Reduced Bioavailability of Antidepressants for the Management of Generalized Anxiety Disorder Following Bariatric Surgery: A Case Study

Bariatric surgery is a commonly performed procedure for patients who have failed to achieve weight loss through medical and lifestyle interventions. However, the altered gastrointestinal anatomy resulting from the surgery can significantly impact the bioavailability of antidepressants in patients with generalized anxiety disorder, potentially leading to uncontrolled anxiety symptoms. This case report describes a patient with generalized anxiety disorder who underwent Roux-en-Y gastric bypass surgery and subsequently experienced increased anxiety symptoms due to poor antidepressant bioavailability. The patient's medication was adjusted to a sublingual formulation, resulting in improved anxiety control and reduced side effects. Healthcare providers should be aware of the potential impact of bariatric surgery on medication absorption and closely monitor patients with generalized anxiety disorder for potential psychiatric medication-related complications postoperatively. The use of alternative routes of administration, such as sublingual medication, may be beneficial in improving drug bioavailability and managing anxiety symptoms. Creating awareness in primary care offices about poor drug absorption and using alternatives such as the sublingual route of administration to achieve optimal systemic delivery requires a multifaceted approach involving education and training for healthcare providers as well as patient education to ensure they are informed and engaged in their own care. By implementing these strategies, primary care providers can improve patient outcomes and prevent unnecessary referrals to specialists.

Antidepressant Use During Hospice Patients' Final Months on Routine Home Care

Background: Antidepressants can be used to manage symptoms at the end of life, but the dying process can impact their use. Objectives: To examine the use of antidepressants during hospice patients' final months of home care. Methods: A retrospective case records review of 227 hospice patients in their last three months of care in a residential setting. Chart reviews were conducted of medication logs, hospice staff notes, and caregiver narratives to examine antidepressant use including types of medications prescribed and factors associated with medication maintenance. Results: Thirty percent of patients were prescribed at least 1 antidepressant for symptoms including depression, anxiety, pain, disturbances in sleep, and poor appetite. The majority (96.1%) of patients were not administered their antidepressant on the day of death, and more than half (61.8%) did not receive their antidepressant during their last 3 days of life. A quarter (25.5%) of patients on antidepressants did not receive medication 4-7 days prior to death while some (12.7%) went without their antidepressant for 8 or more days. Antidepressant use was discontinued by hospice staff or caregivers due to a variety of reasons including difficulty swallowing, minimal consciousness, confusion, nausea, or patient refusal. Conclusions: Antidepressants are prescribed to manage multiple symptoms at the end of life, but use is often disrupted during patients' final days. Tapering and other prescription adjustments may be warranted to avoid risk of antidepressant discontinuation syndrome (ADS).

Roller microneedles transdermal delivery of compound lidocaine cream for enhancing the analgesic effect: A randomized self-controlled trial

OBJECTIVE

The purpose of this article is to investigate whether the percutaneous delivery of compound lidocaine cream by roller microneedles can shorten the minimal effective onset time of anesthesia, enhance the intensity of anesthesia and prolong the analgesic time, so as to provide a theoretical basis for exploring a comfortable, safe and effective anesthesia method for photoelectric cosmetic surgery.

METHODS

A total of 90 healthy volunteers, including 18 male and 72 female, met the criteria and were enrolled in the study from December 2020 to September 2021 in Department of Plastic and Burn Surgery of the First Affiliated Hospital of Chongqing Medical University. This study adopted a two-factor randomized block design of 3 (anesthesia time on the test side: 30, 45, 60 min) × 2 (the test side: the left and right side), and the subjects were divided into group A (n = 30), group B (n = 30), and group C (n = 30). On the test side, the compound lidocaine cream was used for topic anesthesia for 10 min, then the roller microneedle was used to roll on the treatment area, compound lidocaine cream was appropriately supplemented, and the topic anesthesia was kept continued for 20 min (group A), 35 min (group B), and 50 min (group C), respectively. The mirrorsymmetrical area of the test side of the three groups was the control side, and the compound lidocaine cream was used for topic anesthesia for 60 min. Photoelectric therapy was performed after anesthesia was completed. The analgesic effect of the subjects on both sides was comprehensively compared; the scores were obtained using the Kuttner Facial Expression Scale, the Frankl Treatment Compliance Scale, the Houpt Behavior Scale, and the Visual Analog Scale (VAS); the satisfaction with anesthesia was investigated. Before and after treatment the skin temperature, color and adverse reactions of the subjects were recorded.

RESULTS

Comparing both sides of the same group, there was no significant difference in terms of the comprehensive evaluation, intraoperative comfort, tolerance, cooperation, pain or satisfaction between the 30-min test side and the routine anesthesia side in group A; the comprehensive evaluation, intraoperative tolerance, cooperation degree, pain degree and satisfaction evaluation of the subjects on the 45-min test side in group B were significantly better than those on the control side; the comprehensive evaluation, intraoperative comfort, tolerance, cooperation, pain and satisfaction of the subjects on the 60-min test side in group C were significantly better than those on the control side. Comparing groups on the control side, there was no significant difference in the comprehensive evaluation, intraoperative comfort, tolerance, cooperation, pain or satisfaction between the three groups of subjects on the control side. Comparing the three groups on the test side, with the prolongation of compound lidocaine cream indwelling time, the subjects' comprehensive evaluation, comfort and pain degree were significantly improved. There was no significant difference in postoperative bruising, swelling, pain, discoloration, redness, or tenderness between the test side and the control side.

CONCLUSION

The percutaneous delivery of compound lidocaine cream by roller microneedles can not only shorten the effective time of anesthesia, but also has a good analgesic effect without obvious adverse reactions.

Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness

An estimated one in six children in the United States suffers from a mental disorder, including mood, anxiety, or behavioral disorders. This rate is even higher in children with chronic medical illness. This manuscript provides a concise review of the symptoms that comprise mental conditions often observed in children with chronic illness or at the end of life. It further provides some guidance to help clinicians distinguish normative from pathological presentations. Evidence-based psychotherapy interventions, potentially applicable to the acute inpatient setting, are briefly summarized. Broad recommendations are made regarding both psychotherapeutic as well as pharmacotherapeutic interventions, with a review of common or serious medication side effects. Finally, delirium recognition and management are summarized.

Intravenous ketamine for rapid treatment of major depressive disorder in the general medical hospital

Major depressive disorder (MDD) is common in general medical settings, and can usually be treated with conventional oral antidepressants. For some patients, however, oral treatment is refused or not possible, and the untreated symptoms can have a significant impact on the treatment of the acute medical problem. Use of intravenous ketamine has been widely reported in mental health settings for the treatment of MDD. We describe use of intravenous ketamine in a general medical hospital for the treatment of MDD in an 83-year-old male patient who refused food, fluid and medical investigations following a stroke.

Transdermal Route: A Viable Option for Systemic Delivery of Antidepressants

The high rise in the population suffering from depression depicts the need for improved and highly effective treatment options for this condition. Efforts to develop existing drugs into user-friendly dosage forms with a number of advantages in major depressive states, including but not limited to: sustained drug release, reduced drug dosing frequency, improved tolerance and adherence, suitability for use in diverse populations and different treatment scenarios, as well as less central nervous system side effects are required. One such non-invasive drug delivery route that could provide the aforementioned benefits in the treatment of depression is the transdermal route. A number of conventional and emerging transdermal delivery strategies have been investigated for some potent antidepressants and results depict the potential of this route as a viable means for systemic delivery of therapeutically relevant doses of the tested agents, with Emsam®, the commercially available patch of selegiline, being an evidence for the same. The investigated approaches include the formulation of transdermal patches, use of vesicular drug carriers, pro-drug approach, microemulsification, chemical as well as physical enhancement technologies. This review provides a comprehensive account of the rationale, developments made till date, scope and future prospects of delivering antidepressants via the transdermal1 route of administration.

Preparation of orally fast-dissolving tablets of etilefrine hydrochloride to achieve efficient absorption

Etilefrine hydrochloride (ET) is commonly used in the treatment of hypotension in dosage forms of oral tablets and parenteral injections. However, oral tablets only temporarily achieve high plasma levels and have low bioavailability (BA), while intravenous injections may cause pain and necrosis around administration sites. In an attempt to overcome these limitations, the buccal delivery of ET using oral droplets has been investigated. In this study, a buccal tablet as an alternative dosage form was developed for practical use. Buccal tablets were prepared by the direct compression method with sodium alginate (AL) and mannitol (MA) as excipients. Their disintegration and in vitro drug release were rapid (more than 50% being released after 3 min). Furthermore, effective plasma levels (> 5-7 ng/mL) were reached within 0.5 h of buccal administration in rats. The systemic absorption of these tablets was similar to that of buccal droplets. Therefore, the ET buccal tablets developed herein have potential as an alternative dosage form for hypotension therapy.

The Gut Microbiome and Treatment-Resistance in Schizophrenia

The effect of antipsychotic medication is poor in 30-40% of patients with schizophrenia; treatment resistance is usually met with shifts to new drugs or drug augmentation strategies or a trial of clozapine. The purpose of this review was to examine the potential role of intestinal bacteria in the bioavailability of antipsychotic medication and the possibility that parenterally administered antipsychotics might be able to overcome treatment resistance. Databases were searched with appropriate terms to locate relevant papers dealing with the effect of antipsychotic drugs on the gut microbiome and the effect of bacterial metabolizing enzymes on antipsychotic drugs. Also searched were papers addressing the various current parenteral formulations of antipsychotic drugs. Sixty-five recent pertinent papers were reviewed and the results are suggestive of the premise that there is a drug refractory form of psychosis for which the composition of gut bacteria is responsible, and that parenteral drug administration could overcome the problem.

Transdermal Asenapine in Schizophrenia: A Systematic Review

BACKGROUND

Asenapine is a novel antipsychotic that has demonstrated efficacy in controlling psychosis in schizophrenia and mania in bipolar illness. It must be administered as a sublingual formulation because it is nearly completely metabolized in the first pass through the liver. Recently, a transdermal formulation of asenapine has been approved for schizophrenia by the Food and Drug Administration.

METHODS

A systematic review of transdermal asenapine was done utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model.

DISCUSSION

There are several formulations of transdermal asenapine but only Secuado^® has been approved for clinical use. Total bioavailability is 35%. Peak plasma concentration (Cmax) is 4 ng/mL and occurs within 1 hr (Tmax); elimination half-life (t_1/2) is 24 hrs (range 13.4 to 39.2 h). Asenapine is highly bound (95%) to albumin and α₁-acid glycoprotein. It has a unique receptor profile in which it functions as an antagonist at multiple receptors with affinity that is higher than D₂ (K_i = 1.3) including D₃, D₄, 5HT_2A, 5HT_2C, 5HT_2B, 5HT₇, 5HT₆, H₁, and α2. This profile suggests that asenapine may be of particular value off label for bipolar depression, anxiety, and aggression. Transdermal asenapine was only tested in one randomized, placebo-controlled study of acute psychosis in schizophrenia. It was superior to placebo at week 6 with nearly one-third of patients experiencing >30% improvement in total PANSS score which translates in a number needed to treat (NNT) of 9.

Transdermal Delivery of Antipsychotics: Rationale and Current Status

The aim of this article is to provide the rationale for the development of transdermal formulations of antipsychotics by highlighting their main advantages, starting with an overview of the antipsychotic formulations that are currently available on the market. Progress regarding transdermal antipsychotic formulations was investigated by performing a search of papers, patents and clinical trials published in the last 10 years. Available data on antipsychotic transdermal formulations are reported and discussed, focusing on the characteristics of the dosage forms and their ability to promote drug absorption. Despite the current availability of a large number of antipsychotics, only a few of these drugs (e.g. aripiprazole, asenapine, blonanserin, chlorpromazine, haloperidol, olanzapine, prochlorperazine, quetiapine, and risperidone) have been developed as transdermal delivery systems. Several papers and patents show that transdermal formulations, such as creams, films, gels, nanosystems, patches, solutions, and sprays, have been evaluated with the aim of expanding the clinical utility of antipsychotic drugs. In particular, the employment of different strategies, such as the use of nanoparticles/vesicles, or permeation enhancers as well as microneedles with iontophoresis, may improve the absorption of antipsychotic drugs through the skin. However, few clinical trials on transdermal delivery of antipsychotic drugs are available and only delivery systems containing asenapine and blonanserin have shown interesting clinical results in terms of pharmacokinetic data, efficacy, and tolerability. Recently, the transdermal patch formulation of blonanserin was approved in Japan for the treatment of schizophrenia.

Formulation and Characterization of Fast-Dissolving Sublingual Film of Iloperidone Using Box-Behnken Design for Enhancement of Oral Bioavailability

Iloperidone is a second-generation antipsychotic drug which is used for the treatment of schizophrenia and has very low aqueous solubility and bioavailability. This drug also undergoes first-pass metabolism. The aim of this work is to formulate fast-dissolving sublingual films of iloperidone to improve its bioavailability. Sublingual films were prepared by solvent casting method. Hydroxypropyl methyl cellulose E5, propylene glycol 400, and transcutol HP were optimized using Box-Behnken three-level statistical design on the basis of disintegration time and folding endurance of films. Iloperidone:hydroxypropyl-β-cyclodextrin kneaded complex was used in films instead of plain drug due to its low solubility. Optimized film was further evaluated for drug content, pH, dissolution studies, ex vivo permeation studies, and pharmacokinetic studies in rats. The optimized film disintegrated within 30 s. The in vitro dissolution of the film showed 80.3 ± 3.4% drug dissolved within first 5 min. In ex vivo permeation studies using sublingual tissue, flux achieved within first 15 min by film was around 117.1 ± 0.35 (mcg/cm²/h) which was ten times more than that of plain drug. This formulation showed excellent uniformity. AUC and C_max of film were significantly higher (p < 0.001) as compared to plain drug and relative bioavailability of the films was 148% when compared to the plain drug. Thus, this study showed optimized fast-dissolving sublingual film to improve permeation and bioavailability of iloperidone. Fast-dissolving films will be customer-friendly approach for geadiatric schizophrenic patients.

Intranasal delivery of antipsychotic drugs

Antipsychotic drugs are used to treat psychotic disorders that afflict millions globally and cause tremendous emotional, economic and healthcare burdens. However, the potential of intranasal delivery to improve brain-specific targeting remains unrealized. In this article, we review the mechanisms and methods used for brain targeting via the intranasal (IN) route as well as the potential advantages of improving this type of delivery. We extensively review experimental studies relevant to intranasal delivery of therapeutic agents for the treatment of psychosis and mental illnesses. We also review clinical studies in which intranasal delivery of peptides, like oxytocin (7 studies) and desmopressin (1), were used as an adjuvant to antipsychotic treatment with promising results. Experimental animal studies (17) investigating intranasal delivery of mainstream antipsychotic drugs have revealed successful targeting to the brain as suggested by pharmacokinetic parameters and behavioral effects. To improve delivery to the brain, nanotechnology-based carriers like nanoparticles and nanoemulsions have been used in several studies. However, human studies assessing intranasal delivery of mainstream antipsychotic drugs are lacking, and the potential toxicity of nanoformulations used in animal studies has not been explored. A brief discussion of future directions anticipates that if limitations of low aqueous solubility of antipsychotic drugs can be overcome and non-toxic formulations used, IN delivery (particularly targeting specific tissues within the brain) will gain more importance moving forward given the inherent benefits of IN delivery in comparison to other methods.

The Role of Inhaled Loxapine in the Treatment of Acute Agitation in Patients with Psychiatric Disorders: A Clinical Review

Loxapine is a first generation antipsychotic, belonging to the dibenzoxazepine class. Recently, loxapine has been reformulated at a lower dose, producing an inhaled powder that can be directly administered to the lungs to treat the agitation associated with psychiatric disorders, such as schizophrenia and bipolar disorder. Thus, the aim of this narrative and clinical mini-review was to evaluate the efficacy and tolerability of inhaled loxapine in the treatment of acute agitation in patients with psychiatric disorders. The efficacy of inhaled loxapine has been evaluated in one Phase II trial on patients with schizophrenia, and in two Phase III trials in patients with schizophrenia and bipolar disorder. Moreover, there are two published case series on patients with borderline personality disorder and dual diagnosis patients. Inhaled loxapine has proven to be effective and generally well tolerated when administered to agitated patients with schizophrenia and bipolar disorder. Two case series have suggested that inhaled loxapine may also be useful to treat agitation in patients with borderline personality disorder and with dual diagnosis, but further studies are needed to clarify this point. However, the administration of inhaled loxapine requires at least some kind of patient collaboration, and is not recommended in the treatment of severe agitation in totally uncooperative patients. Moreover, the drug-related risk of bronchospasm must always be kept in mind when planning to use inhaled loxapine, leading to a careful patient assessment prior to, and after, administration. Also, the higher costs of inhaled loxapine, when compared to oral and intramuscular medications, should be taken into account when selecting it for the treatment of agitation.

Considering future pharmacotherapy for PTSD

Posttraumatic stress disorder (PTSD) is a prevalent, disabling, and often chronic condition that may develop following exposure to a traumatic event. Despite the immense social and economic ramifications of PTSD, there has been relatively little recent development of new pharmacotherapies. The majority of pharmacological randomized clinical trials (RCTs) that has been conducted are now dated. Existing treatments for PTSD primarily have come out of research that tested medications developed for other disorders such as antidepressants, anti-hypertensives, antipsychotics, anticonvulsants, and anxiolytics. With an improved understanding of the complex pathophysiology of PTSD, we consider why it has taken so long to identify important targets to advance the field by addressing the underlying pathophysiology in pharmacological interventions. Exciting developments include research into PTSD-related abnormalities associated with dysregulation of adrenergic, hypothalamic-pituitary-adrenocortical, monoaminergic, peptide, glutamatergic, GABAergic, cannabinoid, opioid, and other neurotransmitter and neuroendocrine systems. Yet, this is a broad list and there are many unanswered questions. Current research on biomarkers associated with different clinical phenotypes of PTSD should lead to novel and more specific pharmacotherapeutic strategies. In this brief review, we consider key questions regarding current knowledge on pharmacological treatments for PTSD and highlight evolving practices in future research.

The promise and pitfalls of intranasally administering psychopharmacological agents for the treatment of psychiatric disorders

Accumulating research demonstrates the potential of intranasal delivery of psychopharmacological agents to treat a range of psychiatric disorders and symptoms. It is believed that intranasal administration offers both direct and indirect pathways to deliver psychopharmacological agents to the central nervous system. This administration route provides a unique opportunity to repurpose both old drugs for new uses and improve currently approved drugs that are indicated for other administration routes. Despite this promise, however, the physiology of intranasal delivery and related assumptions behind the bypassing of the blood brain barrier is seldom considered in detail in clinical trials and translational research. In this review, we describe the current state of the art in intranasal psychopharmacological agent delivery research and current challenges using this administration route, and discuss important aspects of nose-to-brain delivery that may improve the efficacy of these new therapies in future research. We also highlight current gaps in the literature and suggest how research can directly examine the assumptions of nose-to-brain delivery of psychopharmacological agents in humans.