Postinjection Delirium/Sedation Syndrome After 31st Long-Acting Olanzapine Depot Injection

Postinjection delirium/sedation syndrome in a transgender man undergoing hormone therapy

Background

Long-acting injectable medications have become an important tool in the treatment of schizophrenia and schizoaffective disorder due to the high rates of medication nonadherence. Olanzapine long-acting injection (OLAI) is a useful therapeutic option for patients who have good tolerability and efficacy to oral olanzapine. Postinjection delirium/sedation syndrome (PDSS) is a rare but potentially serious event with the proposed mechanism of inadvertent intravascular injection of OLAI. This concern necessitates the requirement of a 3-hour monitoring period postinjection. Based on a literature review, there are no clearly defined risk factors for developing PDSS.

Case Report

A case is presented that describes PDSS in a transgender man undergoing hormone therapy with testosterone. The patient received OLAI for more than 3 years and developed PDSS 9 months after the initiation of injectable testosterone.

Discussion

There are published case reports of PDSS with the use of OLAI; however, there are no documented cases in a patient undergoing concurrent testosterone therapy. The effect that testosterone has on the vascular system and how it may alter the pharmacokinetics of OLAI has not been studied.

Conclusion

Despite proper injection technique, PDSS can occur after injection with OLAI. Further research is necessary to identify specific risk factors for the development of PDSS, including the potential effect that hormone therapy may have.

Can the use of long-acting injectable antipsychotic preparations be increased in routine clinical practice and the benefits realised?

BACKGROUND

The use of continuing antipsychotic medication is an established evidence-based strategy for preventing relapse in people with schizophrenia, but medication adherence is known to be suboptimal. Covert non-adherence can be eliminated by the use of long-acting injectable (LAI) formulations. We sought to (1) raise awareness among clinicians of the potential benefits of LAI antipsychotic formulations, (2) increase use of these formulations for the treatment of schizophrenia in routine clinical practice and thereby (3) reduce the number of relapses requiring hospitalisation in patients with schizophrenia under our care.

METHOD

Educational initiatives, promotion of reflective practice and patient-specific reminders were used to prompt increased use of LAI antipsychotic medication for patients with schizophrenia. Data relating to the use of these medications and the number of acute admissions for schizophrenia spectrum disorders (F20-29, ICD-10) over time were extracted from existing clinical information systems.

RESULTS

Over the 3-year time frame of our local initiative, the use of LAI antipsychotic preparations increased by 11%, the number of acute admissions for schizophrenia/schizoaffective disorder (F20 and F25) decreased by 26% and the number of acute bed days occupied by patients with these diagnoses decreased by 8%. The number of admissions for other psychosis diagnoses (F21-24 and F28-29) did not show the same pattern of improvement.

CONCLUSION

In our health care organisation, raising clinicians' awareness of the evidence base relating to the potentially favourable benefit-risk balance for LAI antipsychotic medication compared with oral formulations resulted in more use of the former. There were accompanying reductions in acute admissions and occupied bed days for patients with schizophrenia.

Delirium Research in India: A Systematic Review

Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( n = 81), and these were followed by, case reports ( n = 58), review articles ( n = 10), letter to the editor (not as case reports but as a communication; n = 13), editorials ( n = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.

Olanzapine Pamoate Use for Schizophrenia: Retrospective Records Based Study from a Tertiary Care Hospital

BACKGROUND

Little is known from India about the experience of using olanzapine long-acting antipsychotic injectables (LAI). In this background, this study aimed to evaluate the clinical profile of patients suffering from schizophrenia who were prescribed olanzapine LAI and to evaluate the usefulness and acceptability of olanzapine LAI among these patients.

METHODS

In this retrospective study, data of all the patients with schizophrenia receiving olanzapine pamoate, was extracted.

RESULTS

40 patients (males-55%; mean [SD] age- 36.2 (12) years; mean duration of illness (SD) prior to depot-143.3 (115.9) months) were included in the study. Olanzapine LAI was invariably prescribed in patients with a past history of non-compliance. Data was available for a mean (SD) follow-up duration of 17 (10.8) months. The most frequently used dose of olanzapine LAI used was 300 mg every two weeks (55%). This was followed by 405 mg every four weeks in (32.5%). Mean Clinical Global Impression (CGI) Severity score prior to starting of olanzapine LAI was 5.8 (0.7), which reduced to 2.7 (1.1) at the time of last follow-up or the last use of olanzapine LAI, and this was a statistically significant improvement (paired t-test value = 16.41; P < 0.001). Only one (2.5%) patient experienced Post injection Delirium/Sedation Syndrome during the study period. Only one patient was hospitalized after starting depot olanzapine.

CONCLUSION

Olanzapine LAI is mostly used in patients with a history of non-compliance. Olanzapine LAI is associated with a significant reduction in the severity of illness.