suddenly became too sensitive to getting the shots every two weeks. So that interval is something else that you should consider. I'll stop talking. There's another question in there. So we have another question. Are LAIs only used for patients having adherence issues? If you look at the APA Schizophrenia Guidelines that were recently published, the LAIs are recommended for those who have adherence problems and those patients who select an injection as their dosage form of choice. So it's not just reserved for those with adherence issues. It should be offered to everyone as a potential dosage form that they could consider. And so I think the movement is to try to get away from the stigmatizing. You don't take your medication, so you have to have an injection. We can offer you a potential medication that you only have to receive once a month or every other week or every two months or up to every six months. And so offering it as a potential treatment option should be considered first line. Absolutely. There's also patients that I've had that have a pretty fast relapse if they miss one or two doses of their antipsychotic, they end up getting sick. So they're interested in getting that LAI just to avoid that happening just from missing one dose. Right. And another reason or a couple of reasons why this might be the future for more and more people is they have more point of contact with a nurse or a clinician or whomever's giving them the LAI. They can get assessed and catch side effects earlier if they're coming in more frequently for an LAI. But also I've heard people tell me about privacy and stigma and they don't like having pills laying around their house that somebody could find and understand their issues and they would rather just go to a medical appointment, get a shot and not have the pills laying around at home. So there are a bunch of reasons why we're seeing an uptick in this use of LAIs. There are a couple more questions in the bottom there. Oh, good. I cannot see them. I don't know where they went. So what is the closest time frame that you have given in between Abilify Mantenna injections without a level? Oh, this is a good question because there is a package insert requirement where you can only give them. And off the top of my head, I want to say it's every 26 days, but I'm going to look just to make sure it's not 21 days. And that would be the earliest that I would ever do it. Andrea, is this for a new initiation or is this somebody that's been on maintenance? maintenance. It's the same maintenance. Oh, I keep scrolling. Thanks. While Megan is looking for that, I'll read it out. I apologize it's taking a minute. Any suggestions for patients that are able to fill the LAI but have difficulty finding someone to administer. Oh, that's an excellent question. One of your favorite questions. One of my absolute favorite questions because in 48 of 50 states your community pharmacists can administer long acting injectable medications. So, I would suggest there are many industry websites that have injection site provider lookups and so you can type in the address, and it will give you the closest injection site location, it might be a pharmacy where your pharmacist administers it, or it could be a pharmacy that partners with a nurse who comes in and administers the medication. So that would be my first suggestion, also traveling nurses or immunization, like health nurses that give travel like for get to get ready for travel, or things of that sort can also provide this service. And so many of the industry partners have already sort of capitalized on this and they have them all on a website that you can look it up to find a provider who will inject for you. I'm also going to put our tip. I can't write anything in here. There is a tip on our LAI Center of Excellence site under administration section, and there's a map to which states pharmacists may legally administer LAI antipsychotics. That would answer our what are the two states that cannot administer at a pharmacy. Those two states would be New York, and DC, I'm looking at the DC, DC cannot. Rhode Island, Rhode Island. Yep. So, some of the retail chains Safeway, Albertsons, Genoa pharmacies. Most of them are providing these services across the board, except for those states in DC. Some of the retail chains, maybe don't have every pharmacy on board and trained and so sometimes seeking out one of those specialty type niche pharmacies. It looks like Maggie's put the link in the chat section, not the q&a but in the chat so if you're interested in that map. Hopefully you can see that there. We have a question from Andrea, who was asking about the closest timeframe for the antenna, and the patients on maintenance but it says she feels is always short a few days and notices your ability. So we're looking at breakthrough symptoms that sounds like So the earliest you could give it is, or 26 days, so every 26 days would be the earliest that you could give the dose. With a similar issue and we actually supplemented with oral abilify for those few days. But it sounds like within 28, you said so perhaps considering giving it a few days earlier. I've got a patient who was stable on respite all constant for many years but started to have breakthrough symptoms for the last two days before the shot was due so we made it was three days, we ended up putting ordering it for every 10 days, and it's working beautifully. And this is a patient that will not take any oral supplementation. And we also have a tip I can put in the chat on breakthrough symptoms for some other. So while you're while you're doing that Donna I'm going to take us to the next slide. So we're right past the question slide. So if there are any topics covered in the webinar today that you'd like to discuss with colleagues in the mental health field, please post a question or comment on our discussion board. This is an easy way to network share ideas participate with others in the webinar. After the webinars over. If you have questions about the webinar or other topics related to evidence based care for SMI. You can get an answer within one business day from one of the SMI advisors national experts. This service is available to all mental health clinician peer support specialist administrators, anyone in the mental health field who works with individuals with SMI it's completely free and confidential. So please use the consult service at any time. After that slide is our new resource slide SMI advisor offers more evidence based guidance on LAI's Donna discuss the LAI conversion tool. The tool is designed to provide dosing recommendations for initial and maintenance doses of LAI's based on oral doses. So access the link in the chat or downloading the slides and look for it in the app. It's also available online. Again, to claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession after the webinar ends, please click continue to complete the program evaluation. The system then verifies your attendance for credit claim can take up to an hour and can vary based on where you are and the usage of our platform. I do invite you to join us next week on September 22 as Dr. Jennifer Payne presents the management of psychiatric disorders during and after pregnancy. The webinar is on September 22 from 2 to 3pm. Thank you all for joining us and as we are at the top of the hour. Thank you for your time and have a nice afternoon.

Long-Acting Injectable Antipsychotic Medication

Webinar

SMI Advisor

Administration

Injection Sites

Dosing Conversions

Patient Choice

Clinical Considerations

Medication Regimens

Q&A Session

Long-Acting Injectable

Antipsychotic Medication

Administration Intervals

Patient Preferences

Preparation Techniques

Administration Techniques