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Strategies for Success: Using Long-Acting Injectab ...
Presentation Q&A
Presentation Q&A
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Video Transcription
Why don't we hop into the questions? The first question that came in refers to slides 11 and 12, where you talked about oral versus long-acting injectables. That's where you showed the Kaplan-Meier curves, and then you were showing those meta-analyses. And the writer says, should every patient be started with a long-acting injectable based on these data? So I don't know if you have thoughts about that. Should we be thinking about LAIs more first-line? It's like someone planted that question in the audience for me. No, I'm kidding. Thank you so much for that question. I thought about that myself, especially in light of its efficacy in first-episode patients. And I mentioned, in other countries, long-acting injectables are first-line. How incredibly logical, right? I think that if we lived in a society and a culture that wasn't so avoidant, and that didn't stigmatize the idea of an injectable medication quite so much, then it probably would be first-line. I also will say, we probably offer LAIs or clozapine to maybe 80% of the patients in our clinic. Because any residual symptoms, or especially if they're still distressing, LAIs and clozapine are the next step. I guess building on that, we had a question that come in that says, are there any clinical characteristics of patients with psychosis that seem to make LAIs a top choice? For example, being disorganized or paranoid, and any tips with dealing with those? I guess, both in terms of getting them to take the LAI, and are they better candidates in a certain way? Really interesting question. There's a few different facets to it. First of all, of course, if a patient is just responding really poorly to PO, if there's a risk to somebody else or risk to others because of their paranoia, that would make switching them to an LAI a priority. That being said, I don't think there's any evidence that I know, any literature that speaks directly to saying that there's a sub-population of patients with schizophrenia with a particular type of psychosis that would benefit more from an LAI. I don't think that's the case. I feel like there's a third part to that question that I wanted to talk about, but I can't remember the entire question right now. All right. Well, I think you answered the parts that I was thinking about. Okay, great. Okay, good. I'm wondering, again, we're thinking a little bit about patient selection. We have another question that came in that says, how long would you want someone to take a medication before transitioning them to an LAI? I work at a crisis clinic where many patients are homeless and stay for 17 days. Is that enough time to start them on something like risperidone and then transition them to an LAI? What do you think? Yeah, that's a great question. It's not well answered by the literature, but from what I have seen, I think 14 days in most cases is enough. I don't think there are any firm recommendations. I know that in some other acute settings, such as incarceration, they'll use even shorter periods of oral dosing before transitioning to an LAI. The most important, I think two weeks is enough to make sure that really severe side effects aren't going to happen. Somebody writes in based on their own experience with LAIs saying, after a deltoid injections, a patient complained of over sedation and confusion for two or three days. Would changing the injection site or changing the dosage and or frequency improve tolerability? Probably. First of all, I'm not sure how you decided to proceed after that. Even with oral medications, patients can have symptoms that only last a couple of days. I think you said ataxia or something like that, this dizziness, over sedation. Confusion is definitely really concerning. You probably discontinued the medication, but transitioning to a gluteal site probably would help with spreading the exposure to the dose out over more time. Certainly, a lower dose would be ... If it were me, I'd probably switch to a lower dose in the gluteal muscle and see how that goes. Great. This next one asks about resources for patients. We have some on SMI Advisor, probably not as many as we need based on the enthusiasm in today's talk, but are there sources out there to give patients about LAIs? At a local inpatient hospital, they had a huge issue where patients were getting an LAI shot and then believed that they never had to take medication again. I feel like there was a huge barrier between physician and patient understanding about these injections. Having sources of additional information would be very helpful. Are there places that you send patients for information? That is such a great question. Boy, I don't have a good answer for that. Usually, definitely the SMI Advisor LAI COE has some information for patients. I often use information for patients from up-to-date. They sometimes have some good handouts that can be printed out, but I completely sympathize. Things that we take for granted, that we assume our patients know, they often don't. I think the most important thing is that providers need to keep in mind that nothing should be assumed. There's no reason a patient would know anything about an LAI the way that a provider does. Even the most basic ideas need to be made clear. That's a sad story, but not too surprising, actually, I guess. I think the idea of clarity, and even involving families in those discussions where you can, is really helpful in making sure people have a shared understanding of treatment. I think that leads us into the next question, which really focuses on, for physicians who want to get started in this, maybe they are in a group practice or maybe they have a relationship with a nurse. How do you suggest they take those first steps? Maybe they haven't given a shot since medical school. They don't even know. Are there resources or places that you might suggest people get started, or who they might talk to? That's a great question. If a physician is interested in administering a shot themselves, they might want to just, if they have a relationship with a nurse, they could watch the nurse. For instance, here in our clinic, we have our nurse do an in-service with all the residents, go through each of the different long-acting injectables, because each of them actually has a different method of being. Some of them need to be reconstituted in a certain volume of saline, for instance. Others need to be shaken a certain way at a certain rate, with a certain vigor, for a certain number of minutes, and they are actually training syringes to practice. First of all, the manufacturers do provide that type of education and training material just as part of the packaging of the injections themselves. Secondly, nurses are a great resource for learning how to do that. I think most nurses won't have any trouble, if they haven't done this type of injection before, they'll have no trouble administering it, though. It's actually very straightforward. But outside of that, I don't know of any refresher programs for this type of thing. I'm being nudged by one of my program managers, who's actually reminding me that this year at APA's annual meeting, we're going to be doing a long-acting injectable lab, where I think we're going to have oranges and syringes, and all sorts of things. So if people happen to be in Philadelphia, and at the end of April, you want to join us in our learning lab, you'll have an opportunity to practice some of those things. Questions are pouring in here. Okay. Can you please speak to the use of LAIs in the elderly with baseline neurocognitive disease? Any special considerations there? That's a great question. I actually don't have any specific insights to offer. I'm trying to think if there was a study. I don't think there are any studies that have been specifically in an over 65 population. Typically you take renal and hepatic impairment into account with dose adjustments, but sometimes, especially in the case of cognitive impairment, LAIs can be helpful, because you really worry about your patients not remembering to take their oral medication. The next person writes, I wanted to ask about partnering with primary care physicians to initiate and deliver LAIs. I have seen many PCPs inherit patients with LAIs, but I wonder if use could be expanded if we reached out to family practitioners as well. I'm thinking a little bit about the collaborative care model and ways in which psychiatrists partner with primary care. Is that a model that you've seen used at other places? Yeah, absolutely. I think integrated care is terrific. I have not seen any programs initiated specifically like that, but we use that model all the time in our primary care integrated mental health clinic, actually. I think it's a great idea. We had a couple of questions around Risperidone and Invega. One asks if you could talk about, is there a literature supporting a direct conversion from Risperidone PO to Invega Sustana? Another one asks about general advice around managing hyperprolactinemia in patients who have maybe responded well to Risperidone or paliperidone and need a long-acting injectable. Yeah, sure. In terms of the first one, I will tell you what I do personally, which is that I basically calculate a paliperidone oral dose based on a two milligrams of Risperidone to three milligrams of paliperidone, so I convert the Risperidone oral to a paliperidone oral dose, and then I use the manufacturer's conversion chart to convert to the LAI formulation of paliperidone. That was the first question. I think in the case of hyperprolactinemia, which is actually, I'm glad you brought it up because that's such a devastating side effect, especially in terms of how it can affect someone's self-esteem if they have gynecomastia, in the case of males, and certainly the sexual side effects, I think oral treatment with aripiprazole on top of a long-acting injectable paliperidone would be something to consider, and then you just have to be, you could treat with a relatively low dose of aripiprazole so that you don't overexpose your patient to antipsychotics. I'm happy to talk about polypharmacy at another time. Yeah, it sounds like a talk all in and of itself, and I would encourage folks who have questions around polypharmacy to go ahead and submit them through the consult service, and we can route them to members of our clozapine and our long-acting injectable teams to help you sort through some of these more tricky and complicated issues as well. I think we have time for one more question. David reads, any thoughts about starting patients in hospitals or jails or forensic settings and then transitioning to community care? Anything that we should be thinking about if we were going to be moving patients from inpatient or institutional settings out into the community, and special considerations there? That's a great question. I just saw a poster on this at ACNP, and I think it can be done successfully. I think it's great if a patient can be transitioned to an LAI while they're institutionalized to help actually increase the likelihood of a good outcome after they're discharged. If only because transitions of care are such a point of weakness in our healthcare system, having somebody be on a long-acting injectable is a great thing. Yeah, I think it can and should be prioritized, actually. Just out of curiosity, do patients, if they're started inpatient on an injectable, are they given a card or something that they can take to their outpatient clinician as a routine matter to let them know that they received the injection and the date, or are we relying on EMRs and discharge paperwork largely to do those kinds of things? Have you seen a best practice around that? The best practice is prior to discharge that there is a discussion between the inpatient clinicians and the outpatient clinician about what's happened. Here at our hospital, patients really don't leave unless they have an appointment set up in their outpatient clinic, in an ideal situation, at least. That's what happens. And at that same time, during that handoff of care, their provider should be made aware that they've been transitioned to an LAI. Here at the VA, because we have such close integration of care between inpatient and outpatient, we do have a shared EMR, and that is fantastic. So systems with a shared EMR, it's ideal.
Video Summary
In this video transcript, the speaker answers questions regarding the use of long-acting injectables (LAI) for patients with psychosis. The first question asks if every patient should be started on LAIs based on the data presented. The speaker believes that in a society that is less avoidant and stigmatizing, LAIs would be first-line treatment. The second question asks about characteristics of patients that make them good candidates for LAIs, to which the speaker responds that there is no specific sub-population that benefits more from LAIs. The video also addresses the duration of oral medication before transitioning to LAIs and managing side effects such as over-sedation and confusion. The speaker recommends involving primary care physicians in initiating and delivering LAIs and discusses considerations for transitioning patients from inpatient to community care. There is also a discussion about managing hyperprolactinemia in patients who respond well to Risperidone or Paliperidone. The video concludes with a mention of a poster presented at ACNP about transitioning patients to LAIs while they are institutionalized. Overall, the video provides insights and recommendations on the use of LAIs in the treatment of psychosis.
Keywords
long-acting injectables
psychosis treatment
patient characteristics
side effects management
community care transition
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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